Shaping Birth by Connecting, Protecting, and Intervening: The Nurse-Midwifery Process of Care and Evidence Based Practice 公开
Lewitt, MaryJane (2013)
Published
Abstract
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 1Pregnancy 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 5Chapter 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 13How 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 35Constructionist grounded theory 35
Situational analysis 36
Discourse analysis 37
Study sample 39Participant enrollment 40
Consent process 41
Interview procedures 42
Description of participants 47
Data analysis 48Research Integrity, Reflexivity and Difficulties 57
Theoretical Sensitivity 63
Difficulties 64
Limitations 66 Credibility 68 Chapter 4: Process and Outcomes 72Overview 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 163Implementation 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
Table 5: Selected excerpts from my pre-understanding of nurse-midwifery practice 63
FiguresFigure 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 57Figure 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 91Figure 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
AppendixAppendix 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 206About this Dissertation
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