DOI: 10.1097/JPN.0000000000000026
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Reliability and Validity of an Instrument to Measure the Beliefs of Intrapartum Nurses Ellise D. Adams, PhD, CNM; Donna J. Sauls, PhD, RN ABSTRACT Intrapartum nurses assume a central role in the birth process and make decisions driven by a set of beliefs. Therefore, the purpose of this study was to develop a valid and reliable instrument to measure birth beliefs of intrapartum nurses related to birth practice. A total of 313 intrapartum nurses accessed this online, self-administered instrument over a 3-month period. The Theory of Planned Behavior guided development of the Intrapartum Nurses’ Beliefs Related to Birth Practice scale and provided a basis for the connection between beliefs and practice. This article describes the psychometric analysis of the instrument. Findings include a moderate, positive correlation with a similar instrument, a Cronbach α of 0.797, and 2 factors identifying belief systems. With further revision, this instrument may provide an accurate measure of the birth beliefs of intrapartum nurses. Key Words: instrument, intrapartum nursing, medicalized birth, normal birth
ntrapartum nurses play an important role in the birth process of hospitalized laboring women. It can be stated, then, that the practice of intrapartum nurses can positively or negatively influence the course of the birth process and birth outcomes. Birth practices, or actions implemented during the birth process, are
I
Author Affiliation: College of Nursing, The University of Alabama in Huntsville (Dr Adams); and Texas Woman’s University College of Nursing, Denton, Texas (Dr Sauls). Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Ellise D. Adams, PhD, CNM, College of Nursing, The University of Alabama in Huntsville, 301 Sparkman Dr, Huntsville, AL 35899 ([email protected]). Submitted for publication: January 6, 2014; accepted for publication: February 21, 2014. The Journal of Perinatal & Neonatal Nursing
influenced by a care provider’s beliefs about birth.1,2 Therefore, identification of beliefs, specifically those of intrapartum nurses, may lead to improvement in birth practices, the birth process, and subsequent outcomes for both the mother and the newborn. While the phenomenon of birth beliefs related to birth practice of intrapartum nurses was thought to exist, no quantitative instrument to measure the construct could be found. The purpose of this methodological study was to determine the reliability and validity of an instrument to measure the beliefs of intrapartum nurses.
CONCEPTUAL FRAMEWORK Beliefs of individuals and the collective beliefs of organizations guide actions.1 Beliefs are defined as the subjective probability that an object has a certain attribute.1 An individual’s beliefs are developed by (a) direct observation, (b) indirectly through the influence of others, and (c) through inference or experience.1,2 These beliefs can last over time, be forgotten, and developed new throughout the life span. According to the Theory of Planned Behavior, the intent to perform certain behaviors is influenced by behavioral beliefs, normative beliefs, and control beliefs.2 The birth practice of intrapartum nurses can be influenced, either facilitated or barred, by behavioral, normative, and control beliefs. Collective beliefs or beliefs of organizations or large systems also influence behaviors and practices.2 In 2008, an extensive report was written to determine the state of maternity care in the United States and to provide evidenced-based information about the best birth practices.3 This report compiled evidence from numerous high-quality research studies that demonstrate the health benefits of birth practices in hospitals in the United States, classified as physiologic or normal, and the detrimental effects to mothers and newborns of many routine interventions such as elective inductions, www.jpnnjournal.com
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epidural anesthesia, episiotomies, and cesarean birth. Major healthcare organizations have recognized the need to produce position statements and clinical guidelines to promote birth practices associated with healthy mothers and healthy newborns.4–9 These organizations provide descriptors of physiologic or normal birth practices that are associated with decreased pain medications in labor, decreased use of labor stimulants, enhanced maternal/newborn bonding, and improved exclusive breast-feeding rates.
REVIEW OF LITERATURE To guide this study and explore the connection between beliefs of intrapartum nurses, birth practices and birth outcomes, an extensive review of literature was conducted. Literature was reviewed related to categories of birth beliefs, beliefs of intrapartum nurses, and instruments to measure the beliefs of intrapartum nurses. Categories of birth beliefs Two categories of beliefs related to birth practice seem to exist: (1) medicalized birth and (2) normal birth.10–12 Most of the resources discovered, however, discussed these 2 categories of beliefs related to the practice of midwifery, thus providing the rationale to describe the birth beliefs of intrapartum nurses.13–16 Medicalized birth practices are technologically based, and the birth process is controlled rather than allowed to occur naturally.12,13,17 Normal birth practices are assistive of the natural process and are typically womanfocused.14–16 Often, medicalized birth practices are associated with negative birth outcomes such as low birth weight, surgical complications, and increased maternal and newborn morbidity and mortality.3,18–20 Normal birth practices are associated with positive outcomes for mothers and newborns such as enhanced bonding and exclusive breast-feeding.3,21 The concepts of medicalized birth and normal birth related to the practice of intrapartum nursing are outlined more completely elsewhere.10 Intrapartum nurses who hold beliefs related to either medicalized birth or normal birth might be more likely to implement certain birth practices associated with these belief systems related to birth practice. For example, several researchers3,11,22,23 identified a set of practices or labor support behaviors implemented by intrapartum nurses and associated with normal birth. Labor support is defined as the intentional human interaction between the intrapartum nurse and the laboring woman that assists with coping during labor
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and birth.22 Labor support behaviors are specific, nonpharmacologic nursing behaviors that are helpful to women during labor and birth and can be assigned into 4 categories: physical, emotional, advocacy, and instructional/informational.24 Labor support is closely associated with normal birth beliefs, and for the intrapartum nurse to implement these behaviors, a belief system related to normal birth must exist.
Beliefs of intrapartum nurses Evidence from the literature related to the birth practices of intrapartum nurses demonstrated an understanding of these providers’ beliefs related to birth practice. In a qualitative study, the researchers25 identified themes that hinder or guide the practice of intrapartum nursing care. Themes that hinder practice closely align with elements of medicalized birth and are typically technologybased. Themes that guide the practice of intrapartum nurses closely align with normal birth and are identified with nonpharmacologic care. For example, intrapartum nurses indicated that technology associated with medicalized birth was a barrier to normal birth. These researchers discovered that intrapartum nurses identified beliefs related to normal birth as critical in facilitating the best care for mothers and newborns. Beliefs also affect the quality of care provided by intrapartum nurses. In a meta-analysis26 to identify the elements of expert intrapartum care, themes associated with the practice of midwifery and nursing were identified. Themes included wisdom, skilled practice, and enacted vocation. Wisdom and skill are necessary practices of midwives and nurses. Enacted vocation includes beliefs in the physiological process and in a woman’s capacity to give birth, which are essential elements of normal birth. Normal birth beliefs were discovered in this study as vital to the facilitation of a safe birth process. To determine the perceived influence of intrapartum nurses on the type of birth, researchers27 used a qualitative process. The results of in-depth interviews determined that intrapartum nurses claimed to influence whether a woman has a vaginal or cesarean birth. This influence may be achieved by negotiating with the birth attendant for more time. Intrapartum nurses use knowledge related to the birth process and knowledge of the particular practices of birth attendants to exert influence. This study provides foundational insights about the impact of intrapartum nursing interventions on birth outcomes. Finally, a survey of 545 registered nurses was conducted to assess attitudes toward birth practices.28 These researchers assessed the influence of years of
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experience and the place of employment on attitudes or beliefs. There was only a weak relationship between experience and attitudes related to birth practices associated with medicalized birth. However, a significant relationship existed between intrapartum nurses who worked at tertiary hospitals (more typically associated with medicalized birth practices) and less positive attitudes about the importance of a vaginal birth and positive attitudes about epidural anesthesia. The beliefs and attitudes of intrapartum nurses appear to be influenced by the culture of birth at the practice site.
Instruments measuring similar concepts to nursing beliefs Because there were no quantitative instruments specifically measuring birth beliefs of intrapartum nurses, 4 instruments that measured intrapartum nurses’ attitudes related to labor support, a practice associated with normal birth and frequently implemented by intrapartum nurses, were reviewed. Labor support is an element of the practice of normal birth. However, assessment of attitudes and beliefs related to labor support cannot fully describe the birth beliefs of intrapartum nurses. The Labor Support Questionnaire 1 (LSQ1) is a self-administered paper-and-pencil instrument with 29 items.22 The items are rated on a 6-point Likert-type scale, with one additional item to rate the perception of the importance of labor support. The LSQ1 has been tested for reliability and validity in a number of different settings and demonstrates internal consistency reliability for the total scale (Cronbach α = 0.94) and construct validity tested with exploratory factor analysis (total amount of variance explained by each factor was 61%). This instrument appeared to be a valid and reliable measure of attitudes of intrapartum nurses regarding labor support. Its use provides knowledge about the practice of labor support among intrapartum nurses. A 14-item questionnaire, the Self-Efficacy Labor Support Scale, was developed to assess intrapartum nurses’ self-efficacy related to labor support and to describe factors assisting and preventing the implementation of labor support.23 The instrument used a 7-point Likerttype scale anchored by strongly disagree and strongly agree for 11 items to determine how confident the participants were providing labor support behaviors. Three items asked the participant to rate personal skill level in providing labor support behaviors. Construct validity of the Self-Efficacy Labor Support Scale was assessed using a known groups approach. Intrapartum nurses who worked full-time were expected to have a higher self-efficacy rating than intrapartum nurses who did not work full-time. The Cronbach α
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was used to measure internal consistency with a coefficient of 0.98. Stability was measured using a testretest method. The correlation coefficient for stability was 0.93. The Self-Efficacy Labor Support Scale was determined to be a valid and reliable instrument measuring the intrapartum nurses’ self-efficacy in providing labor support behaviors. The concept of self-efficacy is closely related to the Ajzen2 concept of perceived behavioral control. Self-efficacy is therefore related to a set of beliefs that propel intrapartum nurses toward a choice of certain birth practices but is only an element of these beliefs. The Nurses’ Views on Continuous Labor Support scale29 was based on the Theory of Planned Behavior and designed to examine the determinants of intrapartum nurses’ intentions to implement labor support. It used case scenarios and 24 items requiring the participant to indicate agreement or disagreement with statements related to labor support. The items were categorized according to the Theory of Planned Behavior. Higher scores on the Nurses’ Views on Continuous Labor Support scale indicated a stronger influence on the participant’s intention to perform labor support. Following multiple regression analysis, results related to the belief system of intrapartum nurses indicated that subjective norms or peers explained 88% of the variance in intention to provide labor support. This finding indicated that when the belief system of intrapartum nurses indicated a preference to perform certain behaviors, actually performing those behaviors may be thwarted by pressure to conform to a different belief system held by peers. The Labor Support Scale was developed in an effort to describe the frequency of labor support behaviors performed by intrapartum nurses and to determine the perceived helpfulness of these interventions.11 Two subscales, Frequency and Helpfulness, were developed. The α coefficient for the frequency section was .93 and for the helpfulness section was .95. The Labor Support Scale could identify elements of intrapartum nurses’ birth practice, especially the interventions of labor support.
MEASURING BIRTH BELIEFS OF INTRAPARTUM NURSES To provide a link between birth practices and beliefs related to birth practices, the Intrapartum Nurses’ Beliefs Related to Birth Practice (IPNBBP) scale was designed to measure the birth beliefs of intrapartum nurses related to their birth practice. Identification of beliefs associated with current birth practices of intrapartum nurses was necessary to accurately identify the influence
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of intrapartum nurses on the birth process and birth outcomes. The IPNBBP scale has 2 subscales: Medicalized Birth Beliefs and Normal Birth Beliefs. Conceptual definitions that guided this study are defined in Table 1. The IPNBBP scale was designed to be an online, self-administered instrument using a 6-point Likert-type scale to indicate beliefs related to birth practice.30 Total scores on the IPNBBP scale range from 36 to 216 points. Lower scores more closely align with medicalized birth beliefs, and higher scores more closely align with normal birth beliefs. Two open-ended questions allow intrapartum nurses to express beliefs related to birth practice in a narrative manner. Testing of the IPNBBP scale was guided by the following hypotheses: 1. The IPNBBP scale will demonstrate acceptable reliability by estimates supporting internal consistency. 2. The IPNBBP scale will demonstrate acceptable convergent validity when compared with the LSQ1.22 3. The IPNBBP scale will demonstrate acceptable construct validity.
METHODS Setting, population, and sample Participants accessed the instruments through an Internet link on any technology available to them. Participants for this study were intrapartum registered nurses currently working as staff nurses, clinical educators, or nurse managers in a hospital intrapartum unit in the United States with a minimum of 2 years’ experience
as an intrapartum nurse. Any age, gender, ethnicity, or academic preparation was acceptable. Participants had to be English-speaking. Permission from the Texas Woman’s University institutional review board was obtained for this study. Approximately 3500 potential participants were recruited to participate in the study via (a) a perinatal listserve, (b) recruitment at a national perinatal nursing conference, (c) use of a purchased, targeted mailing list from a perinatal nursing organization, (d) use of a state board e-mailing list, and (e) the use of snowball sampling. The process of snowball sampling allows targeted participants to invite potential participants to contribute to the study.32 Of this population, 365 individuals accessed the Internet link to the demographic section, IPNBBP scale, and LSQ1 during a 3-month time frame. Using the principle of consecutive sampling, the researchers reviewed data from the 365 entries for completeness and reduced eligible participants to 313.
Psychometric measurements The psychometric properties of a new instrument or scale require multiple testing phases. The main measures for a new instrument are reliability and validity. The reliability of an instrument is the degree of consistency with which it measures a variable. Without reliability, any conclusion drawn may be questionable. To establish reliability of the IPNBBP scale, the internal consistency method was used. Internal consistency of an instrument refers to the homogeneity of content, that is, the degree to which the individual items are interrelated or belong together.32 Internal consistency was estimated through item-total correlation, item-toitem correlation, and Cronbach α. The following criteria were used to assess the reliability: (a) item-total
Table 1. Conceptual definitions of the variables for the IPNBBP scale Variable
Subscales
Conceptual definition Core beliefs held by the intrapartum nurse related to the process of birth and birth practices during the birth process.4–10,30
Birth beliefs related to birth practice of the intrapartum nurse Medicalized Birth Beliefs
Normal Birth Beliefs
Beliefs that consider labor and birth to occur in a clinical environment and be continually monitored through technological means.10,30,31 Birth is viewed as a pathological process in which complications can be catastrophic and interventions must be implemented to prevent them.12 Beliefs that consider labor and birth to be a physiological life event that is unique to each laboring woman and not bound by time or boundaries.4–10,30
Abbreviations: IPNBBP, Intrapartum Nurses’ Beliefs Related to Birth Practice.
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correlation estimate greater than 0.3033 ; (b) item-to-item correlation estimates between 0.30 and 0.70 with half of the other items34 ; and (c) Cronbach α 0.70 or more.34 Validity refers to the degree to which an instrument measures what it is intended to measure. There are several methods that can be used to assess validity. To assess the validity of the IPNBBP scale, both convergent validity and construct validity were used. Convergence validity refers to the degree to which 2 different instruments or methods are able to measure constructs that are theoretically similar or related.32 The Pearson product-moment correlation test was used to determine convergent validity. In this test, the total mean score from the subcategory of normal birth beliefs is compared with total mean scores of the LSQ1. The LSQ1 and the IPNBBP scale are designed to measure theoretically related constructs. The LSQ1 measures personal attitudes, subjective norms, perceived behavioral control, and behavioral intention related to labor support, an intervention closely related to the belief system of normal birth. Higher scores on the LSQ1 would indicate that the participant perceived labor support behaviors to be important in his or her birth practice. While higher scores on the Normal Birth Beliefs, a subscale of the IPNBBP scale, would indicate a belief system closely related to normal birth, including beliefs related to the importance of labor support. For convergent validity, the correlation should be positive and substantial.35 Construct validity refers to the extent to which an instrument can be said to measure a theoretical concept or construct. Construct validity is estimated using factor analysis. Factor analysis is a family of statistical techniques designed to identify factors or dimensions that make up a construct. Factor analysis examines the degree to which clusters of intercorrelated variables may represent fewer underlying, more basic, hypothetical variables or dimensions.33 Construct validity or the degree to which the IPNBBP scale measures the birth beliefs of intrapartum nurses32 was obtained through exploratory factor analysis using principal components analysis (PCA) with oblique rotation. The 4 criteria used to assess data were (a) eigenvalues more than 1.00, (b) components within the sharp descent before leveling on a scree plot, (c) factors accounting for 70% of the total variance, and (d) those with an assessment of model of fit.35 Prior to the use of factor analysis, data must be assessed for suitability by evaluating sample size and strength of the relationship among items. Sample size (N = 313) was adequate both in total cases and in the case-to-item ratio of 5 to 1.33 The strength of the relationship among items was assessed using the KaiserMeyer-Olkin (0.82) and Bartlett tests of sphericity (P < .0005) and was found to be suitable. The Journal of Perinatal & Neonatal Nursing
RESULTS Description of the sample Of the 313 intrapartum nurses, 308 (98.4%) were females and 5 (1.6%) were males. Participants ranged in age from 23 to 68 years, with a mean age of 45.5 years (SD = 11.05). There were 287 (91.7%) Whites, 10 (3.2%) Hispanics/Latinos, and 9 (2.9%) African Americans. Experience level as an intrapartum nurse ranged from 2 to 46 years, with a mean experience level of 17.3 years (SD = 10.68). Nursing education ranged from a diploma to a doctorate in nursing, with the following distribution: diploma 36 (11.5%), associate degree of nursing 114 (36.4%), bachelor of science in nursing 164 (52.4%), master of science in nursing 42 (13.4%), and doctorate in nursing 2 (0.6%). Only 10.2% of the sample did not have some type of certification related to the role of intrapartum nursing. Participants were able to choose multiple descriptors of their employing agency. One hundred eighty nurses (57.5%) worked in a community hospital, 70 (22.4%) worked in a Magnet hospital, and 53 (16.9%) worked in a private hospital. The hospitals that employed these intrapartum nurses were more frequently listed as urban (70.6%) and had more than 2000 births annually (41.2%). More than 100 participants (34.5%) were employed in a facility with a nonmedically indicated induction rate of 10% or less, whereas 68 (21.7%) identified a rate of 21% to 30%. At facilities employing 42.2% of nurses, the cesarean birth rate was 21% to 30%. Three hundred seven nurses (98.1%) worked with obstetricians, whereas 189 (60.4%) worked with certified nurse-midwives. Additional sample demographics are presented in Table 2. Reliability The criteria used to assess item-total correlation were more than 0.30 to 0.50. Thirteen of the 36 items did not meet these criteria. Items considered for deletion from the IPNBBP scale only increased the estimate of α by .10. The items of the IPNBBP scale demonstrated weak correlation with other items. Twenty-three of the items demonstrated correlations of 0.30 to 0.70 with at least 50% of the other items. The Cronbach α for the total scale of the IPNBBP scale was 0.797, above the acceptable level of a new instrument.34 Validity
Convergent validity Using Pearson product-moment correlation coefficient, a medium, positive correlation between these 2 measures was identified (r = 0.48; P< .0005).36 There is www.jpnnjournal.com
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Table 2. Demographic description of the sample for the psychometric properties of an instrument measuring intrapartum nurses’ beliefs related to birth practice Variable category Personal birth experience
Current work environment
Variable
Type of birth Vaginal birth Forceps delivery Vacuum extraction Cesarean birth Never given birth Place of birth Hospital Home Birth center Nurse-patient staffing ratio 1:1 1:2 1:3 1:4 1:>4
therefore an indication that the IPNBBP scale measures constructs associated with normal birth as does the LSQ1.
Construct validity Principal components analysis revealed 2 components with eigenvalues exceeding 1, explaining 16.8% and 8.3% of the variance or a total of 25.1%. These 2 components were confirmed by inspection of the scree plot. Oblique rotation was performed with 15 items loading on factor 1 and 13 items loading on factor 2. Eight items did not load on either factor, indicating that these items may need to be deleted from the instrument. Items in factor 1 were related to medicalized birth beliefs, and items in factor 2 were related to normal birth beliefs, supporting use of these 2 factors as subscales. Following PCA, the resulting subscales were evaluated using the Cronbach α, resulting in 0.82 for the Medicalized Birth Beliefs subscale and 0.78 for the Normal Birth Beliefs subscale.
DISCUSSION Determining the psychometric properties of a new instrument requires multiple phases.34 Reliability, as assessed by reviewing internal consistency, demonstrated a Cronbach α of 0.797, above the value expected for a new instrument.34 Item-to-item correlations demonstrated that most items did not meet the criteria of 0.30 to 0.70 of 50% of the other items. This may be explained by the fact that the IPNBBP scale was designed to measure 2 opposing concepts: medicalized birth beliefs and normal birth beliefs. Weak correlations would 132
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Frequency (N = 313)
%
209 22 20 71 53
66.8 7 6.4 22.7 16.9
255 9 4
81.5 2.9 1.3
106 190 12 2 3
33.9 60.7 3.8 0.6 1
therefore be expected because items should measure distinctly different concepts. While a medium, positive correlation was obtained, strong correlations between the IPNBBP scale and the LSQ1 would be more indicative of instruments measuring the same construct. These results might indicate that the LSQ1 measures only a subset of the birth beliefs measured by the IPNBBP scale. This finding was expected as no quantitative instrument was discovered that measured the birth beliefs of intrapartum nurses as categorized as medical birth and normal birth. The process of factor analysis improved understanding of the grouping of items into similar concepts. The IPNBBP scale was designed to measure the birth beliefs of intrapartum nurses, and items were written to distinguish between a medicalized birth belief system and a normal birth belief system. The factor analysis procedure determined that 28 of the items fit statistically into 2 factors. These 2 groups of items created the 2, previously hypothesized subscales of Medicalized Birth Beliefs and Normal Birth Beliefs. Following factor analysis, the Cronbach α for these 2 scales indicate internal consistency. Because there were 8 items that did not fit in either factor, it is believed that these items need to be carefully reassessed. It should be noted that these 8 items also did not meet the criteria of item-total correlation. Therefore, deletion of these items is appropriate. The resulting IPNBBP scale would now become a 28-item instrument. Limitations Limitations to this psychometric study need to be identified. Completion of the 36-item IPNBBP scale and the April/June 2014
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29-item LSQ1 required a considerable time commitment from each participant. The demographic section, also lengthy, added to this time commitment. Twenty-five participants did not complete a significant portion of the required instrument and had to be deleted from the database. An additional 27 did not complete the LSQ1, which was the last instrument. The nature of the sampling pool, a perinatal listserve, comprising nursing leaders, membership in a perinatal organization, and convention attendees, might not have been representative of the entire population of intrapartum nurses. The resulting sample contained a majority of White intrapartum nurses who were highly educated and therefore limits generalizability of the findings.
Implications for future research A primary goal related to the development of the IPNBBP scale was refinement of the items and continued testing for validity and reliability. Following this methodological study, editing and deleting of items, reevaluation of reliability and validity, and the use of factor analysis are indicated to improve the instrument. Stability was not assessed in this study and should be reviewed by test-retest methods. The instrument should be tested in a variety of settings such as intrapartum units in a variety of geographic regions. Using the IPNBBP scale in clinical settings would address the stated limitation of representation of the entire intrapartum nursing population. Following revision and refinement of the IPNBBP scale, the instrument can be used to provide thorough descriptions of specific beliefs of intrapartum nurses. Because the IPNBBP scale assesses the birth beliefs of intrapartum nurses in both qualitative and quantitative manners, the rich data provided will assist nurse scholars to develop descriptions of the epistemology and philosophy of intrapartum nurses. Data could also assist in the development of middle-range theories linking intrapartum nursing beliefs and maternal and newborn outcomes.
Implications for clinical practice The IPNBBP scale could be used by nurse managers to assess the birth beliefs of current and potential intrapartum nurses. Managers may desire to implement normal birth practices in an effort to improve birth outcomes. Assessment of birth beliefs would provide assistance in planning continuing education for hospital-based nurses. Nurse educators could also use the IPNBBP scale as a self-assessment tool for nursing students in maternal care courses. Self-assessment of beliefs and a study of the relationship of beliefs, birth The Journal of Perinatal & Neonatal Nursing
practice, and birth outcomes could assist in educating future intrapartum nurses.
CONCLUSION The IPNBBP scale could be a valuable instrument to identify the impact of intrapartum nurses’ birth beliefs and birth practices on birth outcomes. By identifying birth beliefs and categorizing them as medicalized birth beliefs or normal birth beliefs, staff nurses, nurse managers, and nurse educators could adjust practices to positively affect outcomes. By understanding the connection between birth beliefs and practices, intrapartum nursing practice can then be refined to assist in reversing this trend of medicalized birth practices in the United States. References 1. Fischbein M, Ajzen I. Predicting and Changing Behavior: The Reasoned Action Approach. New York, NY: Psychology Press; 2010. 2. Ajzen I. Organizational Behavior and Human Decision Processes. New York, NY: Academic Press; 2005. 3. Sakala C, Corry M. Evidenced-Based Maternity Care: What It Is and What It Can Achieve. New York, NY: Milbank Memorial Fund; 2008. 4. Gould D. Normal labor: a concept analysis. J Adv Nurs. 2000;31(2):418–427. 5. World Health Organization. Care in Normal Birth: A Practical Guide. Geneva, Switzerland: Department of Reproductive Health and Research Switzerland, World Health Organization; 1996. http://www.who.int. Accessed July 27, 2012. 6. American College of Nurse-Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. Washington, DC: American College of NurseMidwives; 2012. http://www.midwife.org. Accessed July 27, 2012. 7. International Confederation of Midwives. Position Statement: Keeping Birth Normal. The Hague, the Netherlands: International Confederation of Midwives; 2008. http://www. internationalmidwives.org. Accessed February 20, 2014. 8. Society of Obstetricians and Gynaecologists of Canada. Joint policy statement on normal childbirth. JOGC. 2008;221:1163– 1165. 9. Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, and The National Childbirth Trust. Making Normal Birth a Reality: Consensus Statement From the Maternity Care Working Party, Our Shared Views About the Need to Recognise, Facilitate and Audit Normal Birth. London, United Kingdom: The National Childbirth Trust; 2007. www.nct.org.uk. Accessed July 27, 2012. 10. Adams E. The Psychometric Properties of an Instrument Measuring Intrapartum Nurses’ Beliefs Related to Birth Practice [e-book]. Denton, TX: Texas Woman’s University; 2012. 11. Sleutel M. Development and testing of the labor support scale. J Nurs Meas. 2002;10:249–262. 12. Davis-Floyd R, Sargent C, eds. Childbirth and Authoritative Knowledge: Cross Cultural Perspectives. Berkley, CA: University of California Press; 1996. 13. Downe S, ed. Normal Childbirth: Evidence and Debate. 2nd ed. Edinburgh, England: Churchill Livingstone; 2008. www.jpnnjournal.com
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14. Blaaka G, Schauer T. Doing midwifery between different belief systems. Midwifery. 2008;24:344–352. 15. Guiver D. The epistemological foundation of midwiferyled care that facilitates normal birth. Midwives. 2004;2: 28–34. 16. Kennedy HP, Grant J, Watson C, Shaw-Battista J, Sandall J. Normalizing birth in England: a qualitative study. J Midwifery Womens Health. 2010;55:262–269. 17. Cahill H. Male appropriation and medicalization of childbirth: an historical analysis. J Adv Nurs. 2001;33:334–342. 18. Davidoff MJ, Dias T, Damus R, et al. Changes in the gestational age distribution among U.S. singleton births: impact on rates of late preterm birth, 1992 to 2002. Semin Perinatol. 2006;30:8–15. 19. Engle WA. A recommendation for the definition of “late preterm” (near-term) and the birth-weight gestational age classification system. Semin Perinatol. 2006;30:2–7. 20. Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol. 2007;109:669– 677. 21. Crenshaw JT, Cadwell K, Brimdyr K, et al. Use of a videoethnographic model (PRECESS immersion method) to improve skin-to-skin care and breast-feeding rates. Breastfeed Med. 2012;7:69–78. 22. Sauls D. The labor support questionnaire: development and psychometric analysis. J Nurs Meas. 2004;12:123– 132. 23. Davies B, Hodnett E. Labor support: nurses’ self-efficacy and views about factors influencing implementation. J Obstet Gynecol Neonatal Nurs. 2002;31:48–55. 24. Adams ED, Bianchi AL. A practical approach to labor support. J Obstet Gynecol Neonatal Nurs. 2008;37:106–115.
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25. Sleutel M, Schultz S, Wyble K. Nurses’ views of factors that help and hinder their intrapartum care. J Obstet Gynecol Neonatal Nurs. 2007;36:203–211. 26. Downe S, Simpson L, Trafford K. Expert intrapartum maternity care: a meta-synthesis. J Adv Nurs. 2006;57:127–140. 27. Edmonds JK, Jones EJ. Intrapartum nurses’ perceived influence on delivery mode decisions and outcomes. J Obstet Gynecol Neonatal Nurs. 2013;427:3–11. 28. Liva SJ, Hall WA, Klein MC, Wong ST. Factors associated with differences in Canadian perinatal nurses’ attitudes toward birth practices. J Obstet Gynecol Neonatal Nurs. 2012;41:761– 773. 29. Payant L, Davies B, Graham I, Peterson W, Clinch J. Nurses’ intentions to provide continuous labor support to women. J Obstet Gynecol Neonatal Nurs. 2008;37:405–414. 30. Adams E, Sauls D. Development of the Intrapartum Nurses’ Beliefs Related To Birth Practice scale. J Nurs Meas. 2014;22:1–10. 31. Fahy K, Parratt J. Birth territory: a theory of midwifery practice. Women Birth. 2006;19:45–50. 32. Polit D, Beck C. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. 33. Tabachnick B, Fidell L. Using Multivariate Statistics. 5th ed. Boston, MA: Pearson Education; 2007. 34. DeVellis R. Scale Development: Theory and Applications. 3rd ed. Los Angeles, CA: Sage; 2012. 35. Pallant J. SPSS Survival Manual: A Step-by-Step Guide to Data Analysis Using SPSS Version 15. 3rd ed. Maidenhead, Berkshire, England: Open University Press; 2007. 36. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
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Reliability and Validity of an Instrument to Measure the Beliefs of Intrapartum Nurses Ellise D. Adams, PhD, CNM; Donna J. Sauls, PhD, RN ABSTRACT Intrapartum nurses assume a central role in the birth process and make decisions driven by a set of beliefs. Therefore, the purpose of this study was to develop a valid and reliable instrument to measure birth beliefs of intrapartum nurses related to birth practice. A total of 313 intrapartum nurses accessed this online, self-administered instrument over a 3-month period. The Theory of Planned Behavior guided development of the Intrapartum Nurses’ Beliefs Related to Birth Practice scale and provided a basis for the connection between beliefs and practice. This article describes the psychometric analysis of the instrument. Findings include a moderate, positive correlation with a similar instrument, a Cronbach α of 0.797, and 2 factors identifying belief systems. With further revision, this instrument may provide an accurate measure of the birth beliefs of intrapartum nurses. Key Words: instrument, intrapartum nursing, medicalized birth, normal birth
ntrapartum nurses play an important role in the birth process of hospitalized laboring women. It can be stated, then, that the practice of intrapartum nurses can positively or negatively influence the course of the birth process and birth outcomes. Birth practices, or actions implemented during the birth process, are
I
Author Affiliation: College of Nursing, The University of Alabama in Huntsville (Dr Adams); and Texas Woman’s University College of Nursing, Denton, Texas (Dr Sauls). Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Ellise D. Adams, PhD, CNM, College of Nursing, The University of Alabama in Huntsville, 301 Sparkman Dr, Huntsville, AL 35899 ([email protected]). Submitted for publication: January 6, 2014; accepted for publication: February 21, 2014. The Journal of Perinatal & Neonatal Nursing
influenced by a care provider’s beliefs about birth.1,2 Therefore, identification of beliefs, specifically those of intrapartum nurses, may lead to improvement in birth practices, the birth process, and subsequent outcomes for both the mother and the newborn. While the phenomenon of birth beliefs related to birth practice of intrapartum nurses was thought to exist, no quantitative instrument to measure the construct could be found. The purpose of this methodological study was to determine the reliability and validity of an instrument to measure the beliefs of intrapartum nurses.
CONCEPTUAL FRAMEWORK Beliefs of individuals and the collective beliefs of organizations guide actions.1 Beliefs are defined as the subjective probability that an object has a certain attribute.1 An individual’s beliefs are developed by (a) direct observation, (b) indirectly through the influence of others, and (c) through inference or experience.1,2 These beliefs can last over time, be forgotten, and developed new throughout the life span. According to the Theory of Planned Behavior, the intent to perform certain behaviors is influenced by behavioral beliefs, normative beliefs, and control beliefs.2 The birth practice of intrapartum nurses can be influenced, either facilitated or barred, by behavioral, normative, and control beliefs. Collective beliefs or beliefs of organizations or large systems also influence behaviors and practices.2 In 2008, an extensive report was written to determine the state of maternity care in the United States and to provide evidenced-based information about the best birth practices.3 This report compiled evidence from numerous high-quality research studies that demonstrate the health benefits of birth practices in hospitals in the United States, classified as physiologic or normal, and the detrimental effects to mothers and newborns of many routine interventions such as elective inductions, www.jpnnjournal.com
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epidural anesthesia, episiotomies, and cesarean birth. Major healthcare organizations have recognized the need to produce position statements and clinical guidelines to promote birth practices associated with healthy mothers and healthy newborns.4–9 These organizations provide descriptors of physiologic or normal birth practices that are associated with decreased pain medications in labor, decreased use of labor stimulants, enhanced maternal/newborn bonding, and improved exclusive breast-feeding rates.
REVIEW OF LITERATURE To guide this study and explore the connection between beliefs of intrapartum nurses, birth practices and birth outcomes, an extensive review of literature was conducted. Literature was reviewed related to categories of birth beliefs, beliefs of intrapartum nurses, and instruments to measure the beliefs of intrapartum nurses. Categories of birth beliefs Two categories of beliefs related to birth practice seem to exist: (1) medicalized birth and (2) normal birth.10–12 Most of the resources discovered, however, discussed these 2 categories of beliefs related to the practice of midwifery, thus providing the rationale to describe the birth beliefs of intrapartum nurses.13–16 Medicalized birth practices are technologically based, and the birth process is controlled rather than allowed to occur naturally.12,13,17 Normal birth practices are assistive of the natural process and are typically womanfocused.14–16 Often, medicalized birth practices are associated with negative birth outcomes such as low birth weight, surgical complications, and increased maternal and newborn morbidity and mortality.3,18–20 Normal birth practices are associated with positive outcomes for mothers and newborns such as enhanced bonding and exclusive breast-feeding.3,21 The concepts of medicalized birth and normal birth related to the practice of intrapartum nursing are outlined more completely elsewhere.10 Intrapartum nurses who hold beliefs related to either medicalized birth or normal birth might be more likely to implement certain birth practices associated with these belief systems related to birth practice. For example, several researchers3,11,22,23 identified a set of practices or labor support behaviors implemented by intrapartum nurses and associated with normal birth. Labor support is defined as the intentional human interaction between the intrapartum nurse and the laboring woman that assists with coping during labor
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and birth.22 Labor support behaviors are specific, nonpharmacologic nursing behaviors that are helpful to women during labor and birth and can be assigned into 4 categories: physical, emotional, advocacy, and instructional/informational.24 Labor support is closely associated with normal birth beliefs, and for the intrapartum nurse to implement these behaviors, a belief system related to normal birth must exist.
Beliefs of intrapartum nurses Evidence from the literature related to the birth practices of intrapartum nurses demonstrated an understanding of these providers’ beliefs related to birth practice. In a qualitative study, the researchers25 identified themes that hinder or guide the practice of intrapartum nursing care. Themes that hinder practice closely align with elements of medicalized birth and are typically technologybased. Themes that guide the practice of intrapartum nurses closely align with normal birth and are identified with nonpharmacologic care. For example, intrapartum nurses indicated that technology associated with medicalized birth was a barrier to normal birth. These researchers discovered that intrapartum nurses identified beliefs related to normal birth as critical in facilitating the best care for mothers and newborns. Beliefs also affect the quality of care provided by intrapartum nurses. In a meta-analysis26 to identify the elements of expert intrapartum care, themes associated with the practice of midwifery and nursing were identified. Themes included wisdom, skilled practice, and enacted vocation. Wisdom and skill are necessary practices of midwives and nurses. Enacted vocation includes beliefs in the physiological process and in a woman’s capacity to give birth, which are essential elements of normal birth. Normal birth beliefs were discovered in this study as vital to the facilitation of a safe birth process. To determine the perceived influence of intrapartum nurses on the type of birth, researchers27 used a qualitative process. The results of in-depth interviews determined that intrapartum nurses claimed to influence whether a woman has a vaginal or cesarean birth. This influence may be achieved by negotiating with the birth attendant for more time. Intrapartum nurses use knowledge related to the birth process and knowledge of the particular practices of birth attendants to exert influence. This study provides foundational insights about the impact of intrapartum nursing interventions on birth outcomes. Finally, a survey of 545 registered nurses was conducted to assess attitudes toward birth practices.28 These researchers assessed the influence of years of
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experience and the place of employment on attitudes or beliefs. There was only a weak relationship between experience and attitudes related to birth practices associated with medicalized birth. However, a significant relationship existed between intrapartum nurses who worked at tertiary hospitals (more typically associated with medicalized birth practices) and less positive attitudes about the importance of a vaginal birth and positive attitudes about epidural anesthesia. The beliefs and attitudes of intrapartum nurses appear to be influenced by the culture of birth at the practice site.
Instruments measuring similar concepts to nursing beliefs Because there were no quantitative instruments specifically measuring birth beliefs of intrapartum nurses, 4 instruments that measured intrapartum nurses’ attitudes related to labor support, a practice associated with normal birth and frequently implemented by intrapartum nurses, were reviewed. Labor support is an element of the practice of normal birth. However, assessment of attitudes and beliefs related to labor support cannot fully describe the birth beliefs of intrapartum nurses. The Labor Support Questionnaire 1 (LSQ1) is a self-administered paper-and-pencil instrument with 29 items.22 The items are rated on a 6-point Likert-type scale, with one additional item to rate the perception of the importance of labor support. The LSQ1 has been tested for reliability and validity in a number of different settings and demonstrates internal consistency reliability for the total scale (Cronbach α = 0.94) and construct validity tested with exploratory factor analysis (total amount of variance explained by each factor was 61%). This instrument appeared to be a valid and reliable measure of attitudes of intrapartum nurses regarding labor support. Its use provides knowledge about the practice of labor support among intrapartum nurses. A 14-item questionnaire, the Self-Efficacy Labor Support Scale, was developed to assess intrapartum nurses’ self-efficacy related to labor support and to describe factors assisting and preventing the implementation of labor support.23 The instrument used a 7-point Likerttype scale anchored by strongly disagree and strongly agree for 11 items to determine how confident the participants were providing labor support behaviors. Three items asked the participant to rate personal skill level in providing labor support behaviors. Construct validity of the Self-Efficacy Labor Support Scale was assessed using a known groups approach. Intrapartum nurses who worked full-time were expected to have a higher self-efficacy rating than intrapartum nurses who did not work full-time. The Cronbach α
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was used to measure internal consistency with a coefficient of 0.98. Stability was measured using a testretest method. The correlation coefficient for stability was 0.93. The Self-Efficacy Labor Support Scale was determined to be a valid and reliable instrument measuring the intrapartum nurses’ self-efficacy in providing labor support behaviors. The concept of self-efficacy is closely related to the Ajzen2 concept of perceived behavioral control. Self-efficacy is therefore related to a set of beliefs that propel intrapartum nurses toward a choice of certain birth practices but is only an element of these beliefs. The Nurses’ Views on Continuous Labor Support scale29 was based on the Theory of Planned Behavior and designed to examine the determinants of intrapartum nurses’ intentions to implement labor support. It used case scenarios and 24 items requiring the participant to indicate agreement or disagreement with statements related to labor support. The items were categorized according to the Theory of Planned Behavior. Higher scores on the Nurses’ Views on Continuous Labor Support scale indicated a stronger influence on the participant’s intention to perform labor support. Following multiple regression analysis, results related to the belief system of intrapartum nurses indicated that subjective norms or peers explained 88% of the variance in intention to provide labor support. This finding indicated that when the belief system of intrapartum nurses indicated a preference to perform certain behaviors, actually performing those behaviors may be thwarted by pressure to conform to a different belief system held by peers. The Labor Support Scale was developed in an effort to describe the frequency of labor support behaviors performed by intrapartum nurses and to determine the perceived helpfulness of these interventions.11 Two subscales, Frequency and Helpfulness, were developed. The α coefficient for the frequency section was .93 and for the helpfulness section was .95. The Labor Support Scale could identify elements of intrapartum nurses’ birth practice, especially the interventions of labor support.
MEASURING BIRTH BELIEFS OF INTRAPARTUM NURSES To provide a link between birth practices and beliefs related to birth practices, the Intrapartum Nurses’ Beliefs Related to Birth Practice (IPNBBP) scale was designed to measure the birth beliefs of intrapartum nurses related to their birth practice. Identification of beliefs associated with current birth practices of intrapartum nurses was necessary to accurately identify the influence
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of intrapartum nurses on the birth process and birth outcomes. The IPNBBP scale has 2 subscales: Medicalized Birth Beliefs and Normal Birth Beliefs. Conceptual definitions that guided this study are defined in Table 1. The IPNBBP scale was designed to be an online, self-administered instrument using a 6-point Likert-type scale to indicate beliefs related to birth practice.30 Total scores on the IPNBBP scale range from 36 to 216 points. Lower scores more closely align with medicalized birth beliefs, and higher scores more closely align with normal birth beliefs. Two open-ended questions allow intrapartum nurses to express beliefs related to birth practice in a narrative manner. Testing of the IPNBBP scale was guided by the following hypotheses: 1. The IPNBBP scale will demonstrate acceptable reliability by estimates supporting internal consistency. 2. The IPNBBP scale will demonstrate acceptable convergent validity when compared with the LSQ1.22 3. The IPNBBP scale will demonstrate acceptable construct validity.
METHODS Setting, population, and sample Participants accessed the instruments through an Internet link on any technology available to them. Participants for this study were intrapartum registered nurses currently working as staff nurses, clinical educators, or nurse managers in a hospital intrapartum unit in the United States with a minimum of 2 years’ experience
as an intrapartum nurse. Any age, gender, ethnicity, or academic preparation was acceptable. Participants had to be English-speaking. Permission from the Texas Woman’s University institutional review board was obtained for this study. Approximately 3500 potential participants were recruited to participate in the study via (a) a perinatal listserve, (b) recruitment at a national perinatal nursing conference, (c) use of a purchased, targeted mailing list from a perinatal nursing organization, (d) use of a state board e-mailing list, and (e) the use of snowball sampling. The process of snowball sampling allows targeted participants to invite potential participants to contribute to the study.32 Of this population, 365 individuals accessed the Internet link to the demographic section, IPNBBP scale, and LSQ1 during a 3-month time frame. Using the principle of consecutive sampling, the researchers reviewed data from the 365 entries for completeness and reduced eligible participants to 313.
Psychometric measurements The psychometric properties of a new instrument or scale require multiple testing phases. The main measures for a new instrument are reliability and validity. The reliability of an instrument is the degree of consistency with which it measures a variable. Without reliability, any conclusion drawn may be questionable. To establish reliability of the IPNBBP scale, the internal consistency method was used. Internal consistency of an instrument refers to the homogeneity of content, that is, the degree to which the individual items are interrelated or belong together.32 Internal consistency was estimated through item-total correlation, item-toitem correlation, and Cronbach α. The following criteria were used to assess the reliability: (a) item-total
Table 1. Conceptual definitions of the variables for the IPNBBP scale Variable
Subscales
Conceptual definition Core beliefs held by the intrapartum nurse related to the process of birth and birth practices during the birth process.4–10,30
Birth beliefs related to birth practice of the intrapartum nurse Medicalized Birth Beliefs
Normal Birth Beliefs
Beliefs that consider labor and birth to occur in a clinical environment and be continually monitored through technological means.10,30,31 Birth is viewed as a pathological process in which complications can be catastrophic and interventions must be implemented to prevent them.12 Beliefs that consider labor and birth to be a physiological life event that is unique to each laboring woman and not bound by time or boundaries.4–10,30
Abbreviations: IPNBBP, Intrapartum Nurses’ Beliefs Related to Birth Practice.
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correlation estimate greater than 0.3033 ; (b) item-to-item correlation estimates between 0.30 and 0.70 with half of the other items34 ; and (c) Cronbach α 0.70 or more.34 Validity refers to the degree to which an instrument measures what it is intended to measure. There are several methods that can be used to assess validity. To assess the validity of the IPNBBP scale, both convergent validity and construct validity were used. Convergence validity refers to the degree to which 2 different instruments or methods are able to measure constructs that are theoretically similar or related.32 The Pearson product-moment correlation test was used to determine convergent validity. In this test, the total mean score from the subcategory of normal birth beliefs is compared with total mean scores of the LSQ1. The LSQ1 and the IPNBBP scale are designed to measure theoretically related constructs. The LSQ1 measures personal attitudes, subjective norms, perceived behavioral control, and behavioral intention related to labor support, an intervention closely related to the belief system of normal birth. Higher scores on the LSQ1 would indicate that the participant perceived labor support behaviors to be important in his or her birth practice. While higher scores on the Normal Birth Beliefs, a subscale of the IPNBBP scale, would indicate a belief system closely related to normal birth, including beliefs related to the importance of labor support. For convergent validity, the correlation should be positive and substantial.35 Construct validity refers to the extent to which an instrument can be said to measure a theoretical concept or construct. Construct validity is estimated using factor analysis. Factor analysis is a family of statistical techniques designed to identify factors or dimensions that make up a construct. Factor analysis examines the degree to which clusters of intercorrelated variables may represent fewer underlying, more basic, hypothetical variables or dimensions.33 Construct validity or the degree to which the IPNBBP scale measures the birth beliefs of intrapartum nurses32 was obtained through exploratory factor analysis using principal components analysis (PCA) with oblique rotation. The 4 criteria used to assess data were (a) eigenvalues more than 1.00, (b) components within the sharp descent before leveling on a scree plot, (c) factors accounting for 70% of the total variance, and (d) those with an assessment of model of fit.35 Prior to the use of factor analysis, data must be assessed for suitability by evaluating sample size and strength of the relationship among items. Sample size (N = 313) was adequate both in total cases and in the case-to-item ratio of 5 to 1.33 The strength of the relationship among items was assessed using the KaiserMeyer-Olkin (0.82) and Bartlett tests of sphericity (P < .0005) and was found to be suitable. The Journal of Perinatal & Neonatal Nursing
RESULTS Description of the sample Of the 313 intrapartum nurses, 308 (98.4%) were females and 5 (1.6%) were males. Participants ranged in age from 23 to 68 years, with a mean age of 45.5 years (SD = 11.05). There were 287 (91.7%) Whites, 10 (3.2%) Hispanics/Latinos, and 9 (2.9%) African Americans. Experience level as an intrapartum nurse ranged from 2 to 46 years, with a mean experience level of 17.3 years (SD = 10.68). Nursing education ranged from a diploma to a doctorate in nursing, with the following distribution: diploma 36 (11.5%), associate degree of nursing 114 (36.4%), bachelor of science in nursing 164 (52.4%), master of science in nursing 42 (13.4%), and doctorate in nursing 2 (0.6%). Only 10.2% of the sample did not have some type of certification related to the role of intrapartum nursing. Participants were able to choose multiple descriptors of their employing agency. One hundred eighty nurses (57.5%) worked in a community hospital, 70 (22.4%) worked in a Magnet hospital, and 53 (16.9%) worked in a private hospital. The hospitals that employed these intrapartum nurses were more frequently listed as urban (70.6%) and had more than 2000 births annually (41.2%). More than 100 participants (34.5%) were employed in a facility with a nonmedically indicated induction rate of 10% or less, whereas 68 (21.7%) identified a rate of 21% to 30%. At facilities employing 42.2% of nurses, the cesarean birth rate was 21% to 30%. Three hundred seven nurses (98.1%) worked with obstetricians, whereas 189 (60.4%) worked with certified nurse-midwives. Additional sample demographics are presented in Table 2. Reliability The criteria used to assess item-total correlation were more than 0.30 to 0.50. Thirteen of the 36 items did not meet these criteria. Items considered for deletion from the IPNBBP scale only increased the estimate of α by .10. The items of the IPNBBP scale demonstrated weak correlation with other items. Twenty-three of the items demonstrated correlations of 0.30 to 0.70 with at least 50% of the other items. The Cronbach α for the total scale of the IPNBBP scale was 0.797, above the acceptable level of a new instrument.34 Validity
Convergent validity Using Pearson product-moment correlation coefficient, a medium, positive correlation between these 2 measures was identified (r = 0.48; P< .0005).36 There is www.jpnnjournal.com
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Table 2. Demographic description of the sample for the psychometric properties of an instrument measuring intrapartum nurses’ beliefs related to birth practice Variable category Personal birth experience
Current work environment
Variable
Type of birth Vaginal birth Forceps delivery Vacuum extraction Cesarean birth Never given birth Place of birth Hospital Home Birth center Nurse-patient staffing ratio 1:1 1:2 1:3 1:4 1:>4
therefore an indication that the IPNBBP scale measures constructs associated with normal birth as does the LSQ1.
Construct validity Principal components analysis revealed 2 components with eigenvalues exceeding 1, explaining 16.8% and 8.3% of the variance or a total of 25.1%. These 2 components were confirmed by inspection of the scree plot. Oblique rotation was performed with 15 items loading on factor 1 and 13 items loading on factor 2. Eight items did not load on either factor, indicating that these items may need to be deleted from the instrument. Items in factor 1 were related to medicalized birth beliefs, and items in factor 2 were related to normal birth beliefs, supporting use of these 2 factors as subscales. Following PCA, the resulting subscales were evaluated using the Cronbach α, resulting in 0.82 for the Medicalized Birth Beliefs subscale and 0.78 for the Normal Birth Beliefs subscale.
DISCUSSION Determining the psychometric properties of a new instrument requires multiple phases.34 Reliability, as assessed by reviewing internal consistency, demonstrated a Cronbach α of 0.797, above the value expected for a new instrument.34 Item-to-item correlations demonstrated that most items did not meet the criteria of 0.30 to 0.70 of 50% of the other items. This may be explained by the fact that the IPNBBP scale was designed to measure 2 opposing concepts: medicalized birth beliefs and normal birth beliefs. Weak correlations would 132
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Frequency (N = 313)
%
209 22 20 71 53
66.8 7 6.4 22.7 16.9
255 9 4
81.5 2.9 1.3
106 190 12 2 3
33.9 60.7 3.8 0.6 1
therefore be expected because items should measure distinctly different concepts. While a medium, positive correlation was obtained, strong correlations between the IPNBBP scale and the LSQ1 would be more indicative of instruments measuring the same construct. These results might indicate that the LSQ1 measures only a subset of the birth beliefs measured by the IPNBBP scale. This finding was expected as no quantitative instrument was discovered that measured the birth beliefs of intrapartum nurses as categorized as medical birth and normal birth. The process of factor analysis improved understanding of the grouping of items into similar concepts. The IPNBBP scale was designed to measure the birth beliefs of intrapartum nurses, and items were written to distinguish between a medicalized birth belief system and a normal birth belief system. The factor analysis procedure determined that 28 of the items fit statistically into 2 factors. These 2 groups of items created the 2, previously hypothesized subscales of Medicalized Birth Beliefs and Normal Birth Beliefs. Following factor analysis, the Cronbach α for these 2 scales indicate internal consistency. Because there were 8 items that did not fit in either factor, it is believed that these items need to be carefully reassessed. It should be noted that these 8 items also did not meet the criteria of item-total correlation. Therefore, deletion of these items is appropriate. The resulting IPNBBP scale would now become a 28-item instrument. Limitations Limitations to this psychometric study need to be identified. Completion of the 36-item IPNBBP scale and the April/June 2014
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29-item LSQ1 required a considerable time commitment from each participant. The demographic section, also lengthy, added to this time commitment. Twenty-five participants did not complete a significant portion of the required instrument and had to be deleted from the database. An additional 27 did not complete the LSQ1, which was the last instrument. The nature of the sampling pool, a perinatal listserve, comprising nursing leaders, membership in a perinatal organization, and convention attendees, might not have been representative of the entire population of intrapartum nurses. The resulting sample contained a majority of White intrapartum nurses who were highly educated and therefore limits generalizability of the findings.
Implications for future research A primary goal related to the development of the IPNBBP scale was refinement of the items and continued testing for validity and reliability. Following this methodological study, editing and deleting of items, reevaluation of reliability and validity, and the use of factor analysis are indicated to improve the instrument. Stability was not assessed in this study and should be reviewed by test-retest methods. The instrument should be tested in a variety of settings such as intrapartum units in a variety of geographic regions. Using the IPNBBP scale in clinical settings would address the stated limitation of representation of the entire intrapartum nursing population. Following revision and refinement of the IPNBBP scale, the instrument can be used to provide thorough descriptions of specific beliefs of intrapartum nurses. Because the IPNBBP scale assesses the birth beliefs of intrapartum nurses in both qualitative and quantitative manners, the rich data provided will assist nurse scholars to develop descriptions of the epistemology and philosophy of intrapartum nurses. Data could also assist in the development of middle-range theories linking intrapartum nursing beliefs and maternal and newborn outcomes.
Implications for clinical practice The IPNBBP scale could be used by nurse managers to assess the birth beliefs of current and potential intrapartum nurses. Managers may desire to implement normal birth practices in an effort to improve birth outcomes. Assessment of birth beliefs would provide assistance in planning continuing education for hospital-based nurses. Nurse educators could also use the IPNBBP scale as a self-assessment tool for nursing students in maternal care courses. Self-assessment of beliefs and a study of the relationship of beliefs, birth The Journal of Perinatal & Neonatal Nursing
practice, and birth outcomes could assist in educating future intrapartum nurses.
CONCLUSION The IPNBBP scale could be a valuable instrument to identify the impact of intrapartum nurses’ birth beliefs and birth practices on birth outcomes. By identifying birth beliefs and categorizing them as medicalized birth beliefs or normal birth beliefs, staff nurses, nurse managers, and nurse educators could adjust practices to positively affect outcomes. By understanding the connection between birth beliefs and practices, intrapartum nursing practice can then be refined to assist in reversing this trend of medicalized birth practices in the United States. References 1. Fischbein M, Ajzen I. Predicting and Changing Behavior: The Reasoned Action Approach. New York, NY: Psychology Press; 2010. 2. Ajzen I. Organizational Behavior and Human Decision Processes. New York, NY: Academic Press; 2005. 3. Sakala C, Corry M. Evidenced-Based Maternity Care: What It Is and What It Can Achieve. New York, NY: Milbank Memorial Fund; 2008. 4. Gould D. Normal labor: a concept analysis. J Adv Nurs. 2000;31(2):418–427. 5. World Health Organization. Care in Normal Birth: A Practical Guide. Geneva, Switzerland: Department of Reproductive Health and Research Switzerland, World Health Organization; 1996. http://www.who.int. Accessed July 27, 2012. 6. American College of Nurse-Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. Washington, DC: American College of NurseMidwives; 2012. http://www.midwife.org. Accessed July 27, 2012. 7. International Confederation of Midwives. Position Statement: Keeping Birth Normal. The Hague, the Netherlands: International Confederation of Midwives; 2008. http://www. internationalmidwives.org. Accessed February 20, 2014. 8. Society of Obstetricians and Gynaecologists of Canada. Joint policy statement on normal childbirth. JOGC. 2008;221:1163– 1165. 9. Royal College of Midwives, The Royal College of Obstetricians and Gynaecologists, and The National Childbirth Trust. Making Normal Birth a Reality: Consensus Statement From the Maternity Care Working Party, Our Shared Views About the Need to Recognise, Facilitate and Audit Normal Birth. London, United Kingdom: The National Childbirth Trust; 2007. www.nct.org.uk. Accessed July 27, 2012. 10. Adams E. The Psychometric Properties of an Instrument Measuring Intrapartum Nurses’ Beliefs Related to Birth Practice [e-book]. Denton, TX: Texas Woman’s University; 2012. 11. Sleutel M. Development and testing of the labor support scale. J Nurs Meas. 2002;10:249–262. 12. Davis-Floyd R, Sargent C, eds. Childbirth and Authoritative Knowledge: Cross Cultural Perspectives. Berkley, CA: University of California Press; 1996. 13. Downe S, ed. Normal Childbirth: Evidence and Debate. 2nd ed. Edinburgh, England: Churchill Livingstone; 2008. www.jpnnjournal.com
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