Joumal of Advanced Nursing, 1992,17, 1465-1471

Research and the practice of midwifery* Jennifer Sleep SRN SCM MTD BA Research Co-ordinator, Berkshire College of Nursing and Midwifery, Royal Berkshire Hospttal Craven Road, Reading, Berkshire RGl 5AN, England

Accepted for publicahon 30 March 1992

SLEEP J (1992) foumal of Advanced Nurstng 1 7 , 1 4 6 5 - 1 4 7 1 Research and the practice of midwifery Dunng the past decade, the professional joumals have contained numerous papers authored by nurses and nurse-researchers descnbmg the gap which persists betv\^een research and clinical practice Problems have been highhghted and challenges explored m the quest to discover ways of encouraging practitioners to become more aware of research evidence as a knowledge base for practice Many of the identified issues may be transposed mto a midwifery setting but other factors may be recognized which are specific to the practice of midwifery This paper considers both conceptual and pragmatic issues m an attempt to explore the complexity of the influences which may affect the integration of research into midwifery practice

INTRODUCTION In recent years, increasing emphasis has been placed on the unportance of research evidence as a basis for professional practice Although much of the published work has been authored by nurses seeking to identify aspects specifically related to nursmg pradice, the issues can also be contextualized withm a midwifery settmg For many people, research is considered to be of little value unless it is applied m practice, resulhng in improved care Essentially, this requires a two-fold approach first, to enhance practitioners' knowledge of research to enable them to read cntically and to evaluate pubhshed research papers, and secondly, to prepare dmiaans for their role as change agents capable of plannmg, introducing and sustammg mnovation in a practice setting Both requirements present enormous challenges Withm the last decade, educahonal mihahves to mhoduce research mto the cumculum of every pre- and postregistration programme have rapidly accelerated progress m increasmg research awareness amongst both nurses and midwives The statutory body which has responsibihty for midwifery and nursing education withm the UK advocates that pre-registration students should be able to 'identify 'Paper is based on an inaugural ledtire presented at the tnvtiahon of the Mtdwtves Information and Resource Servtce (MIDIRS) Bnstol, June 1990

the nature of knowledge which informs practice, basing all practice cn relevant, available research findings' (ENB 1989) This view is also endorsed in a document which sets out the framework for post-registration education This requires that practitioners demonstrate 'the abihty to use research to plan, implement and evaluate concepts and strategies leading to improvements m care' (ENB 1990) These directives provide a focus for educational plarming International literature The mtemational hterature cites many examples of creative strategies used to introduce researdi mto nursmg/ midwifery programmes Qanken et al 1988, Laschmger et al 1990, Lee 1988) That is not to say that there is a consensus amongst educators as to the most effective means of achieving the desired leammg outcomes Some advocate a research awareness approach whereas others encourage students to leam about research by 'doing' it (Clark & Sleep 1991) Whichever approach is adopted, it is unrealistic for educational programmes to place upon practitioners the burden of introducing research mto the workplace, unless the dimate prevailing in both service and management spheres is receptive to change A recent North Amencan study suggested that a major mfluence m the utilization of 1465

J Sleep research was the amount of support nurses received from their leaders and admimstrators which may not necessanly be forthcommg (Champion & Leach 1989) This view is endorsed by Funk et al (1989) who suggest that mnovation m pradice is not always valued by either dimaans or their employers Thus, no matter how much dmiaans leam about research m the educational settmg, there is a problem about transfemng this knowledge mto the real world of prachce Resistance to change is ated by several authors as a major mfluence inhibiting the mtroduchon of research into dmical care Horsley et al (1983) descnbe resistance to change as 'any response or behaviour that serves to keep thmgs as they are m the face of the pressure to change' They consider this to be a protechve mechamsm which guards agamst the consequences of change that 'threaten beliefs, values, athtudes and behaviour central to those affeded' Robmson (1987) also recognizes that new knowledge can be threatenmg since it can throw mto question the meanmg which practitioners have given to their workmg hves for many years We should not be surpnsed therefore if the validity of the proposals is demed and if practihoners mamtam that because it is they who do the work, only they can be expected to know what is best The issues are dearly complex, requmng that all those mvolved at all levels withm the orgamzahon are both mterested m and comnutted to the use of research m pradice

Responsibility MacFarlane (1984) contends that all nurses (and midwives), whether dmiaans, educators or managers, have a responsibihty to use research 'neglect of that responsibility could he dassed as professional neghgence' In one of the few pajjers to explore the problems m relahon to the pradice of midwifery, Renfrew (1989) condudes that the t)est efforts of researchers are rendered virtually worthless unless sound research evidence is used as the basis for enhancing the care given to women, their babies and their famihes Given these imperatives, how then can strategies be identified and developed to bndge the apparent divide t)etween research and prachce — the credibihty gap — m order to improve midwifery care? It is useful to begm by ldentifymg a number of reac±ionary forces which mitigate against such an advancement (Table 1)

PROCBDURALIZATION Schon (1987) descnbes proceduralization as 'attempts to reduce professional pradice to a set of absolutely dear. 1466

Table 1 Reactionary forces Proceduralization Delegated responsibility Operatmg a double standard Medical dominance Hierarchical structure of midwifery

prease, implementable procedures, coupled with controls which are designed to enforce the procedures and eliminate' [what he descnbes as] 'surpnse' By 'control' Schon means 'how to get people to do what you thmk they ought to do' He goes on to descnbe one of the mam consequences of prcx:eduralizahon to be 'the multiplication of systems of control so that when thmgs go wrong, the response is to increase and improve procedures' to stop problems from recumng In pradice this is typically exemphfied by the development and imposition of a framework of pohaes and procedures which often serve to confine and limit the achons of the dmician, leavmg httle scop)e for professional judgement, sbll, wisdom or creativity Moreover, the rahonale underlymg the development of such diredives is frequently based on histoncal catastrophes rather than soimd research evidence As a consequence these pohaes can, and frequently do, vary widely from umt to umt demonstrating geographical dif]Ferences These wide national vanances are illustrated m a survey of midwifery pohaes and prachces which was conducted m 220 Enghsh consultant matermty umts (Garaa & Garforth 1989) In parhcular, the pohaes relahng to food and dnnk m labour reflect the current diversity of opmion as well as the confusion about women's nutnhonal needs at this parhcular time Half the umts restncted food m the achve part of labour, and only a few allowed women to eat whatever and whenever they wished The rest (39%) did not allow food at all A third of the umts allowed women to have dnnks other than water at any hme dunng labour, a further third restncted dnnks to early or 'non-estabhshed' labour The majonty allowed women to cinnk water at any hme There were also geographical differences 'northem' umts were more likely to have a pohcy specifying that a woman should not eat at any time dunng labour compared with umts m the south-east of England One jushficahon for the existence of pohaes is that they are of value to students However, m this study the 20% of umts with no student midwives did not have different care pohaes from umts where students were present It is widely beheved that such documentation assures safe practice Menzies (1970), however, suggests that it provides a copmg

Research and the practice of midwifery

strategy for the professional, admg as a defence against personal anxiety (sometimes referred to as obstetnaans' or midwives' distress)

DELEGATED RESPONSIBILITY In health care terms, delegated responsibihty has been descnbed as 'lnnovahons by Doctors which once rouhmzed are then delegated to nurses and other paramedical occupations' (Hughes 1971) The practice of midwifery is peppered with examples which, until recently, have been grouped under the umbrella term of 'extended roles' for example, the siting of intravenous mfusions, regulatmg the dosage of syntoanon, topping up epidural anaesthesia It IS currently considered that many of these speaalized skills form an integral part of dimcal practice whilst others are locally determined and, therefore, specific to individual employing authonties (UKCC 1991) Some climcians beheve that the acquisition of such skills empowers midwives to provide hohstic care for women and their babies, others consider that these delegated tasks provide opportunities to improve their dimcal status However, before rushing to embrace these wider responsibilities, a measure of circumspection would seem m order For the most part, these newly acquired skills do not represent midwifery mnovations prompted and directed by the needs of nonnally labounng women Many are developed as a consequence of praditioners' fmstrahon and consumer dissatisfadion and as such provide a means of reducmg the tune spent waitmg for junior dodors to make and unplement dmical decisions Dingwall and colleagues (1988) caution that 'this downward delegation of routinized, albeit skilled, medical tasks is at the expanse of the (midwives'l role as a spmtual, or m modem terms, psychological support for the mother'

An example of such a debate is the current controversy surrounding the publication of a large-scale study designed to compare routme achve management of the third stage of labour with physiological management (Prendeville et al 1988) This well-conducted tnal has been reported m considerable detail, the paper mdudes the researchers' honest cnhcism of the tnal design and condud The results of the study are unequivocal physiological management of the third stage, as currently prachsed by a generahon of UK midwives skilled m achve management, IS potentially dangerous for mothers These findmgs, however, do not concur with the personal views of many prachtioners, some of whom have attempted to chscredit the study (Inch 1990), or who would wish to see a greater move towards passive management (Isherwood 1989) Before mshmg to the offensive, it is important that each nudwife accepts the responsibility to read carefully the ongmal report for her/himself and to consider all the evidence judiaously Ethical questions A double standard also exists when considenng the ethical questions related to both practice and researdi New therapies are frequently mtroduced or routme practices perf>etuated without question or formal evaluation for example, the use of new suture matenals and water births These mnovations rapidly become mtegrated mto the normal pattem of care However, when a research study is subsequently proposed to evaluate such practices, a storm of protest frequently ensues on the basis that it is unethical to withold what may come to be regarded as a potentially benefiaal treatment This 'logic' flies m the face of reason Chalmers (1989) urges caution 'we have to begin by accephng that m deahng with basically healthy people, there is considerable potential for domg more harm than good on a very large scale'

An example of such a double standard is the enema study conducted by Romney & Gordon (1981), where the proposed witholdmg of 'routine' enemas from women was considered by the prachhoners at the time to be unethical The operation of a double standard CKcurs when evidence Persuaded otherwise, a randomized controlled tnal was which IS in accord with one's own philosophy and prachce subsequently mounted Recruitment to the tnal was, IS readily accepted, whereas data which challenge those however, prematurely terminated Confronted with the behefs are ignored as flawed Chalmers (1983) proposes expenence of a fonnal companson between the routme and that discretional use of enemas, the opimon of the chmaans had been reversed They now dedared it unethical to subject the problem is not that those engaged m pubhc debate about women to this intervention care dunng ciuldbirth always ignore scienhfic evidence, it is that they allude to it only when it suits them their mterests MEDICAL DOMINANCE are best served by complete absence of relevant, saentifically denved mformahon or where most of the evidence is denved By defimtion, medical dommance lmphes male dommance Many currently prachsmg midwives have only expenenced fi'om 'weak' stuciies

THE O P E R A T I O N O F A D O U B L E STANDARD

1467

J Sleep a system whereby the majonty of chmcal deasions are unposed by male obstetnaans An example of this is highlighted m a review of developments m Bntish obstetnc textbooks 1960-1980 (Schwarz 1990) The author ates the following example taken from Mtdwtfery by Ten Teachers (Roques et al 1961) The first chapter of the 1961 edihon begins, 'Of all the jobs undertaken by the medical profession midwifery is the most rewardmg Its aim is normality and if normality is achieved there is a glow of sahsfaction on all those who have assisted the woman in her supreme fulfilment' Eleven years later (Qayton et al 1972) the book opens hke this, 'Many doctors find great satisfadion m the prachce of obstetncs, the doctor forms a personal relationship with his pregnant patient which is umque m medicine' This view IS compounded by Myles who states m the preface to the mnth edition (1981), 'the basic role of the Bntish midwife who prachsed independently has been superseded it would now be considered a retrograde step for a midwife to take sole charge of an expectant mother, thereby depnvmg her of the scienhfic expert care only the obstetnc team can provide' Schwarz goes on to suggest that the midwife has thus become a sub-contractor m the obstetnc engmeenng programme A similar situation exists m the field of research where many midwives have developed expertise by actmg as data coUectors withm an mterdisaphnary team, usually headed by an obstetnaan (usually male) This could lead to a dichotomy between the needs of women as consumers and the research methodologies midwives acquire from the traditional natural saences and from medicme We need to consider a vanety of research approaches to evaluate issues of concem to mothers and to midwives Exf)enmental stuches are needed to test theones and to evaluate altemative forms of care for example, Alexander's (1991) study companng treatments for non-protractile mpples m women who intend to breast feed and the report by Needs and colleagues (1992) evaluatmg three types of fetal scalp electrodes However, we also need qualitative studies which help to provide insight mto the expenences of mothers and their famihes and seek to explore the way that professional carers lnterad with women and with each other for example, Kirkham's (1989) observations of midwives' mteradions with labounng women and McHafifie's (1990) study to mveshgate the percephons of the mothers of very low birthweight mfants

Hierarchical structure of midwifery Midwives are voaferous over the issue of obstetnc/male dormnance but if that was to vamsh tomorrow the 1468

Table 2 Counter measures Challengmg authonty Playmg power pohtics and gaming peer support Developmg intellectual cunosity and the power of reflective thinking Faahtahng cntical readmg skills Promotmg, evaluatmg and valumg mnovahon Fostenng skill acquisihon and dimcal judgement

hierarchical structure within the midwifery profession would almost certainly remam Midwives are prone to the indulgence of self-denial 'It was not my fault I was told to do it that IS someone else's responsibihty' In the next breath they talk of autonomy and accountability We carmot have it both ways To be accountable means that actions must be explainable, defensible and based on knowledge rather than on tradition, authonty or myth As such, accountability cannot be delegated to others higher up or lower down m the orgaruzahon, neither can it be Ignored In simple terms it means bemg answerable for what you do Roch (1988) suggests that 'a consequence of accountabihty is that it makes us admit when we are wrong, we then have to a d to corred the situation and this is a pamful process for the praditioner' If midwives wish to be considered as 'autonomous practitioners' they have to stop trying to blame someone else for every misfortune, whether colleagues or managers If these represent some of the reactionary forces, we need to develop a number of counter measures which can and must he used as a positive force Ways m which this may be achieved are given in Table 2

CHALLENGING AUTHORITY A good starting point m challenging authonty is to review pohcy and procedure documents which still exist in the majonty of matemity units in the UK They are sometimes dated, occasionally signed, rarely referenced, yet, wntten m tablets of stone, they dictate countless women's expenence of pregnancy and childbirth We need to begin by fostenng a greater sense of uncertainty m our approach to care, admithng that 'we do not know' can provide an impetus to the discovery and evaluation of ways m which pradice can be improved One way of generating uncertainty is through research which begms by queshonmg assumphons and challenging chenshed behefs about the effeds of care Chalmers (1983) suggests that one of the features of scientific inquiry is its anh-authontanan nature which promotes the quest to discover better grounds for planmng and achon He suggests

Research and the practtce of mtdwtfery

that 'the saentific method offers an efifiaent framework withm which to protect families from the unmtended adverse consequences of authontanan prescnphons and proscnphons in pennatal care and education' However, challengmg authonty is never a comfortable ophon, especially if dmiaans lack the necessary shlls cnhcally to evaluate pubhshed research as the basis for changmg pradice Midwives are now fortunate to be supported in this dilemma by the availability of an invaluable resource which offers a comprehensive review of all current research evidence m which altemative forms of care have been formally evaluated Effechve Care tn Pregnancy artd Chtldbtrth (ECPC) (Chahners et al 1989) This work ends with a senes of four appenchces 1 2 3 4

forms of care that reduce the negative outcomes of pregnancy and childbirth, forms of care that appear promising but require further evaluation, forms of care with unknown effects which require further evaluation, forms of care which should be abandoned in the hght of available evidence

This resource provides midwives with the evidence upon which we can challenge authonty and to do so with confidence

PLAYING POWER POLITICS Midwives possess considerable power to influence decision making in prachce, management and educahonal settmgs However, this power is not always used appropnately or skilfully to achieve the desired outcome Power and mfluence are two sides of the same com Thus, if midwives wish to be influential m achievmg positive change they must first leam to understand and to use power dynamics skilfriUy For example, Manley (1991) ates the way in which chmaans are 'identified as possessmg a great deal of power which they use very subtly and skilfully to influence mechcal deasion-makmg regardmg patient management' This should be a familiar scenano to most practising midwives' Manley, however, cautions that the skill hes m usmg power appropnately, thus avoidmg aggression and confrontation whilst achievmg the desured outcome One way m which midwives can extend their sphere of influence is through improved education Educational opportumhes strengthen the knowledge base of the profession and m doing so enhance confidence This is a goal shared with other health professionals such as physiotherapists, radiographers and nursmg colleagues who are

seekmg improved academic status by forging strong links with institutes of higher education m developmg innovative programmes for advanced practice In many arenas midwifery education is advanang at the same pace but, in others. Project 2000 and post-basic programmes for registered nurses gather momentum whilst midwives are diverted by the quest for autonomy, and separate professional status at the expense of educational mnovation We need to be m the forefront of negotiations with colleagues m discussing the development of core cumcula and shared leaming opportumties This need not lead to a dilution of skills but the strengthening and broadenmg of the shared knowledge base which directs practice Exciting opportumties exist for midwives to spearhead developments m post-basic education by plannmg academically accredited programmes designed to meet the needs of practitioners

Active decision-making role Playmg power pohhcs also requu-es that midwives play an achve role m decision-making about the future of the service they provide, for example, the extent to which care should be concentrated in large hospitals rather than smaller local umts or the way m which the commumty service should be staffed and organized

DEVELOPING INTELLECTUAL CURIOSITY AND THE POWER OF REFLECTIVE THINKING Schon (1983) descnbes reflective thinking as a development of what he calls 'mtuitive knowing', that is, 'the spontaneous performance of the actions of everyday life/ practice without bemg able to descnbe what it is that we know or the criteria by which we make judgements' If we carmot, therefore, begin by descnbmg what we perceive to be 'good practice', then we cannot conceptualize and recogmze the qualities of 'goodness' related to carmg Schon also wams agamst undervalumg intuition, instinct, and a quality he refers to as 'savvy', but goes on to suggest that we need to recogmze and constmctively use the element of surpnse, that IS, 'when spontaneous performance yields unanticipated results which may be pleasmg, distressmg, unwanted' or even disastrous We should then respond by reflection, that is, by thmkmg about our actions Benner (1984) descnbes this as the 'growing edge of chmcal knowledge — the difference between knowing that and knowing how' Benner's work is charactenzed by the extensive use of exemplars, stones told by dmiaans m which they descnbe speafic care situahons where they felt 1469

J Sleep that theu" contnbuhon has made a positive difference to the patient's welfare These do not represent abstractions, they emerge fiom the imperfections and contmgenaes with whicii nurses [and midwives] work daily but, by their expressioa foster the development of perceptual awareness This, in tum, leads to early identification of problems and the search for confumatory evidence Descnptions that are not very good may still be good enough to enable an enquirer to evaluate and restmcture his/her understandmg so as to produce new actions to unprove the situation or tngger a reframing of the problem This can provide a powerful learmng and teachmg tool with the potenhal to make a vital contnbution to the development of new educahon programmes which, m tum, provide the key to unproved standards of care Such exemplars can also help the current dmical expert to feel valued as a source of midwifery excellence, both for the profession, for women and for their famihes

FACILITATING CRITICAL READING SKILLS Reference has already been made to ECPC but midwives have another strength m the availability of an information service which is unique to midwifery, the Midwives Information and Resource Service (MIDIRS) This not only provides a review of the current literature both nationally and mtemahonally but also guides the reader m offenng commentary of published work. In addihon, an extensive database is available enabling the user to scan defined topics and gam mformation through an absfradmg service Access to such a service empowers midwives to develop their knowledge base and, m domg so, enhance professional confidence Midwives cannot become confident and sblled consumers of research unless they have access to mformahon sources and possess the necessary skills to read and cnhcally evaluate published research These sblls are necessary prerequisites to enable chmaans to recogmze the potential of researdi to influence and improve health care

PROMOTING, EVALUATING AND VALUING INNOVATION Promohng, evaluating and valumg mnovahon is as much concemed with valumg the contnbuhon of the mdividual as the acquisition of new sblls We therefore need to value and support those who have the courage of their convichons to question estabhshed norms We also need to 1470

nurture creahve talent which ciisplays lmhahve, mdependent judgement and the wilhngness as well as the abihty to take nsks m plarmmg and mtroducmg change Innovation, however, is a nsky busmess which poses a threat to the status quo The successful mtroduchon of change requires both peer and managenal support Phillips (1986) sees the need for this to be covert as well as overt Of the two types of support, covert support is probably the more important for assunng on-gomg, consistent efl^orts towards achieving change A midwife manager can tell staff that usmg research evidence m prachce is important, but if there is covert disapproval displayed when chmaans are 'caught' reading or shanng ideas at work, then umovahve moves are doomed to failure The recent mtrodudion of performance mdicators, mdividual performance review, even m some mstances performance-related pay, could offer a means of providmg orgamzahonal rewards for innovators Chmaans should be adively encouraged to develop and use their creahve sblls m planmng mnovative strategies for the mtegration of research into prachce Supportmg and faahtahng this process is one of the greatest challenges facmg supervisors of midwives who are m a unique and pnvileged posihon to act as midwife advocates CONCLUSION If midwives are to move towards the pnme goal of achieving exceUence, they need to identify and value the mtuihve, creahve, expenential influences which provide a source of professional skill 2md wisdom, the 'know how' This must be harnessed to the saence of midwifery that IS its research base which can help to ensure a better understandmg of prachce, the 'know why' Achievmg this outcome requu-es the courage to challenge Ball (1987) condudes that 'm the past few years midwives have challenged the very framework of our prachce, enema, 3rd stage confrol, shavmg, episiotomy Our audacity has not brought God's wrath down on us — mstead Midwives have found a new freedom to challenge and to change' The challenge is to idenhfy and sustam strategies to bndge the credibihty gap between researdi and pradice Freedom hes m achievmg this goal and m domg so unleashmg the power and the creative potential of the practice of midwifery Acknowledgement The author is mdebted to Dr Elisabeth Clark of Middlesex Umversity who crffered construchve comments on numerous drafts with a grace she would hope to emulate

Research and the practtce of mtdtmfery

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