Risk in Maternity Care: A Concept Analysis

Transformative learning in nursing education: A concept analysis

Objective

There is vast literature on transformative learning, which is an important aspect of nursing education, but its meaning remains unclear. It is therefore important to clarify the meaning of transformative learning, identify its attributes, antecedents and consequences to increase its use in nursing education, practice and research.

Methods

Walker and Avant's method was used, and the process provided a structured way to analyse the concept of 'transformative learning'. Nursing education dictionaries, encyclopaedias, conference papers, research articles, dissertations, theses, journal articles, thesauri and relevant books through the database library and internet searches were reviewed. One hundred and two literature sources were reviewed, and data saturation was reached.

Results

The results of the concept analysis of transformative learning within the context of nursing education identified three categories, namely, 1)Antecedents as cognitive and affective perspective, democratic education principles and inspiration; 2)Process through three phases, namely i) awareness through self-reflection, ii) the meaningful interactive, integrative and democratic construction process, and iii) metacognitive reasoning abilities; and 3)Outcomes. A theoretical definition of transformative learning was formulated. Theoretical validity was ensured.

Conclusion

The results of the concept analysis of transformative learning were used to describe a model to facilitate transformative learning within the context of nursing education.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Midwifery students' understanding and knowledge of normal birth before 'delivery' of curriculum

OBJECTIVE

To generate new knowledge that describes and explains the views and understanding, regarding midwifery and normal birth, that newly enrolled midwifery students hold at the commencement of their midwifery education.

DESIGN

A qualitative descriptive approach was used in conjunction with an anonymous questionnaire.

SETTING

A tertiary University in Western Australia FINDINGS: Eighteen postgraduate midwifery students (PG), and twenty undergraduate midwifery students (UG), completed the questionnaire.Postgraduate midwifery students with a nursing background had a pronounced medical terminology and philosophy, as opposed to undergraduate midwifery students.

IMPLICATIONS FOR PRACTICE

Midwifery educators will need to ensure the teaching of midwifery philosophy and normal birth at the commencement of midwifery courses, before historical perspectives and anatomy and physiology. Students need to be aware that birth is not reliant on risk management or student's personal values, otherwise it will be difficult for new midwifery students to understand birth as a normal, physiological process.

Women׳s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand

OBJECTIVE

to explore women׳s birthplace decision-making and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit rather than in an obstetric-led tertiary level maternity hospital in New Zealand.

DESIGN

a mixed methods prospective cohort design.

METHODS

data from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. The qualitative data from the focus groups and survey were the primary data sources and were integrated at the analysis stage; and the secondary qualitative and quantitative data were integrated at the interpretation stage.

SETTING

Christchurch, New Zealand, with one tertiary maternity hospital and four primary level maternity units (2010-2012).

PARTICIPANTS

well (at 'low risk' of developing complications), pregnant women booked to give birth in one of the primary units or the tertiary hospital. All women received midwifery continuity of care, regardless of their intended or actual birthplace.

FINDINGS

five core themes were identified: the birth process, women׳s self-belief in their ability to give birth, midwives, the health system and birth place. 'Confidence' was identified as the overarching concept influencing the themes. Women who chose to give birth in a primary maternity unit appeared to differ markedly in their beliefs regarding their optimal birthplace compared to women who chose to give birth in a tertiary maternity hospital. The women who planned a primary maternity unit birth expressed confidence in the birth process, their ability to give birth, their midwife, the maternity system and/or the primary unit itself. The women planning to give birth in a tertiary hospital did not express confidence in the birth process, their ability to give birth, the system for transfers and/or the primary unit as a birthplace, although they did express confidence in their midwife.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

birthplace is a profoundly important aspect of women׳s experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. A multiplicity of factors needs converge in order for all those involved to gain the confidence required to plan what, in this context, might be considered a 'countercultural' decision to give birth at a midwife-led primary maternity unit.

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour

BACKGROUND

Approximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of 'normal' labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context.

AIM

To examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth.

METHODS

Ethnography, underpinned by a critical medical anthropology methodology.

RESULTS

These findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence.

CONCLUSIONS

As we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a 'risky' practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more 'dangerous' option.

An Exploratory Survey of Low-Risk Pregnant Women’s Perceptions of Antenatal Care and Services in Southern Ireland

Ireland currently has the highest birthrate of the 27 European Union countries which has led to an increase in demand for maternity services. In the Irish Republic, most maternity units have traditionally followed the medical-led model of care, which, as a result, has limited women’s choice for maternity care. Although various different midwifery-led schemes are available, concerns exist regarding the knowledge and accessibility of these schemes.

The aim of this descriptive, exploratory survey was to explore and determine the views of “low-risk” pregnant women (n= 394) regarding their antenatal care and services. A purposive homogeneous sample comprised the first phase of a mixed methods study and data were analyzed using Predictive Analytics Software. The findings identified a lack of awareness and understanding of the concept of a low-risk pregnancy. Consequently, women identified an overall lack of information and an inability to access available options for their care.

Salutogenically focused outcomes in systematic reviews of intrapartum interventions: a systematic review of systematic reviews

INTRODUCTION

research on intrapartum interventions in maternity care has focused traditionally on the identification of risk factors' and on the reduction of adverse outcomes with less attention given to the measurement of factors that contribute to well-being and positive health outcomes. We conducted a systematic review of reviews to determine the type and number of salutogenically-focused reported outcomes in current maternity care intrapartum intervention-based research. For the conduct of this review, we interpreted salutogenic outcomes as those relating to optimum and/or positive maternal and neonatal health and well-being.

OBJECTIVES

to identify salutogenically-focused outcomes reported in systematic reviews of randomised trials of intrapartum interventions.

REVIEW METHODS

we searched Issue 9 (September) 2011 of the Cochrane Database of Systematic Reviews for all reviews of intrapartum interventions published by the Cochrane Pregnancy and Childbirth Group using the group filter "hm-preg". Systematic reviews of randomised trials of intrapartum interventions were eligible for inclusion. We excluded protocols for systematic reviews and systematic reviews that had been withdrawn. Outcome data were extracted independently from each included review by at least two review authors. Unique lists of salutogenically and non-salutogenically focused outcomes were established.

RESULTS

16 salutogenically-focused outcome categories were identified in 102 included reviews. Maternal satisfaction and breast feeding were reported most frequently. 49 non-salutogenically-focused outcome categories were identified in the 102 included reviews. Measures of neonatal morbidity were reported most frequently.

CONCLUSION

there is an absence of salutogenically-focused outcomes reported in intrapartum intervention-based research. We recommend the development of a core outcome data set of salutogenically-focused outcomes for intrapartum research.

Predicting birth outcomes: together, mother and health care provider know best

OBJECTIVE

To examine contributors to perceived risk in pregnancy and its utility in predicting lower birth weight and earlier delivery in conjunction with health care providers' assessment of obstetric risk.

METHODS

165 pregnant women at high (n=34) or low (n=131) obstetric risk completed assessments of perceived risk, stress, optimism, and health behaviors using well-validated instruments and measures designed for this study. Medical charts were abstracted for gestational age at delivery and birth weight.

RESULTS

40% of the sample perceived their risk status differently than their health care provider. Stress, poor reproductive history, provider assigned risk, and unhealthful behaviors were significant, independent predictors of perceived risk (R(2)=.37). The greatest difference in birth weight (p=.003) and gestational age (p=.05) was between women considered at low risk by both self and provider and women considered at high risk by both. Perceived risk improved prediction of adverse birth outcomes, especially lower birth weight, in women considered by providers to be at low risk.

CONCLUSION

Women's perceptions of risk are an important contributor to prediction of birth outcomes, but the combination of information from both a woman and her health care provider is superior. Incorporating women's perceptions into obstetric risk determination may help to reduce the number of women identified as high risk who subsequently have a normal birth outcome (false positives), and more importantly, the number of women considered to be at low risk who ultimately experience an adverse outcome (false negatives).

Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis

Background

Current recommendations do not support the use of continuous electronic fetal monitoring (EFM) for low risk women during labour, yet EFM remains widespread in clinical practice. Consideration of the views, perspectives and experiences of individuals directly concerned with EFM application may be beneficial for identifying barriers to and facilitators for implementing evidence-based maternity care. The aim of this paper is to offer insight and understanding, through systematic review and thematic analysis, of research into professionals’ views on fetal heart rate monitoring during labour.

Methods

Any study whose aim was to explore professional views of fetal monitoring during labour was considered eligible for inclusion. The electronic databases of MEDLINE (1966–2010), CINAHL (1980–2010), EMBASE (1974–2010) and Maternity and Infant Care: MIDIRS (1971–2010) were searched in January 2010 and an updated search was performed in March 2012. Quality appraisal of each included study was performed. Data extraction tables were developed to collect data. Data synthesis was by thematic analysis.

Results

Eleven studies, including 1,194 participants, were identified and included in this review. Four themes emerged from the data: 1) reassurance, 2) technology, 3) communication/education and 4) midwife by proxy.

Conclusion

This systematic review and thematic analysis offers insight into some of the views of professionals on fetal monitoring during labour. It provides evidence for the continuing use of EFM when caring for low-risk women, contrary to current research evidence. Further research to ascertain how some of these views might be addressed to ensure the provision of evidence-based care for women and their babies is recommended.