Perceptions of labour: discrepancies between midwives' and patients' ratings

Skilled health attendants' knowledge and practice of pain management during labour in health care facilities in Ibadan, Nigeria

INTRODUCTION

Skilled health attendants occupy an important position in the management of women's pain during labour. Their professional goal is to ensure safety and minimum pain in labour. It has been revealed that nurse-midwives are deficient in knowledge and practice of pain management during labour. Hence, this study examined skilled health attendants' knowledge and practice of pain management in health care facilities in Ibadan, Nigeria.

METHODS

A cross-sectional design was used to collect data from 227 skilled health attendants, in the maternity units of the three purposively selected hospitals for 12 weeks. A structured questionnaire and observational check lists were used for data collection. Data were analyzed using descriptive statistics and significants level was set with p<0.05.

RESULTS

Results on respondents' level of knowledge revealed that 6% had low knowledge, 40.5% moderate, and 56.8% had a high level. The majority, 79.7%, were registered nurse-midwives (RN/RM) and 90.1% employed reassurance for pain relief. No significant associations were found between respondents' level of education and reassurance, exercise, allay of fear, use of drugs, and TENS (p>0.05). However, there were significant associations between respondents' educational level and rubbing of back/massage, position change, cold/warm bath, relaxation, and social support (p<0.05).

CONCLUSIONS

It is recommended that seminars and workshops should be organized regularly and assessment tools should be supplied, to enhance effective pain assessment as this will provide adequate and holistic labour-pain management by nurse-midwives.

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60-84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.

A simple tool to measure patient perceptions of operative birth

OBJECTIVE

To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery.

DESIGN

Cross-sectional survey.

SETTING

A large maternity unit in England.

SAMPLE

150 women who had had an operative birth.

METHODS

We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified).

MAIN OUTCOME MEASURES

Participation rate to determine feasibility; Cronbach's alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity.

RESULTS

Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach's alpha=0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman's r=0.64, P<0.001).

CONCLUSIONS

The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training.

User involvement in healthcare technology development and assessment: structured literature review

PURPOSE

Medical device users are one of the principal medical device technology stakeholders. The involvement of users in medical device technology development and assessment is central to meet their needs. This study aims to examine this issue.

DESIGN/METHODOLOGY/APPROACH

A structured review of the literature published from 1980 to 2005 in peer-reviewed journals was carried out from a social science perspective to investigate user involvement practice in the development and assessment of medical device technologies. This was followed by a qualitative thematic analysis.

FINDINGS

Medical device users include clinicians, patients, carers and others. Different kinds of medical devices are developed and assessed by user involvement. The user involvement occurs at different stages of the medical device technology lifecycle and the degree of user involvement is in the order of: design > testing and trials > deployment > concept stages. The methods most commonly used for capturing users' perspectives are usability tests, interviews and questionnaire surveys.

RESEARCH LIMITATIONS/IMPLICATIONS

The relevant engineering, medical and nursing literature, which might have been useful, was not reviewed. However, useful findings emerge that apply to health care generally.

ORIGINALITY/VALUE

This study shows that medical device users are not homogeneous but heterogeneous in several aspects, such as needs, skills and working environments. This is an important consideration for incorporating users' perspectives in medical device technologies.

Cultural identities and perceptions of health among health care providers and older American Indians

BACKGROUND

Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients' cultural identities may be related to discordant perceptions.

OBJECTIVE

To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients' strength of affiliation with American-Indian and white-American cultural identities.

DESIGN

Survey of patients and providers following primary care office visits.

PARTICIPANTS

One hundred and fifteen patients > or =50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities.

MEASUREMENTS

Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient's health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients' cultural identities with differences in provider-patient health rating.

RESULTS

In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients' self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity.

CONCLUSIONS

American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions.

Selected coping strategies in labor: an investigation of women's experiences

BACKGROUND

Antenatal education classes offer women information about labor and birth and ways of coping with pain and emotional distress. The purpose of this paper was to describe women's experiences of using, starting, and discontinuing three coping strategies in labor that were taught in antenatal education classes.

METHODS

An exploratory research design was used in which 121 women were interviewed within 72 hours of the birth of their first child. Information was obtained on why women initiated and discontinued their use of three coping strategies (breathing technique, postural changes, relaxation technique) and the reported effects of use.

RESULTS

The effects of the coping strategies investigated varied widely among participants. Common aspects of care, changes of environment, and use of pharmacological pain relief affected women's discontinuation of coping strategies.

CONCLUSIONS

The implications of study findings for clinical practice include the need for caregivers to provide women with accurate information about the effects of coping strategies and to be alert to aspects of care that may disrupt women's use of strategies.

Perceptions of labour pain by mothers and their attending midwives

AIMS

The aim of the current study was to examine the perception of pain by labouring women and their attendant midwife, from the onset of labour to delivery.

RATIONALE

Accurate measurement and appropriate management of pain is a significant problem for attendant medical and nursing personnel. Both the experience and perception of pain are regarded as subjective and are therefore difficult to measure objectively. Indeed, much of the literature reports that pain is often under- or over-estimated by nursing staff who as a consequence consistently fail to administer adequate analgesia. Few studies have specifically examined the ability of midwives to assess the pain of labouring women.

DESIGN

The short form McGill Pain Questionnaire (SF-MPQ), routinely used to assess pain in obstetric environments, was used to determine pain perception. Thirteen labouring women and nine midwives completed the SF-MPQ every 15 minutes beginning at the time of admittance to the delivery suite. Peak pain ratings for the preceding 15 minutes were obtained without reference to prior ratings or each other's scores. Further, midwives in the maternity unit of The Queen Elizabeth Hospital (TQEH), Adelaide, South Australia completed a survey investigating the cues they use to assess pain during labour.

RESULTS

On each measure of pain on the SF-MPQ, the midwives scores correlated with the mothers' scores across the entire pain range. Further analysis showed that mothers' and midwives' pain scores were similar at mild-moderate pain levels, but midwives significantly underestimated pain intensity at levels that mothers described as severe. The survey responses indicated that midwives rely on both verbal and nonverbal cues to assess pain levels.

CONCLUSIONS

The cues used by midwives to differentiate pain intensities and qualities are similar to those used in other clinical settings, but may have limited discriminatory value as pain levels become severe.

Maternal satisfaction with labour analgesia

Satisfaction with childbirth is a multidimensional issue, of which analgesia is but one component. The importance of analgesia as a contribution to overall satisfaction has been recognized increasingly in the last 50 years, but improvement in quality of available analgesia has not always resulted in commensurate improvement in satisfaction. Satisfaction by its very nature has proved to be difficult both to define and to quantify, and no reliable standards of measurement have been accepted. Pain relief in childbirth is subject to many social and cultural modifiers, which continue to change. Control of pain rather than absolute amelioration is seen by many to provide greater satisfaction. Analgesia issues still do not figure prominently in the overall satisfaction of the birthing process for the vast majority of women, despite the availability of and demand for improved methods of relief. The interpersonal relationships established between patient and healthcare providers may ultimately be of more importance in the determination of satisfaction with management.

What determines quality in maternity care? Comparing the perceptions of childbearing women and midwives

BACKGROUND

In the current climate of consumer orientation in health care services, a clear need has emerged to understand the extent of consumer focus among primary health care professionals. Few studies have compared the beliefs of health care staff with those of patients. This study sought to identify and compare the perceptions of women and midwives concerning women's beliefs about what constitutes quality in maternity services.

METHODS

Focus groups were conducted from July 1994 to June 1997 with 38 pregnant and postnatal women, and 47 midwives who were based in two large maternity units in Yorkshire, England. Transcriptions of data were analyzed to identify broad themes.

RESULTS

Ten dimensions of quality were identified. Similarities between midwives and women included beliefs about the importance of the relationship between the two parties, desired attributes of staff, and the environment of care. Key differences included underestimating the importance of information antenatally and postnatally, the importance of continuity during labor, need for control and confidence in adjusting to the maternal role, and involvement of the woman's partner in the delivery of care.

CONCLUSIONS

An understanding of the concerns of women by maternity care staff is important in the development of a woman-focused service, in line with current policy recommendations, and has implications for risk management and improving the service quality for those who provide and experience the service.

Perceptions of pain and pain relief in labour: the gulf between experience and observation

In a national sample of 10,702 women delivered in one week in 1990 data on their perceptions of pain and the effectiveness of pain relief methods were compared with those of the professionals attending them. Professionals' conceptions of pain relief tended to be restricted to pharmacological methods. Overall, the level of agreement about effectiveness of pain relief was quite low, with medical staff commonly believing they were providing adequate pain relief while the women reported it as unsatisfactory. This was particularly the case for pethidine, while 'Entonox' was rated more highly by women than staff. Professionals were significantly more likely to agree with one another about effectiveness than to agree with the women, and were less likely to have responded where the women judged their pain relief as poor.

Dimensions of nurse and patient roles in labor

Nurses, as the principal caregivers during labor, play a major role in structuring the social context of childbirth. The influence of nurse-patient verbal interaction on the social construction of the childbirth experience was investigated. Verbatim records of nurse-patient interaction during labor were analyzed using Stiles's (1978a) Taxonomy of Verbal Response Modes. Nurse and patient scores on three dimensions of interpersonal roles, attentiveness, acquiescence, and presumptuousness, were determined. The results indicated that nurses established and maintained control over the definition of the childbirth experience. The viewpoint of the laboring woman was seldom acknowledged as relevant. Presumption of knowledge of the laboring woman's experience and failure to determine her perception of the situation can have a negative impact on individualization of care and the creation of a patient-centered birthing environment.

Mothers', midwives' and obstetricians' views on the features of obstetric care which influence satisfaction with childbirth

A sample of 15 women was interviewed 18-96 h postnatally to identify objective features of labour and postnatal care about which they expressed preferences. The importance of each item to a mother's satisfaction was then rated by a sample of 224 similar women. The same questionnaire was also completed by 28 midwives and 52 obstetricians. The items rated most important concerned the explanation of procedures and the involvement of mothers in administering or choosing them. Second was support from the presence of a partner and qualified hospital staff, third the physical comfort of the postnatal ward. The avoidance of obstetric interventions, such as episiotomy or use of forceps, was less important than the presence of these other features. The mean ranking given to each item by the midwives and obstetricians correlated very highly with that given by the mothers; those caring for obstetric patients are much more sensitive to their preferences than is popularly believed. There was no evidence that midwives perceived patients' needs more accurately than did the obstetricians. Discrepancies between the three groups' ranking of specific items may reflect the defence of their respective roles by each profession.

The social bases of discrepancies in health/illness perceptions

Health care professionals generally assume that their perceptions and assessments of their patients' health status are accurate and are congruent with those of the patient and other health care providers. However, despite the patient education process, there is evidence that discrepancies in perceptions persist. These discrepancies are of particular concern to nurses because they may interfere with the provision of quality patient care. Poor communication, non-compliance with the treatment regimen, inadequate or unnecessary treatment, and ethical problems could be outcomes of discrepancies in perceptions. In this paper, the literature pertaining to discrepancies in health/illness perceptions is reviewed. As well, several social factors that may affect perceptions are described. These include cultural background, gender, socioeconomic status, experience and role. The effect of occupational role on health/illness perceptions has not been examined systematically. Regarding differences in perceptions of physicians, nurses and patients, further research is required to clarify and explain the nature of discrepancies in health/illness perceptions.