The last few weeks I’ve had to do readings on nursing theory. You see, when you are going to become a professional researcher, you need to understand the framework of the discipline within which you intend to study. This gave me two thoughts to share with you.
First, the reality of practice is that a midwife is by nature an inter-disciplinary practitioner. You must understand physiology, development, medicine, sociology, psychology, pharmacology…need I go on? It makes me wonder what role a discipline-specific theory plays in a multi-discipline practice. I am not alone. Midwifery’s sister discipline, nursing, has been struggling through this concept for the better part of 60 years. If nursing uses knowlege from so many disciplines, what is unique about nursing?
The second is that theory drives your perception of real-life situations. Whether you know it or not, you are subscribing to different “theories” of pregnancy, birth, and early parenting. These theories may not be spelled out with diagrams of conceptual frameworks or models, but they are verbally shared through the apprentice process, and they are shared through the books want-to-be midwives read as they prepare for childbirth, doula work or to become childbirth educators. I would challenge you to spend some time really considering the theories you are learning. How do those theories drive your decision making during normal pregnancy and birth? How do they drive your perceptions of unusual and unhealthy variations?
At a conference I attended this weekend, one of the topics was the level of understanding needed to assess a study. The question went something like this: If a clinician doesn’t understand how research is conducted or if the statistical tests used are valid, can the clinician really assess the validity and usefulness to practice of any study?
It’s a good question. I’ve seen midwives and doulas cling to one piece of research over another not because the results were more robust, but because the authors conclusions were in line with what the midwife wanted to believe. But the results are only as good as the quality of the research methods. I just read an article last night that concluded induction of labor at 41 weeks for postdates and expectant management result in the same rate of cesarean – but upon critical review of the article I noticed the subjects were divided into groups based on the preferred practice of the physician attending that woman. This tells me the paper is NOT about the overall differences of the two protocols because too much other pieces of practice style is built into the dividing of the two groups.
In a class I am working with a group of nurses were concerned they shouldn’t pursue their topic for an evidence based practice project because there was already a systematic review, and doesn’t that mean the question is already answered. Actually, no. A systematic review is a very specific overview of what information is available. The results are going to be based on the inclusion and exclusion criteria – which means there are many pieces of research that may pertain to the topic that are not included in the review. The review may add some validity to a line of thought about the question, but cannot be the final answer. And a review cannot “keep up” with new research, it is a glimpse of the literature at a specific point in time. The publishing of a single systematic review (or writing of a guideline or protocol) should never prevent clinicians from regularly reviewing and revising practice – without reviewing practice regularly a clinician would miss new information that may change the understanding and types of care given.
With all these questions in mind, I want to share this learning module:
It can help you understand how a systematic review is performed, so you can be a better consumer of research.
I am happy to say I have survived my first week of coursework. I am also happy to say that I am (so far) enjoying the coursework. I had fully expected the program to be rigorous – research can be difficult work. I was not expecting the program to be so challenging to my understanding so quickly.
Challenging? Yes. I had in my mind a concept of research from my MPH, and I understood the parts of a study and how to put it together. But I am getting the impression that is the work of a technician really. A researcher starts several steps back in the process because it takes more than seeing a clinical problem to identify good research questions. I don’t have a concept of what it is yet, I’m sorry. But I know it goes beyond the basics of evidence based practice.
An example from my readings this week. One of the reasons we use theory is because it allows us to predict. As a clinician, this has been my level of theory work – and by itself this can be challenging. My concept of cause and effect in wellness will determine how I work with a client. However, the authors from this week’s readings debate the concept of a theory that goes beyond predicting – ways of thought in which predictive theories become only a piece of the concept. I feel as if I can glimpse this idea, but not fully grasp it because I can only think of it in clinical terms – as similar to a health system or similar to a religion. In a religion you might have a theory about prayer that tells you when and how and how much and what you can expect to change due to prayer. But in that religion, prayer is only one piece of the puzzle of how to grow spiritually, and in most religions is not sufficient without other practices. Or in a health (wellness) system, I think of the use of yoga, a practice which has many variations that all agree yoga is one key to a healthy and balanced life. But in each of those variations is built in the idea that yoga in itself plays only one part and the healthy individual also has other practices such as meditation and deep breathing, or nutritional prescriptions. A person can practice yoga outside the health belief system, and can add it to another health belief system – and the question then becomes how that changes the yoga practice and how it changes the health beliefs. But notice, I am still thinking in terms of the clinical. At least I know I learned how to think like a midwife.
I feel like I’m not describing this very well, but that is unavoidable. I’m only one week into the process and have a very limited understanding of this difference myself. But I am diving in and working hard to “free my mind” from the thought patterns of clinical work. As far as I can tell, my mantra for the next year should be “Question Everything.” Scary really, because I was a rather skeptical and critical person to begin with (probably what drew me to research), and I’m finding I am not even on the first step of learning to critically analyze like a researcher.
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It will take you about an hour to work through the tutorial, but the skills are well worth it.
I’m doing some reading about research on methods to manage labor pain today, and reviewing an old study:
Niven, C. and Gusbers, G. (1984). A Sudy of labour pain using the McGill Pain Questionnaire. Soc Sci Med, 19(12):1347-1351.
Before I had even gotten to the meat of the study, the authors had my attention with one simple and honest assessment of reality – understanding labor pain is difficult. How can a 5 point or 10 point scale of “pain” really capture the full experience of any woman in labor.
- The pain a woman feels may change over time, even if she does nothing different.
- The pain a woman feels may change as she changes positions, even if nothing physically changes with her contractions or labor.
- The pain a woman feels may or may not continue between contractions.
- The pain a woman feels may be less intense or troublesome than negative emotions or negative thoughts she feels during labor.
- The pain a woman feels may or may not reflect how well she feels she is coping with that pain.
And yet, despite the problems with rating pain on a scale, it is the only “objective” measure many women get to share about their labor experience. Nurses may chart both the “pain” and how well the woman feels she is coping, but again, that misses so many aspects of what the pain experience is.
It makes sense women will tell each other labor rates an 11/10 for pain – if the scale isn’t able to measure the full experience, the actual measurement should be off the scale.
The American College of Nurse Midwives has declared August Midwifery Lobby Month. That means they want all members and supporters to talk to legislators about policies that improve access to midwifery care. One of the national bills they encourage support for is MOMS for the 21st Century. Take a look at the information and let me know what you think.
I want to draw your attention to one item this bill would address – maternity care shortage areas. Why? Because this is my main research interest. Currently, we don’t really know where these shortage areas are. How do I know. I just finished my master’s thesis on the subject and honestly, the information doesn’t exist.
We don’t have an accurate count of what, if any, family practice physicians are still providing maternity care and which perform cesareans.
We don’t have an accurate count of which OB-GYNs are providing maternity care, and which are doing only gynecological work or specialized in areas without providing general maternity care.
We don’t have an accurate count of what midwives are providing maternity care – in fact in some states a direct entry midwife could be legally providing care, but there is no registration so there is no count.
As if the lack of numbers of providers were not enough, the estimates of how many providers are needed is really an estimate. There has never been validation of the number based on maternity outcomes.
And when you add in the problem that that United States doesn’t actually have a health system, and that in some states 50% or more of births are paid for through Medicaid, having an accurate number of which practitioners are providing services for medicaid recipients becomes important in determining where care is adequate.
There is a lot of work to be done to improve maternity care in the US, and it isn’t all about changing practice protocols. My research is quite timely, but first I need to make it through two years of coursework.
This article came across my inbox this morning: Yerks Research Center receives five-year, $9.5 million grant to study oxytocin.
As you probably remember, I graduated from the public health and nurse midwifery programs at Emory in December, and am returning to Emory to begin work on a PhD in nursing in just two weeks. I was as excited to see this research project as I was when I learned Lynn Sybley had received an $8.1 million dollar grant to improve maternal and newborn survival rates in rural Ethiopia. She’s a pretty impressive midwife, wouldn’t you say?
As much as I am excited about the new Yerks oxytocin studies, my heart sinks just a bit because there is no midwife included in their research staff. I suppose it is possible a midwife from another part of the university is on this project, but I’m not counting on it.
Why do I care if a midwife is on the project? Because currently the only uses of synthetic oxytocin are reproductive. This means, if there is disruption in oxytocin production or reception associated with these problems, one must question the effect of the use of synthetic oxytocin during labor on these disruptions.
While any PhD can read about the uses, and any doctor will know, and any obstetrician will be familiar with its effects, a midwife brings a unique, holistic understanding of the uses of synthetic oxytocin. This is part of the reason multidisciplinary teams are so important – because each specialty brings a unique perspective to help ask the right questions and interpret the answers.
I understand the order of research, and that before links can be made between synthetic oxytocin use and problems with oxytocin metabolism, you need to find out if problems with oxytocin metabolism really do exist. But I still wish a midwife were on this team to be part of the question generating before the research begins.
This summer I embarked on a project to update the website. This would be only the second real redesign since its humble beginnings in 2000. I had updates style before, and added more articles. But really the website simply grew by lumps and outcroppings the way a small house slowly has rooms added on. The result was a website that didn’t flow well for readers, with redundant information. The growth of the internet as a whole meant some sections which were previously important (such as recipes) were no longer needed.
Along with the update, I decided to put research references for the information right on each page. I had already moved to this style for some topics, but wanted navigating research to be easier for the readers. Sometimes this was easy, other times it mean hours of pouring over studies to gather as much information as possible, and then hours of rewrites to condense the information in as easy to read a format as possible. This consumed my summer.
I am happy to say, it is finished!
Yes, there are still articles I decided to leave as is and add research later. For the most part these are the less debated topics. In the end I felt having the information available to readers was more important than giving research references for the month by month guide to pregnancy.
I hope you’ll spend some time on the updated site. Check out what’s new and let me know what you like or what could be improved.
I’m updating the directory this week, a very boring task involving staring at a computer screen and writing code…….yawn.
But in the midst of these updates I do more research, look for more resources and find more information about midwifery in places I don’t live…like Canada.
Here in the US, midwifery is regulated at the state level. This means laws can be very different depending on where you live. This is not a problem unique to the United States. Canada’s midwifery laws are province specific and create equal havoc for Canadian families. Check out this summary of current midwifery laws.
Not being Canadian, I don’t know the system well enough to know if this is direct entry midwifery or all midwives. At least in the United States, nurse midwifery is legal in all states even if direct entry midwifery is not yet regulated or completely prohibited. So while states may have policies that make it more difficult (or nearly impossible) for a woman to have a midwife, at least there are some midwives.
Perhaps I’ll have the opportunity to look into some of the Canadian midwifery policies when I begin my PhD research this fall.
I’m beginning the last segment of the website reconstruction – cleaning up the Natural Childbirth Directory. This is a big task. The directory has over 200 pages of information just about services available in the United States. Every page has to be reformatted to the new look. Every link has to be checked to ensure it still works. And that is what I find interesting today.
Having a list of useful links on a website is like shooting an arrow at a moving target. The internet is a dynamic information source, changing daily. A link that was helpful last week may be “broken” this week. A website with some interesting articles a year ago may be gone today.
When I began the directory, I wanted to be able to send readers to great sources of information. I wanted the unique articles that start discussions. I sought out web pages that complimented the information on Birthing Naturally, not pages that gave readers the exact same information. I wanted to be a link to resources families might not find otherwise – the hidden gems.
But the internet has changed. I think I first built the directory in 2005, and at that time it felt like a big deal to me to not send families to commercial sites they would find listed in any internet search (remember when search was basically looking through an edited list of websites?). I reasoned that if it took me a long time to find these resources, as plugged into the natural birth community as I was, it would be nearly impossible for families looking for information to find them.
I still think there may be hidden gems out there in the folds of the web, but I don’t spend time each week finding them. Many of the articles I considered great reads don’t exist anymore. But what is more interesting to me is that I don’t need to send families to an unknown webpage in the middle of a family’s personal website to provide research. There are great websites that do a fabulous job of educating women, integrating research and statistics with advice and basic information. Childbirth Connection, La Leche League, even the World Health Organization has pdfs that can be downloaded free to help women plan for birth – and usually in multiple languages.
So, just as in the other sections of the website, I find the needs of readers have changed and the directory must change to provide the best opportunities for the readers.