Defining woman-centred care: A concept analysis.

PROBLEM: In midwifery a shared definition of woman-centred care is lacking, and this remains an identified gap in the evidence underpinning midwifery practice. BACKGROUND: Woman-centred care is an underpinning philosophy used in midwifery practice both nationally and internationally. AIM: To analyse the practice of woman-centred care to clarify its meaning and comprehension and subsequently advance an evidence-based definition of the concept. METHODS: Using an adapted theoretical and colloquial evolutionary model a three-stage concept analysis was conducted to identify attributes, antecedents, and consequences of woman-centred care and subsequently construct an evidence-based, internationally informed definition. FINDINGS: Antecedents of woman-centred care are education, models of care and midwife characteristics. Attributes are choice and control, empowerment, and relationships. Consequences are shared and informed decision making which supports the woman in navigating complex health systems, and improved health outcomes. Whilst important to midwifery practice and midwifery-led models of care, continuity of care is not a core essential element of woman-centred care. DISCUSSION: Analysis, synthesis, and re-examination of the data on woman-centred care facilitated deep immersion, exploration and clarification of this concept that underpins midwifery philosophy and practice. The constructed definition can be used to inform health policy, midwifery research, education, and clinical practice. CONCLUSION: An evidence-based definition of woman-centred care is necessary for conversion of this essential concept to practice. Regardless of model of care all women should receive woman-centre care improving the health outcomes of both the woman and neonate.

Achieving international consensus on the concept of woman-centred care: A Delphi study.

PROBLEM: There is no internationally-informed understanding of how midwives perceive woman-centred care and use it in practice. BACKGROUND: Woman-centred care is integral to the role of the midwife and to determining standards of practice. Few empirical studies have explored the meaning of woman-centred care, and those that have are limited to country specific research. AIM: To gain an in-depth understanding and consensus on the concept of woman-centred care from an international perspective. METHODS: A three round Delphi study was conducted, with surveys distributed online to a group of international expert midwives to draw consensus on the topic of woman-centred care. FINDINGS: A panel of 59 expert midwives representing 22 countries participated. Fifty-nine statements about woman-centred care, of which 63% of statements reached the 75% a priori agreement level, were developed and categorised under four emergent themes: defining characteristics of woman-centred care (n = 17), the role of the midwife in woman-centred care (n = 19), woman-centred care and systems of care (n = 18), woman-centred care in education and research (n = 5). DISCUSSION: Participants agreed that woman-centred care should be provided by any health care professional in any health care setting. Systems of maternity care should provide holistic care tailored for the individual woman rather than subject her to routine practices and policies. Although continuity of care is important to midwifery practice, it was not reported as a core characteristic of woman-centred care. CONCLUSION: This is the first study to investigate the concept of woman-centred care as it is experienced globally by midwives. The findings of this study will be used to contribute to the development of an internationally informed evidence-based definition of woman-centred care.

Development and piloting the Woman Centred Care Scale (WCCS).

PROBLEM/BACKGROUND: In midwifery we espouse a woman centred care approach to practice, yet in midwifery education no valid instrument exists with which to measure the performance of these behaviours in midwifery students. AIM: To develop and validate an instrument to measure woman centred care behaviours in midwifery students. METHOD: We identified four core concepts; woman's sphere, holism, self-determination and the shared power relationship. We mapped 18 individual descriptive care behaviours (from the Australian National Competency Standards for the Midwife) to these concepts to create an instrument to articulate and measure care behaviours that are specifically woman centred. Review by expert midwifery clinicians ensured face, content and construct validity of the scale and predictive validity and reliability were tested in a simulated learning environment. Midwifery students were video recorded performing a clinical skill and the videos were reviewed and rated by two expert clinicians who assessed the woman centred care behaviours demonstrated by the students (n=69). FINDINGS/DISCUSSION: Test and re-test reliability of the instrument was high for each of the individual raters (Kappa 0.946 and 0.849 respectively p<0.001). However, when raters were compared there were differences between their scores suggesting variation in their expectations of woman centred care behaviours (Kappa 0.470, p<0.001). Midwifery students who had repeated exposures to higher levels of simulation fidelity demonstrated higher levels of woman centred care behaviours. CONCLUSION: The WCCS has implications for education and the wider midwifery profession in recognising and maintaining practice consistent with the underlying philosophy of woman centred care.

The effectiveness of varied levels of simulation fidelity on integrated performance of technical skills in midwifery students--a randomised intervention trial.

BACKGROUND: Simulation as a pedagogical approach is used in health professional education to address the need to safely develop effective clinical skills prior to undertaking clinical practice, in complex healthcare environments. Evidence for the use of simulation in midwifery is largely anecdotal, and research evaluating the effectiveness of different levels of simulation fidelity is lacking. OBJECTIVES: To evaluate the effectiveness of varying levels of fidelity on simulated learning experiences and identify which best contributes to integrated and global clinical skills development in midwifery students. DESIGN: Randomised three arm intervention trial. PARTICIPANTS: Midwifery students who had yet to receive theoretical instruction in the performance of the clinical skill of vaginal examination. METHODS: Midwifery students (n=69) received theoretical instruction in the performance of vaginal examination following random allocation into one of three intervention arms. Participants were recorded performing the procedure using low fidelity (part task trainer only), medium fidelity (part task trainer and life sized poster of a pregnant woman) or progressive fidelity (part task trainer and a simulated standardised patient). Senior midwifery students were recruited to act in the role of standardised patients. RESULTS: There was a statistically significant difference in the mean total Global Rating Scale score between at least two of the three groups (p=0.009). The progressive fidelity group revealed as different from both the low fidelity group (p=0.010) and medium fidelity group (p=0.048). There was a statistically significant difference in the mean total Integrated Procedural Performance Instrument score between at least two of the three groups (p=0.012). The progressive fidelity group revealed as different from both the low fidelity group (p=0.026) and medium fidelity group (p=0.026). CONCLUSIONS: Progressive and medium fidelity simulation yields better outcomes than low fidelity simulation and where resources are constrained medium fidelity equipment, such as a life sized poster can produce effective learning experiences for midwifery students.

A protocol for evaluating progressive levels of simulation fidelity in the development of technical skills, integrated performance and woman centred clinical assessment skills in undergraduate midwifery students.

BACKGROUND: Simulation as a pedagogical approach has been used in health professional education to address the need to safely develop effective clinical skills prior to undertaking clinical practice. However, evidence for the use of simulation in midwifery is largely anecdotal, and research evaluating the effectiveness of different levels of simulation fidelity are lacking.Woman centred care is a core premise of the midwifery profession and describes the behaviours of an individual midwife who demonstrates safe and effective care of the individual woman. Woman centred care occurs when the midwife modifies the care to ensure the needs of each individual woman are respected and addressed. However, a review of the literature demonstrates an absence of a valid and reliable tool to measure the development of woman centred care behaviours. This study aims to determine which level of fidelity in simulated learning experiences provides the most effective learning outcomes in the development of woman centred clinical assessment behaviors and skills in student midwives. METHODS/DESIGN: Three-arm, randomised, intervention trial.In this research we plan to:a) trial three levels of simulation fidelity - low, medium and progressive, on student midwives performing the procedure of vaginal examination;b) measure clinical assessment skills using the Global Rating Scale (GRS) and Integrated Procedural Performance Instrument (IPPI); andc) pilot the newly developed Woman Centred Care Scale (WCCS) to measure clinical behaviors related to Woman-Centredness. DISCUSSION: This project aims to enhance knowledge in relation to the appropriate levels of fidelity in simulation that yield the best educational outcomes for the development of woman centred clinical assessment in student midwives. The outcomes of this project may contribute to improved woman centred clinical assessment for student midwives, and more broadly influence decision making regarding education resource allocation for maternity simulation.

Simulation based learning in Australian midwifery curricula: results of a national electronic survey.

OBJECTIVE: The primary aim of this paper is to describe the extent, nature and types of simulation used as a learning method in contemporary Australian midwifery curricula. METHOD: An electronic survey was developed using Graduate e-Cohort Pro and administered to key midwifery academics who had responsibility for 38 curricula leading to initial midwifery registration in Australia. FINDINGS: Engagement of midwifery academics in the survey was high with a response rate of 82%. There is a range of midwifery programs by type and level of award across Australia that vary in duration, enrolments, and by component theoretical and clinical hours. The proportion of simulation hours in curricula varied across programs accounting for up to 17% of clinical program hours. However simulation was used extensively to teach all identified generic technical skills (n=16) midwifery technical skills (n=51) and generic non-technical skills (n=6). Most commonly used simulation types were scenarios, peer-to-peer learning, partial task trainers and standardised patients. Simulation types were suited to the learning tasks. CONCLUSION: Simulation is used extensively in midwifery education in Australia. Further research is required to understand the curriculum development imperatives of simulation and there is a need to adequately resource and support staff in the use of simulation to provide high quality simulation learning experiences for students.

Simulation based learning in midwifery education: a systematic review.

AIM: To critically examine the evidence for simulation based learning in midwifery education. BACKGROUND: Simulated Learning Programs (SLPs) using low to high fidelity techniques are common in obstetric professionals' education and focus on the development of team work, labour and obstetric emergencies. REVIEW METHODS: A systematic review incorporating critical appraisal approaches, setting clear objectives and a defined search and analysis strategy. Evidence from obstetrics, neonatology, technical and non-technical skills (teamwork) was included where it informed the development of midwifery curricula. Studies in English from 2000 to 2010 were included searching CINAHL Plus, OVID Medline, Cochrane, SCOPUS and ProQuest and Google Scholar. RESULTS: Twenty-four papers were identified that met the inclusion criteria. All were quantitative reports; outcomes and levels of evidence varied with two notable papers indicating that simulation had an impact on clinical practice. Benefits of SLP over didactic formats were apparent, as were the development of non-technical skills confidence and competence. The study outcomes were limited by the range of evidence and context of the reports which focussed on obstetric emergency training using a number of simulation techniques. CONCLUSION: There is evidence that simulated learning of midwifery skills is beneficial. Simulation learning has an educational and clinical impact and advantages over didactic approaches. Where clinical practice is infrequent i.e. obstetric emergencies, simulation is an essential component of curricula. Simulation enhances practice and therefore may reduce the time taken to achieve competence; however there is no evidence from the literature that simulation should replace clinical practice.

The perspectives of Australian midwifery academics on barriers and enablers for simulation in midwifery education in Australia: a focus group study.

OBJECTIVE: to describe Australian midwifery academics' perceptions of the current barriers and enablers for simulation in midwifery education in Australia and the potential and resources required for simulation to be increased. DESIGN: a series of 11 focus groups/interviews were held in all states and territories of Australia with 46 participating academics nominated by their heads of discipline from universities across the country. FINDINGS: three themes were identified relating to barriers to the extension of the use of simulated learning environments (SLEs) ('there are things that you can't simulate'; 'not having the appropriate resources'; and professional accreditation requirements) and three themes were identified to facilitate SLE use ('for the bits that you're not likely to see very often in clinical'; ['for students] to figure something out before [they] get to go out there and do it on the real person'; and good resources and support). KEY CONCLUSION: although barriers exist to the adoption and spread of simulated learning in midwifery, there is a long history of simulation and a great willingness to enhance its use among midwifery academics in Australia. IMPLICATIONS FOR PRACTICE: while some aspects of midwifery practice may be impossible to simulate, more collaboration and sharing in the development and use of simulation scenarios, equipment, space and other physical and personnel resources would make the uptake of simulation in midwifery education more widespread. Students would therefore be exposed to the best available preparation for clinical practice contributing to the safety and quality of midwifery care.

Is simulation a substitute for real life clinical experience in midwifery? A qualitative examination of perceptions of educational leaders.

This paper describes the perceptions of midwifery educational leaders concerning the potential for simulation to provide a realistic experience in midwifery education. A qualitative design was employed using focus groups which were audio-taped and transcribed verbatim. Data were analysed using thematic analysis. Eleven focus groups were conducted with 46 key midwifery academics across Australia. Three main themes emerged relating to realism and simulation in midwifery practice: 'we already use a lot of simulation', 'level of realism of manikins', and 'some things cannot be simulated'. Simulation is currently widely used in midwifery education, but this is limited due to realism of available models and equipment. Despite this, within a woman-centred, holistic approach to care there are many aspects of midwifery practice that cannot be easily simulated. There is a need for research and development of realistic simulation approaches to support the enhanced use of simulation. Furthermore, strategies for developing approaches that reflect midwifery care provision need to be developed.