Shaping Birth by Connecting, Protecting, and Intervening: The Nurse-Midwifery Process of Care and Evidence Based Practice Open Access

Lewitt, MaryJane (2013)

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The lack of evidence-based practice (EBP) in US hospitals can exacerbate poor maternal and newborn outcomes, resulting in more expensive care. Nurse-Midwifery is a growing profession, with over 11,000 practitioners, that tend to promote EBP, resulting in documented positive outcomes. Focused studies of how these practitioners use EBP in the achievement of these outcomes is severely lacking. The goal of this research was to understand how nurse-midwives practice in the current US hospital system, focusing on the processes that encourage this health provider to implement EBP. This study was framed by Bourdieu's Theory of Practice which explains that behavior results from a combination of the values and beliefs (habitus), power to act (capital), and environment (field) of the individual. The primary aim of this research was to describe the nurse-midwifery process of care occurring while this provider implements EBPs in birth management. The techniques of constructionist grounded theory were implemented with the transcripts of face to face interviews with 19 nurse-midwives working fulltime and delivering in the hospital setting, in the southeastern United States. The new theory of Shaping Birth describes and explains the nurse-midwifery management of labor and birth care through the processes of connecting, protecting, and intervening. Implementing the techniques of situational analysis and discourse analysis resulted in the description of nurse-midwifery values, beliefs, and the environments (social, structural, and interprofessional) that influence their care within the hospital system. The contextualized theory of Shaping Birth was then analyzed in conjunction with descriptions of the implementation of labor induction/augmentation, medical pain relief and the decision to deliver via caesarean by the nurse-midwives to provide additional depth to the implementation of the theory with EBPs. The information gained from this study will provide the groundwork for a broader research plan aimed at minimizing the underuse, overuse, and misuse of intervention in obstetrics while increasing the use of evidenced-based maternity care. This can result in increased efficiency in maternity care with improvements in effectiveness, safety, quality and team work.

Table of Contents

Table of Contents: Page:

Chapter 1: Aims and theoretical framework 1 Introduction 1

Pregnancy and birth is expensive and potentially risky 1

EBPs can decrease cost and increase positive outcomes. 2

Aims 3 Theoretical framework 3 Social Constructionism 3 Bourdieu's Theory of Practice 5

Chapter 2: Background, literature review, and significance 8

Implementation of EBP improves Quality and Safety 8

The quality and safety of health care in the US needs improving 8

Overuse, underuse, and misuse of interventions 11

Most Births occur to Healthy Women Undergoing a Healthy Process 13

How providers define health may affect use of evidence 13

Biomedical theory views health as achievable only through intervention 14

Salutogenic theory of health views health as being able to realize goals 20

Integration of Salutogenesis and nurse-midwifery philosophy 23

Nurse-midwifery has strong ties to the implementation of EBP 25

Why Study Nurse-Midwives? 26

Nurse-midwifery is uniquely situated 27

Low rates of morbidity and mortality and no known adverse effects 28

The process of nurse-midwifery is unknown 30

Significance 32 Chapter 3: Research design and methods 35 Methodologies 35

Constructionist grounded theory 35

Situational analysis 36

Discourse analysis 37

Study sample 39

Participant enrollment 40

Consent process 41

Interview procedures 42

Description of participants 47

Data analysis 48

Research Integrity, Reflexivity and Difficulties 57

Theoretical Sensitivity 63

Difficulties 64

Limitations 66 Credibility 68 Chapter 4: Process and Outcomes 72

Overview of Shaping birth: The nurse-midwifery process of care 72

Cultural analysis of the work world of nurse-midwives 73

Habitus of nurse-midwives 73

History of nurse-midwifery is embedded in a nurse-midwife's habitus 73

Values and beliefs of practicing nurse-midwives 78

Inner Beliefs 79

Interactive Beliefs 85

Process Focused Beliefs 91

Capital of nurse-midwives 94

Interactions with physicians and nurses 95

Interactions with individuals who influence birth management 102

Interactions with clients/ patients 105

Field of nurse-midwifery care 106

Exposing the field via situational analysis 106

Collective actors and connections affecting nurse-midwifery care 112

Shaping birth by connecting, protecting, and intervening 119

Emergence and evolution of the theory of Shaping Birth 120

Shaping Birth: The nurse-midwife process of care 126

Connecting 128

Protecting 134

Intervening 138

The goal: Achieving a healthy, vaginal birth 143

EBPs and Shaping Birth: The nurse-midwifery process of care 150

Usage of oxytocin for induction or augmentation by nurse-midwives 154

Usage of pain relief in labor by nurse-midwives 157

Cesarean usage by nurse-midwives 159

Chapter 5: Discussion 163

Implementation of Shaping Birth through embodying leadership 166

Significance of the implementation of Shaping Birth 172

Partial implementation of Shaping Birth 176

Implementation of Shaping Birth supports EBP in birth 177 Future steps 178

Tables Table 1: Study Participants 41 Table 2: Statistical Descriptions of Participants 46 Table 3: Categorical Descriptions of Participants 47 Table 4: Exposing the Analysis 51

Table 5: Selected excerpts from my pre-understanding of nurse-midwifery practice 63


Figure 1: Interpretation of Bourdieu's Theory of Practice 7

Figure 2: Health is the ability to realize goals. 21

Figure 3: Image of actual messy working map 57

Figure 4: Values and beliefs of currently practicing nurse-midwives 78

Figure 5: Inner values and beliefs 79 Figure 6: Interactive values and beliefs 85 Figure 7: Process focused values and beliefs 91

Figure 8: The Three Worlds of Medicine, Nursing, and Nurse-Midwifery intersect to form the Central Domain where Patient Care is provided via Teamwork 97

Figure 9: Messy working map of CNM caring for Patient in labor 107

Figure 10: Ordered Situational Map of CNM caring for patient in labor 108

Figure 11: Relational connections around personal factors affecting CNM care 111

Figure 12: Initial model of Nurse-Midwifery Process 120

Figure 13: Intermediate Model of Nurse-Midwifery Process 122

Figure 14: Shaping Birth: The Nurse-Midwifery Process of Care 126

Figure 15: Expanded version of Shaping Birth 127

Figure 16: Connecting: The first step in Shaping Birth 128

Figure 17: Protecting: The second step in Shaping Birth 134

Figure 18: Intervening: The third step in Shaping Birth 138

Figure 19: Achieving healthy vaginal delivery: The goals of Shaping Birth 143


Appendix 1: IRB Approval 182

Appendix 2: ACNM Approval to Solicit Membership for Research Participation 183

Appendix 3: Demographic and Participant Information Form 184

Appendix 4: Participant Screening Form 185

Appendix 5: IRB approved consent 186

Appendix 6: Interview guide 189

Appendix 7: Additional questions 192

Appendix 8: Codes- situational analysis 193

Appendix 9: Codes- values and beliefs 198

Appendix 10: Codes- constructionist grounded theory 202

References 206

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