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A maternity care course component and evaluation
.l'urseEducamnT&v,l989) 9,227-235 0 Longman GroupUK Ltd 1989
02606917/89/0009-0227/)10.00
A maternity evaluation
care course component
and
Rosemary Mander
A Maternity Care Component for Nursing Students has been developed within the Department of Nursing Studies in the University of Edinburgh, utilising an educational approach well-established within the Department. This paper describes the Component and its evaluation, which suggests that fears about certain problems were not justified and that all groups involved in the programme were satisfied with the way in which it operated. There may even have been certain benefits which had not been anticipated.
A MATERNITY CARE COMPONENT AND EVALUATION ‘The need for a reorientation of initial preparation towards the community was one theme which emerged strongly from this review . . . We feel that the time has come for a break with hospitals as the basis for so much initial preparation, and for new thinking about how placements and practical experience could be developed settings’.
in relation (Project
to a whole range of care
2000,
UKCC
1986)
As these words were being written in London the first group of Edinburgh University Nursing Students was completing a novel Maternity Care Component which achieved the aims stated in this quotation.
This
paper
explains
the edu-
approach cational incorporated in this Component, an approach well-established in the Department of Nursing Studies (DNS). The
evaluation,
an essential part of any innovation,
shown to have improved subsequent
The maternity
- The Maternity experience
Those
Care
for first level nursing
is widely recognised
difficulties.
is
during
years.
Background Component students
the experience
to be fraught
with
involved with this component
know the problems
which the student
encoun-
ters when studying all too briefly an area of care which may be perceived as having little relevance to her ultimate
goal. Large
arriving with monotonous motivation teaching
are
number
of students
regularity
and limited
an onerous
staff. Midwifery
staff are presented
responsibility
managers
with numerous
for
and clinical students
at
varying stages in their courses for brief and possibly fragmented experience. Frequent attempts to amend the experience testify
to the intractability
of these difficulties.
Rosemary Mander MSc PhD RGN SCM MTD Lecturer,
The National Board for Nursing,
Department of Nursing Studies, Adam Ferguson Building, George Square, Edinburgh EH8 9LL (Requests for reprints to RM) Manuscript accepted 19 December 1988
Midwifery
and
The female pronoun is used here, regardless of the student’s gender.
227
228
NURSE EDUCATION
TODAY
Health Visiting for Scotland made such an attempt (NB[S] 1985), but was prevented from grasping the nettle by rigid EEC requirements, which have the effect of presenting large numbers of students to institutions whose resources and flexibility of approach are limited by their multiplicity of commitments. Another attempt was made by the midwifery teaching staff of the Queen Mother’s Hospital, Glasgow who organised a scheme for nursing students of the Glasgow College of Technology. This scheme differed in certain crucial respects from the programme being described here: a) It was organised ‘in house’ by health board staff b) The women attended only the hospital antenatal cIinic c) The midwife teacher and student cared for the woman in labour The Glasgow scheme is no longer in operation and although other similar programmes may have been organised it has not been possible to locate details in the literature. The limited value of the traditional Maternity Care experience has been revealed in recent research (Mander 1983). This work indicates that nurses with (and particularly those with more) maternity care experience, far from being better able to make well-informed, durable career decisions, which might be anticipated in view of their experience in the maternity area, are actually over-represented among the student midwives who discontinue training. It was in this context that DNS radically revised the Maternity Care module in order to both enrich its value as a learning experience and to increase its congruity with the philosophy of the undergraduate nursing course.
Background -the
DNS approach
In 1982 DNS took advantage of the need to discontinue the District Nursing element of the BSc (Social Science/Nursing) course to shorten and radically alter the curriculum. These alterations reflect a commitment to a certain view of nursing, summarised by James and Howden
(1985) as *holistic individually-based care’. These authors, both DNS staff at the time, continued their description of the changes they implemented by emphasising the importance of community input into a ‘comprehensive training programme’. They explain the significance of the community experience: ‘The hospital environment provides our students with invaluable experience, but it also fosters a false sense of security and a limited view of society. To say that all human life is there in the community is no exaggeration. We may live our lives outside the hospital and other institutions, but do we always appreciate the complexity, richness and, for some, the despair, of that life in the ‘real world’?’ (James & Howden 1985) Jacobsen (1985) reinforced this view and took her former colleagues’ arguments a stage further. Presenting her view of a more transactional nurse-client relationship, she referred to a less publicised sequel to the Alma Ata Declaration: ‘The changing role of the nurse demands a radical change, not only a sound grasp of nursing knowhow, but in their relationship with other health personnel and the community in need of health care’. (WHO 1985). Jacobsen concluded that nurses, if they are to recognise and utilise the knowledge and experience of clients to develop this new relationship, must consult the clients. She then gave examples of learning in DNS which draw on the knowledge of ‘unqualified’ people, to illustrate this approach. These examples include the health selfappraisal in first year and their visits by second year students to the well elderly, emphasising the student taking a non-nursing approach. These visits enhance the student’s understanding of the support of the family and give her a more realistic picture of the capabilities of elderly people than that to be obtained in other environments. Jacobsen summarises the value of these visits as enabling the student to relate to patients: ‘in such
a way that
their
knowledge
and
NURSE EDUCATION
experience is valued equally with our specialist knowledge’. The examples provided by Jacobsen and by James and Howden serve to reinforce the important concept outlined by Gunter (1969), particularly her emphasis on the learning environment. Her rationale is that the emotional climate of the learning environment influences the processes by which the student experiences psychological development to achieve self-actualisation (Maslow 1954). The extent to which the student develops psychologically must determine her ability to form enduring, therapeutic relationships with those for whom she cares. Gunter implies that it is the teacher’s responsibility to ensure that the learning environment is conducive to healthy psychological development if the student is to function effectively as a nurse. This explains the emphasis within DNS on ensuring the appropriate learning environment. Having reviewed the nature of the problem and the theory underpinning the DNS teaching approach, I will describe the course component which, in the light of these considerations, was planned in conjunction with the health care agencies and the statutory bodies.
The childbearing course
component
of the
The student’s work on childbearing begins in the second year of the course and continues through into the final (fourth) year. Second Year - Introduction
This initial exposure to material and issues constitutes the largest part of the ‘Reproducing’ module in second year and prepares the student for her 2 week clinical experience in third year. Like all the modules in first and second year it utilises the ‘Activities of Living’ Model (Roper, Logan & Tierney 1980). Third Year - Clinical experience
A tutorial during a regular study day sets the scene for the student’s clinical experience in the maternity area. In this small group session a film is used to focus attention on emotional, sociological and psychological aspects of the forthcoming experience. The wide-ranging discussion follow-
TODAY
229
ing the film probes certain aspects of care which the student is likely to encounter, as well as the student’s expectations and any differences between this and other clinical experiences. The student spends one week in the labour ward and one in the post natal area, during which time she is taught by the permanent staff as well as the DNS lecturer. Fourth Year - Two interdependent elements
The student’s work on childbearing in the final year serves to consolidate and to integrate previous work. The two parts begin simultaneously and are interdependent, at least for the first term. A lecture series encourages the student to examine issues which she encountered during the clinical experience. These lectures also provide suggestions for discussion during the other part of the final year work on childbearing, which comprises a series of contacts between the student and a woman experiencing childbearing. The congruity of these two elements received favourable comments from students in the evaluation of the component, one of whom stated: ‘Lectures going along with these visits were both interesting and well timed as (I was) able to follow them up by questioning mother.’ The rationale for these contacts is that the student utilises the knowledge and experience of the woman to learn about normal childbearing, including the provision of care. As mentioned already (above) this approach has been used by the student during visits to the well elderly which she made during second year. Before describing the development of the visits it is necessary to emphasise the role of the student in this context. Her role is that of an interested, caring observer - ‘being a friend’ (Jacobsen 1985). As one student commented: ‘(I) Felt much more of a friend than a student nurse - helped by not being in uniform.’ The student is expected not to provide health care or information and she is advised of the appropriate action if such care or information is sought.
230
NURSE EDUCATION
TODAY
Contingency
Contacts with the woman of the contacts is for the student to come
Theaim
to understand
the experience
from the viewpoint has been assigned. services
and
changes
which
of childbearing
of the woman to whom she This includes
care
provided
learning and
occur
within
the
within the developing
family.
That
being achieved is confirmed
the
woman
and
this aim is
by informal
with students and by an unsolicited
about
about
contacts
comment
by
very beneficial.
It
a student: this scheme
was very interesting received same
unhappily.
had been agreed 1985,
from
time
fessional’s
to view the care Mrs K.
her point
being
of view and at the
aware
of the
health
pro-
point of view’.
pregnancy
with senior
information
obstetricians
of Lothian vulnerability
Board
staff
came to focus on the
of the woman and the role of the
student.
of women
pregnant
woman’s
major source of concern the grounds exposed
vulnerability
that the woman would further
of relationships
was a
to senior midwives, on is already
to a wide range of personnel,
programme
increase
over-
and this
the number
she would be expected
to form.
For this reason it was agreed that, during recruitment,
the woman
participate statement for her.
and
would that
not be pressured
a
written
of the programme
difficult
later
in
approaching
natal clinic.
not be ‘high
b)
4
criteria
for
or other
and
to
verbal
would be provided
February These criteria student
are
intended
of a ‘normal’
are thought to be particularly vulnerable, the student would only visit the woman’s home in the company of the community midwife. The midwoman
and
student
if and when it was appropriate. on community midwives’ times would
of the student
the name
of the student
being
in
No attempt
has been made to include socio-economic
class as
to be involved
who will meet her is
given to her immediately. to be
ineligible
because they plan to move away before
Women
have
been
found
the birth
or because they are not ‘booked’. Although those women who declined to participate are not asked
them some anxiety.
agreed that in one part of the city, where women
the and
the chance
If the woman consents
the
distances
at the time of the birth.
a criterion.
of
to prevent
to increase
that such a role did not develop
To
outcome,
Edinburgh
year nursing
it was
the month
to increase
having to travel excessive
fourth
is not qualified.
city boundary
be due to give birth during
ensure
together Pressure
The
risk’ for obstetric
reason,
the
more
lecturer
4 have had at least one successful pregnancy
of a student
leave
The
a woman are that she should:
for their
would
opt for
suitable women on the advice of the
staff of the ante
presence
wife
unit. As a
would become
pregnancy.
Concern was expressed that the student may act as a health care provider, a role for which a student
is at the woman’s
in Edinburgh
care any approach
likelihood
The
phase began.
(first) visit to the consultant
large majority
in July
problems
senior nursing and midwifery Health
midwives
to the programme
‘booking’
cl live within Edinburgh Planningwith
early or
was given to the consultant
and the recruitment
Recruitment
shared
ending
When the details of the programme
approaches
‘I have found
plans were made for action in the
event of a woman’s
Two
women
spontaneous introduced;
some
who agreed
to participate
of recruitment
are informed
had
GPs and obste-
by letter of the names of
the women
and the students
pating.
letter
The
state that the
abortions before the student was the students were allocated to other
women. On completion tricians
of them
at the birth would cause
who are partici-
to the obstetrician
serves to
prevent more than one such visit being made during pregnancy, resulting in the remaining
provide information, woman’s involvement
contacts being made at the consultant GP ante natal clinic.
notes) and request labour ward staff to inform the student when the woman is in labour.
unit or the
alert the unit staff to the (having been filed in her
NURSE EDUCATION
Introductions are made at one of the woman’s ante
experience.
natal appointments.
that the labour
student serves
The lecturer
to the woman, to protect
introduces
an arrangement
the woman
the
which
in a situation
of
some uncertainty. Difficulties ductions,
in the early days
the women to arrange
as a large proportion
Easy access to a
was added to the criteria
ment in subsequent
for recruit-
years; this additional
ion does not appear of
these intro-
(29% in 1985/6)
had no access to a telephone. telephone
to have changed
socio-economic
class
among
criter-
the range
the
women
progressed
largely
recruited. the contacts
according to plan, the arrangement being as follows:
of the visits
4 visits (including
Labour
home) 1 visit
Post natal
2 visits (including
A small number
case
two
other
emotional
DNS
and
good support
the
support;
on the
good
community
to continue
In
woman
dependent
liaison
midwives
visiting, with
in both settings. have been able
to be with the woman, although there have been certain difficulties. Those births where the student was not informed
with the following
factors: caesarean
deliveries
i.e.
uses this final contact
lationship
A woman with previously
unrecognised
social
problems
to record
including
one baby born
arrival at unit
Debriefing after
the birth
The
keeps a diary, using pseudonyms,
her contacts.
feedback
from
adjustments
undertaken
all involved
in future.
An evaluation
distributed
students
to provide
in order
and to assist planning
been
to
participating
additional
all
to make
of the proquestionnaire
women
and
in the programme
were
questions were
identical, for
initially
the
all over The
except
students.
distributed
for Quest-
to health
board staff and GPs as well, but their responses claimed
insufficient
questionnaire. response
caused
disruption,
in Table
sent
on
the
to answer
the
and because
this
to indicate
that the
personnel
minimal
these
questionnaires
only been responses
knowledge
For this reason,
was interpreted
programme
have
to women
and
subsequently students.
from women and students
The
are shown
1. an item sought opinions
appropriateness
of
the
contact
time
between the woman and the student. This question was necessary in view of anxiety concerning
Table 1 Responses to the evaluation
1986-6 1986-7
births,
midwife.
to draw the re-
to a close.
Each student
emergency
section
rapid
unit and one at home
of the woman being in
have been associated
Complicated
at
one visit to the woman
of the community
In the questionnaire
During the labour most students
before
student
ionnaires
the woman’s part-
students
the
allowed these students
Very
in the company
one at
the visits. In the case of
to be becoming for
to be with
may be resentful
(and baby) in the maternity
questionnaires
have encountered
this was because
of
appeared
labour
birth
Post natal visits comprise
one at
ner had not been involved in her recruitment.
between
at the
as the woman
who were unable
the 3 years that it has been in operation.
of students
in completing
two students
student
rhe woman
has
home)
the
Those
gramme
Ante natal period
problems
had hoped.
An evaluation has been
Duringpregnancy
are disappointed
did not proceed
having missed the experience.
were encountered
in contacting
A small number
23 1
TODAY
involves
the student
informing the lecturer of the outcome. On this occasion most students are elated by their
1987-8
Total
questionnaire
Women
Students
Total
11 47.8% 12 50.0% 13 65.0%
16 69.6% 14 58.3% 7 35.0%
27 58.7% 26 54.2% 20 50.0%
36
37
73
(Percentages are the proportion in that year).
of those participating
232
NURSE EDUCATION
TODAY
Table 2 The contact between the mother and the student was fairly limited. Do you consider that this contact was appropriate, or should there have been more or less contact?
Satisfactory More needed Other/No response Total
Women
Students
Total
20 55.5% 14 38.8% 2 5.5%
21 56.8% 12 32.4% 4 10.8%
41 56.2% 26 35.6% 6 8.2%
36 100%
37 100%
73 100%
that her involvement
in this programme
may
affect her care in some way. The data (Table
3) shows that a large majority
of the respondents the
stated that participation
programme
caused
positively beneficial women
either
in
no effects
or
effects for the woman. Some
interpreted
this item
as meaning
the
relationshiu 1 with the student and indicated that it was ‘helpful’. Twelve (16.4%) respondents considered that health care personnel gave more comprehensive explanations to the woman when the student was present. As well as the possibility of these contacts being
the pregnant such
woman being over-burdened
contacts.
responses
Table
2,
with
summarises
the
and shows that a large majority
of the
women and students consider the time involved to be either acceptable or insufficient, but none considered
it excessive.
women demonstrate
Typical
comments
from
satisfaction:
‘I found that the contact
a burden to the woman it was necessary to assess the extent to which this programme constituted an unnecessary personnel
large proportion stated
that
gramme,
the student
and myself was fine as P---- was able to visit me
4). As mentioned
they
were
unaware
no major
of
this
problems.
stated that it occupied
particularly
a
respondents
midwives’ also
proOnly
staff time,
to the pressure
ward and community these
already
of health board staff and GPs
suggesting
10 respondents referring
between
extra work load for health care
(Table
on labour
time. Some of
suggested
that
there
more times than was stated in the introductory letter.
I considered
as someone
‘Yes definitely
appropriate,
the opportunity to extend Students
than
it appeared
that
regarded
None
the visits as time-consuming,
worthwhile. Suggestions for on the need for more contact,
home
and
post natal
visits and the
need for greater
flexibility.
It was suggested
this programme
of visits should be undertaken
earlier in the course to ease what is perceived
that as a
heavy final year work load and to avoid missing lectures. One student commented: ‘For the purposes contact,
Table 3 Do you consider that involvement any effect on the care provided?
was there if both sides wanted
the contact.’
but generally change focused especially
her more as a friend
doing her job.’
though
of the exercise admittedly
More information/ Reassurance Don’t know/Other/ No response Total
in some
None
respects, was adequate. I feel that in view of other work and similar commitments (to a
Time taken up
young family for instance) afforded much more time.’
Don’t know/Other/ No response
I could
not have
Closely linked with the possibility of the contacts having been a burden to the woman is the chance
Women
Students
Total
32 88.8% 3 8.3% 1 2.7%
26 70.2% 9 24.3% 2 5.4%
58 79.4% 12 16.4% 3 4.1%
36 100%
37 100%
73 100%
Table 4 Do you consider that this scheme had any implications for the staff in the maternity units and other health care personnel?
I felt that the
limited
in this scheme had
Total
Women
Students
Total
29 80.5% 4 11.1% 3 8.3%
29 78.4% 6 16.2% 2 5.4%
58 79.4% 10 13.7% 5 6.8%
36 100%
37 100%
73 100%
NURSE EDUCATION
Table 5 Was the information of visits: Accurate? Adequate? Appropriate?
presence,
given to you about the scheme
Women Satisfactory
Students
33 91.6% 3 8.3%
standing
present:
Don’t know/Other/ No response Total
36 100%
was not invariably
my point of view as a student
4 5.5%
37 100%
73 100%
1 found
the scheme to be well organised. The mother knew exactly what my role was to be, furthermore all the staff I came in contact the woman
An item which was included (Table
with were
of my role and well informed
would be called when labour.’
36 97.3% 1 2.7%
informa-
This lack of under-
aware
Total
adequate
tion having been provided.
‘From
If you have answered NO to any part of this question please describe how the information could have been improved
despite apparently
233
TODAY
personalities
depended
of the
that the success too much on the
woman
Some women assumed
I
to identify problems
6) elicited the suggestion
of the programme
that
went into
and
the
student.
that this was the reason
why their contacts with the student were satisfacmight also be beneficial
effects for staff (Mander
1988).
tory. In view of the fact that ‘matching’of and
student
would
be
Views
on the adequacy
of the information
limited numbers
provided
were also sought,
to assess satisfaction
and a lack of knowledge
and ascertain
whether
the correct
approach
had
depends
(Table 5). Sixty nine respondents stated that the information was satisfactory. Some of the first
who is informed
to make these contacts were dissatisfied
with the information staff, regarding inadequate ward;
provided
for labour
a letter in the woman’s notes as
to alert midwives
in a busy labour
this view was prevalent
who had not been informed in labour.
This
problem
placing a coloured
among
students
that the woman was
has been remedied
by
sticker in the ‘special features’
section of the notes and by speaking ward midwives
ward
during
January,
to the labour in advance
of
woman
because
of willing and suitable of students’
ties, the success or otherwise
been used in written and verbal communication
students
difficult,
of
women
personali-
of the relationship
very much on the efforts of the student, of this prior to the introduction.
Comments
were
Women’s
comments
tive, including the element
made
on
a range
were almost
of
issues.
entirely
posi-
the value of this form of contact, of continuity
it provides
and the
pleasant personality of the student. Those GPs who replied would have appreciated being including
more one
opportunity
involved who
in the programme;
would
to discuss
the
have
liked
woman
more
with
the
when the women are due to give birth. Some students, was unclear
having found that the woman
about what was involved,
suggested
that the woman be allowed more ‘thinking prior to agreeing; and almost Further
this is an offer which is made
invariably
evidence
time’
refused
at recruitment.
of this problem
is provided,
first, by the tendency of some woman to seek health advice from the student, a situation for which she is prepared and, second, one mother’s apology that she failed to demonstrate any medical haps
problems
not
Table 6 Did you encounter any problems with the implementation of this scheme?
to interest
surprisingly
they were repeatedly
the student!
students required
None Calling student
Personalities Don’t know
Per-
reported
that
to explain
their
Total
Women
Students
Total
30 83.3% 2 5.5% 1 2.7% 3 8.3%
31 83.8% 0 0 2.7% 5 13.5%
61 83.6% 2 2.7% 2 2.7% 8 10.9%
36 100%
37 100%
73 100%
234
NURSE EDUCATION
student.
Maternity
ably, perceiving learning.
TODAY
unit staff responded great
All students
favour-
value in this method
reported
that
for
they found
a range
of
of this
experience
valuable
reasons,
particularly
for the insight that it gave them on
the progress
of pregnancy
and the interaction
between
the
woman
the
student
stated:
and
‘I found it a very worthwhile experience.
Gaining including
emotional
and informative
emphasised
what
experience
woman, husband
As one
first hand knowledge
the events of pregnancy aspects,
carers.
a
personal
it could
be
of
various and
for
the
and relatives.’
SUMMARY A fully integrated been introduced Continuing contacts
valuable students, mothers
2)
has
experience
heavy burden
The value of the experience
the
on the women/
student.
to the student
to have been influ-
enced by the commitment the
for
a
or on the health care providers.
and its success appear of
provided
it does not appear to have placed
an unduly
a familiar
of the
programme
that a large majority
are
provides
a basis for ‘fine tuning’
gramme.
Certain
materialise, unexpected Whether
satisfied
able
and
of the pro-
problems
failed to
there appear
to be certain
this or a similar form
of Maternity
benefits.
Care Experience deserves
of
of those
with its operation
anticipated
whereas
has
problem.
is suitable for wider application
consideration.
DNS
to accommodate unpredictable
nursing the
students
irregular
and
timing of the contacts
by virtue
of the flexibility
Teaching
schedules
of their
timetable.
which are more structured
than those used in the university environment may reduce the freedom which permits the
programme
learning
evaluation
Component
principles
involved
are
CONCLUSIONS this
Care
educational
to remedy
indicates
sometimes
1) While
Maternity
based on established
and enthusiasm
Unfortunately
students who were very enthusiastic disappointed at the outcome of experience.
certain were their
3) The recruitment of parous women to participate in this programme is appropriate, as there appear to have been relatively few serious obstetric problems. The penalty to be paid for the involvement of parous women is that a number
student to fit in with the woman’s arrangements. It is for nurse advantages
teachers
to decide
of a programme
weigh the disadvantage
whether
the
such as this out-
involved in introducing
a more flexible timetable.
Acknowledgements I acknowledge the help of all those who were involved in planning, organising and implementing this programme. I would like to thank particularly the former Directors of Midwifery Services in Lothian Health Board, Miss Bess Jamieson and Miss Nora Stephen, and also the current DMSs, Miss Nina Taylor and Miss Sheila Fleming. I am grateful to the former and current officers of the statutory bodies, Miss A S Grant OBE and Miss V Pope respectively, whose foresight facilitated the implementation of this programme. and to the latter for her help in the preparation of this paper. I recognise the contribution of my colleagues in DNS and record my gratitude to the women, students and staff who made the programme both successful and enjoyable.
(six) have had very
rapid labours which prevents the student being with the woman in labour. 4) Women report that there have been certain advantages in being involved in this programme, which were not anticipated during the planning phase.
References Gunter L M 1969 The developing nursing student. Nursing Research Jan/Feb 18, 1: 60-64 Jacobsen F W 1985 The community as a health education resource in students nurse education. Unpublished Paper presented at First International Conference on Health Education in Nursing Midwifery and Health Visiting May 1985, Harrogate
NURSE EDUCATION
James E, Howden C 1985 Removing the blinkers. Nursing Mirror February 160, 8: 31-33 Mander R 1983 Stop and consider! Student midwife wastage in training. Research and the Midwife Conference Proceedings: 38-52 Mander R 1988 What can midwives learn from the babes? Implications for midwives of a maternity care programme for nursing students. Journal of Advanced Nursine 13: 306-313 Maslow A H 1954 Motivation and personality. New York, Harper
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235
NB[S] 1985 Maternity care module component descriptor. National Board for Nursing, Midwifery and Health Visiting for Scotland, Edinburgh Roper N, Logan W, Tierney A i980 The elements of nursing. Churchill Livingstone, Edinburgh UKCC 1986 Project 2000. United Kingdom Central Council for Nursing Midwifery and Health Visiting, London WHO 1985 Press release. February.
02606917/89/0009-0227/)10.00
A maternity evaluation
care course component
and
Rosemary Mander
A Maternity Care Component for Nursing Students has been developed within the Department of Nursing Studies in the University of Edinburgh, utilising an educational approach well-established within the Department. This paper describes the Component and its evaluation, which suggests that fears about certain problems were not justified and that all groups involved in the programme were satisfied with the way in which it operated. There may even have been certain benefits which had not been anticipated.
A MATERNITY CARE COMPONENT AND EVALUATION ‘The need for a reorientation of initial preparation towards the community was one theme which emerged strongly from this review . . . We feel that the time has come for a break with hospitals as the basis for so much initial preparation, and for new thinking about how placements and practical experience could be developed settings’.
in relation (Project
to a whole range of care
2000,
UKCC
1986)
As these words were being written in London the first group of Edinburgh University Nursing Students was completing a novel Maternity Care Component which achieved the aims stated in this quotation.
This
paper
explains
the edu-
approach cational incorporated in this Component, an approach well-established in the Department of Nursing Studies (DNS). The
evaluation,
an essential part of any innovation,
shown to have improved subsequent
The maternity
- The Maternity experience
Those
Care
for first level nursing
is widely recognised
difficulties.
is
during
years.
Background Component students
the experience
to be fraught
with
involved with this component
know the problems
which the student
encoun-
ters when studying all too briefly an area of care which may be perceived as having little relevance to her ultimate
goal. Large
arriving with monotonous motivation teaching
are
number
of students
regularity
and limited
an onerous
staff. Midwifery
staff are presented
responsibility
managers
with numerous
for
and clinical students
at
varying stages in their courses for brief and possibly fragmented experience. Frequent attempts to amend the experience testify
to the intractability
of these difficulties.
Rosemary Mander MSc PhD RGN SCM MTD Lecturer,
The National Board for Nursing,
Department of Nursing Studies, Adam Ferguson Building, George Square, Edinburgh EH8 9LL (Requests for reprints to RM) Manuscript accepted 19 December 1988
Midwifery
and
The female pronoun is used here, regardless of the student’s gender.
227
228
NURSE EDUCATION
TODAY
Health Visiting for Scotland made such an attempt (NB[S] 1985), but was prevented from grasping the nettle by rigid EEC requirements, which have the effect of presenting large numbers of students to institutions whose resources and flexibility of approach are limited by their multiplicity of commitments. Another attempt was made by the midwifery teaching staff of the Queen Mother’s Hospital, Glasgow who organised a scheme for nursing students of the Glasgow College of Technology. This scheme differed in certain crucial respects from the programme being described here: a) It was organised ‘in house’ by health board staff b) The women attended only the hospital antenatal cIinic c) The midwife teacher and student cared for the woman in labour The Glasgow scheme is no longer in operation and although other similar programmes may have been organised it has not been possible to locate details in the literature. The limited value of the traditional Maternity Care experience has been revealed in recent research (Mander 1983). This work indicates that nurses with (and particularly those with more) maternity care experience, far from being better able to make well-informed, durable career decisions, which might be anticipated in view of their experience in the maternity area, are actually over-represented among the student midwives who discontinue training. It was in this context that DNS radically revised the Maternity Care module in order to both enrich its value as a learning experience and to increase its congruity with the philosophy of the undergraduate nursing course.
Background -the
DNS approach
In 1982 DNS took advantage of the need to discontinue the District Nursing element of the BSc (Social Science/Nursing) course to shorten and radically alter the curriculum. These alterations reflect a commitment to a certain view of nursing, summarised by James and Howden
(1985) as *holistic individually-based care’. These authors, both DNS staff at the time, continued their description of the changes they implemented by emphasising the importance of community input into a ‘comprehensive training programme’. They explain the significance of the community experience: ‘The hospital environment provides our students with invaluable experience, but it also fosters a false sense of security and a limited view of society. To say that all human life is there in the community is no exaggeration. We may live our lives outside the hospital and other institutions, but do we always appreciate the complexity, richness and, for some, the despair, of that life in the ‘real world’?’ (James & Howden 1985) Jacobsen (1985) reinforced this view and took her former colleagues’ arguments a stage further. Presenting her view of a more transactional nurse-client relationship, she referred to a less publicised sequel to the Alma Ata Declaration: ‘The changing role of the nurse demands a radical change, not only a sound grasp of nursing knowhow, but in their relationship with other health personnel and the community in need of health care’. (WHO 1985). Jacobsen concluded that nurses, if they are to recognise and utilise the knowledge and experience of clients to develop this new relationship, must consult the clients. She then gave examples of learning in DNS which draw on the knowledge of ‘unqualified’ people, to illustrate this approach. These examples include the health selfappraisal in first year and their visits by second year students to the well elderly, emphasising the student taking a non-nursing approach. These visits enhance the student’s understanding of the support of the family and give her a more realistic picture of the capabilities of elderly people than that to be obtained in other environments. Jacobsen summarises the value of these visits as enabling the student to relate to patients: ‘in such
a way that
their
knowledge
and
NURSE EDUCATION
experience is valued equally with our specialist knowledge’. The examples provided by Jacobsen and by James and Howden serve to reinforce the important concept outlined by Gunter (1969), particularly her emphasis on the learning environment. Her rationale is that the emotional climate of the learning environment influences the processes by which the student experiences psychological development to achieve self-actualisation (Maslow 1954). The extent to which the student develops psychologically must determine her ability to form enduring, therapeutic relationships with those for whom she cares. Gunter implies that it is the teacher’s responsibility to ensure that the learning environment is conducive to healthy psychological development if the student is to function effectively as a nurse. This explains the emphasis within DNS on ensuring the appropriate learning environment. Having reviewed the nature of the problem and the theory underpinning the DNS teaching approach, I will describe the course component which, in the light of these considerations, was planned in conjunction with the health care agencies and the statutory bodies.
The childbearing course
component
of the
The student’s work on childbearing begins in the second year of the course and continues through into the final (fourth) year. Second Year - Introduction
This initial exposure to material and issues constitutes the largest part of the ‘Reproducing’ module in second year and prepares the student for her 2 week clinical experience in third year. Like all the modules in first and second year it utilises the ‘Activities of Living’ Model (Roper, Logan & Tierney 1980). Third Year - Clinical experience
A tutorial during a regular study day sets the scene for the student’s clinical experience in the maternity area. In this small group session a film is used to focus attention on emotional, sociological and psychological aspects of the forthcoming experience. The wide-ranging discussion follow-
TODAY
229
ing the film probes certain aspects of care which the student is likely to encounter, as well as the student’s expectations and any differences between this and other clinical experiences. The student spends one week in the labour ward and one in the post natal area, during which time she is taught by the permanent staff as well as the DNS lecturer. Fourth Year - Two interdependent elements
The student’s work on childbearing in the final year serves to consolidate and to integrate previous work. The two parts begin simultaneously and are interdependent, at least for the first term. A lecture series encourages the student to examine issues which she encountered during the clinical experience. These lectures also provide suggestions for discussion during the other part of the final year work on childbearing, which comprises a series of contacts between the student and a woman experiencing childbearing. The congruity of these two elements received favourable comments from students in the evaluation of the component, one of whom stated: ‘Lectures going along with these visits were both interesting and well timed as (I was) able to follow them up by questioning mother.’ The rationale for these contacts is that the student utilises the knowledge and experience of the woman to learn about normal childbearing, including the provision of care. As mentioned already (above) this approach has been used by the student during visits to the well elderly which she made during second year. Before describing the development of the visits it is necessary to emphasise the role of the student in this context. Her role is that of an interested, caring observer - ‘being a friend’ (Jacobsen 1985). As one student commented: ‘(I) Felt much more of a friend than a student nurse - helped by not being in uniform.’ The student is expected not to provide health care or information and she is advised of the appropriate action if such care or information is sought.
230
NURSE EDUCATION
TODAY
Contingency
Contacts with the woman of the contacts is for the student to come
Theaim
to understand
the experience
from the viewpoint has been assigned. services
and
changes
which
of childbearing
of the woman to whom she This includes
care
provided
learning and
occur
within
the
within the developing
family.
That
being achieved is confirmed
the
woman
and
this aim is
by informal
with students and by an unsolicited
about
about
contacts
comment
by
very beneficial.
It
a student: this scheme
was very interesting received same
unhappily.
had been agreed 1985,
from
time
fessional’s
to view the care Mrs K.
her point
being
of view and at the
aware
of the
health
pro-
point of view’.
pregnancy
with senior
information
obstetricians
of Lothian vulnerability
Board
staff
came to focus on the
of the woman and the role of the
student.
of women
pregnant
woman’s
major source of concern the grounds exposed
vulnerability
that the woman would further
of relationships
was a
to senior midwives, on is already
to a wide range of personnel,
programme
increase
over-
and this
the number
she would be expected
to form.
For this reason it was agreed that, during recruitment,
the woman
participate statement for her.
and
would that
not be pressured
a
written
of the programme
difficult
later
in
approaching
natal clinic.
not be ‘high
b)
4
criteria
for
or other
and
to
verbal
would be provided
February These criteria student
are
intended
of a ‘normal’
are thought to be particularly vulnerable, the student would only visit the woman’s home in the company of the community midwife. The midwoman
and
student
if and when it was appropriate. on community midwives’ times would
of the student
the name
of the student
being
in
No attempt
has been made to include socio-economic
class as
to be involved
who will meet her is
given to her immediately. to be
ineligible
because they plan to move away before
Women
have
been
found
the birth
or because they are not ‘booked’. Although those women who declined to participate are not asked
them some anxiety.
agreed that in one part of the city, where women
the and
the chance
If the woman consents
the
distances
at the time of the birth.
a criterion.
of
to prevent
to increase
that such a role did not develop
To
outcome,
Edinburgh
year nursing
it was
the month
to increase
having to travel excessive
fourth
is not qualified.
city boundary
be due to give birth during
ensure
together Pressure
The
risk’ for obstetric
reason,
the
more
lecturer
4 have had at least one successful pregnancy
of a student
leave
The
a woman are that she should:
for their
would
opt for
suitable women on the advice of the
staff of the ante
presence
wife
unit. As a
would become
pregnancy.
Concern was expressed that the student may act as a health care provider, a role for which a student
is at the woman’s
in Edinburgh
care any approach
likelihood
The
phase began.
(first) visit to the consultant
large majority
in July
problems
senior nursing and midwifery Health
midwives
to the programme
‘booking’
cl live within Edinburgh Planningwith
early or
was given to the consultant
and the recruitment
Recruitment
shared
ending
When the details of the programme
approaches
‘I have found
plans were made for action in the
event of a woman’s
Two
women
spontaneous introduced;
some
who agreed
to participate
of recruitment
are informed
had
GPs and obste-
by letter of the names of
the women
and the students
pating.
letter
The
state that the
abortions before the student was the students were allocated to other
women. On completion tricians
of them
at the birth would cause
who are partici-
to the obstetrician
serves to
prevent more than one such visit being made during pregnancy, resulting in the remaining
provide information, woman’s involvement
contacts being made at the consultant GP ante natal clinic.
notes) and request labour ward staff to inform the student when the woman is in labour.
unit or the
alert the unit staff to the (having been filed in her
NURSE EDUCATION
Introductions are made at one of the woman’s ante
experience.
natal appointments.
that the labour
student serves
The lecturer
to the woman, to protect
introduces
an arrangement
the woman
the
which
in a situation
of
some uncertainty. Difficulties ductions,
in the early days
the women to arrange
as a large proportion
Easy access to a
was added to the criteria
ment in subsequent
for recruit-
years; this additional
ion does not appear of
these intro-
(29% in 1985/6)
had no access to a telephone. telephone
to have changed
socio-economic
class
among
criter-
the range
the
women
progressed
largely
recruited. the contacts
according to plan, the arrangement being as follows:
of the visits
4 visits (including
Labour
home) 1 visit
Post natal
2 visits (including
A small number
case
two
other
emotional
DNS
and
good support
the
support;
on the
good
community
to continue
In
woman
dependent
liaison
midwives
visiting, with
in both settings. have been able
to be with the woman, although there have been certain difficulties. Those births where the student was not informed
with the following
factors: caesarean
deliveries
i.e.
uses this final contact
lationship
A woman with previously
unrecognised
social
problems
to record
including
one baby born
arrival at unit
Debriefing after
the birth
The
keeps a diary, using pseudonyms,
her contacts.
feedback
from
adjustments
undertaken
all involved
in future.
An evaluation
distributed
students
to provide
in order
and to assist planning
been
to
participating
additional
all
to make
of the proquestionnaire
women
and
in the programme
were
questions were
identical, for
initially
the
all over The
except
students.
distributed
for Quest-
to health
board staff and GPs as well, but their responses claimed
insufficient
questionnaire. response
caused
disruption,
in Table
sent
on
the
to answer
the
and because
this
to indicate
that the
personnel
minimal
these
questionnaires
only been responses
knowledge
For this reason,
was interpreted
programme
have
to women
and
subsequently students.
from women and students
The
are shown
1. an item sought opinions
appropriateness
of
the
contact
time
between the woman and the student. This question was necessary in view of anxiety concerning
Table 1 Responses to the evaluation
1986-6 1986-7
births,
midwife.
to draw the re-
to a close.
Each student
emergency
section
rapid
unit and one at home
of the woman being in
have been associated
Complicated
at
one visit to the woman
of the community
In the questionnaire
During the labour most students
before
student
ionnaires
the woman’s part-
students
the
allowed these students
Very
in the company
one at
the visits. In the case of
to be becoming for
to be with
may be resentful
(and baby) in the maternity
questionnaires
have encountered
this was because
of
appeared
labour
birth
Post natal visits comprise
one at
ner had not been involved in her recruitment.
between
at the
as the woman
who were unable
the 3 years that it has been in operation.
of students
in completing
two students
student
rhe woman
has
home)
the
Those
gramme
Ante natal period
problems
had hoped.
An evaluation has been
Duringpregnancy
are disappointed
did not proceed
having missed the experience.
were encountered
in contacting
A small number
23 1
TODAY
involves
the student
informing the lecturer of the outcome. On this occasion most students are elated by their
1987-8
Total
questionnaire
Women
Students
Total
11 47.8% 12 50.0% 13 65.0%
16 69.6% 14 58.3% 7 35.0%
27 58.7% 26 54.2% 20 50.0%
36
37
73
(Percentages are the proportion in that year).
of those participating
232
NURSE EDUCATION
TODAY
Table 2 The contact between the mother and the student was fairly limited. Do you consider that this contact was appropriate, or should there have been more or less contact?
Satisfactory More needed Other/No response Total
Women
Students
Total
20 55.5% 14 38.8% 2 5.5%
21 56.8% 12 32.4% 4 10.8%
41 56.2% 26 35.6% 6 8.2%
36 100%
37 100%
73 100%
that her involvement
in this programme
may
affect her care in some way. The data (Table
3) shows that a large majority
of the respondents the
stated that participation
programme
caused
positively beneficial women
either
in
no effects
or
effects for the woman. Some
interpreted
this item
as meaning
the
relationshiu 1 with the student and indicated that it was ‘helpful’. Twelve (16.4%) respondents considered that health care personnel gave more comprehensive explanations to the woman when the student was present. As well as the possibility of these contacts being
the pregnant such
woman being over-burdened
contacts.
responses
Table
2,
with
summarises
the
and shows that a large majority
of the
women and students consider the time involved to be either acceptable or insufficient, but none considered
it excessive.
women demonstrate
Typical
comments
from
satisfaction:
‘I found that the contact
a burden to the woman it was necessary to assess the extent to which this programme constituted an unnecessary personnel
large proportion stated
that
gramme,
the student
and myself was fine as P---- was able to visit me
4). As mentioned
they
were
unaware
no major
of
this
problems.
stated that it occupied
particularly
a
respondents
midwives’ also
proOnly
staff time,
to the pressure
ward and community these
already
of health board staff and GPs
suggesting
10 respondents referring
between
extra work load for health care
(Table
on labour
time. Some of
suggested
that
there
more times than was stated in the introductory letter.
I considered
as someone
‘Yes definitely
appropriate,
the opportunity to extend Students
than
it appeared
that
regarded
None
the visits as time-consuming,
worthwhile. Suggestions for on the need for more contact,
home
and
post natal
visits and the
need for greater
flexibility.
It was suggested
this programme
of visits should be undertaken
earlier in the course to ease what is perceived
that as a
heavy final year work load and to avoid missing lectures. One student commented: ‘For the purposes contact,
Table 3 Do you consider that involvement any effect on the care provided?
was there if both sides wanted
the contact.’
but generally change focused especially
her more as a friend
doing her job.’
though
of the exercise admittedly
More information/ Reassurance Don’t know/Other/ No response Total
in some
None
respects, was adequate. I feel that in view of other work and similar commitments (to a
Time taken up
young family for instance) afforded much more time.’
Don’t know/Other/ No response
I could
not have
Closely linked with the possibility of the contacts having been a burden to the woman is the chance
Women
Students
Total
32 88.8% 3 8.3% 1 2.7%
26 70.2% 9 24.3% 2 5.4%
58 79.4% 12 16.4% 3 4.1%
36 100%
37 100%
73 100%
Table 4 Do you consider that this scheme had any implications for the staff in the maternity units and other health care personnel?
I felt that the
limited
in this scheme had
Total
Women
Students
Total
29 80.5% 4 11.1% 3 8.3%
29 78.4% 6 16.2% 2 5.4%
58 79.4% 10 13.7% 5 6.8%
36 100%
37 100%
73 100%
NURSE EDUCATION
Table 5 Was the information of visits: Accurate? Adequate? Appropriate?
presence,
given to you about the scheme
Women Satisfactory
Students
33 91.6% 3 8.3%
standing
present:
Don’t know/Other/ No response Total
36 100%
was not invariably
my point of view as a student
4 5.5%
37 100%
73 100%
1 found
the scheme to be well organised. The mother knew exactly what my role was to be, furthermore all the staff I came in contact the woman
An item which was included (Table
with were
of my role and well informed
would be called when labour.’
36 97.3% 1 2.7%
informa-
This lack of under-
aware
Total
adequate
tion having been provided.
‘From
If you have answered NO to any part of this question please describe how the information could have been improved
despite apparently
233
TODAY
personalities
depended
of the
that the success too much on the
woman
Some women assumed
I
to identify problems
6) elicited the suggestion
of the programme
that
went into
and
the
student.
that this was the reason
why their contacts with the student were satisfacmight also be beneficial
effects for staff (Mander
1988).
tory. In view of the fact that ‘matching’of and
student
would
be
Views
on the adequacy
of the information
limited numbers
provided
were also sought,
to assess satisfaction
and a lack of knowledge
and ascertain
whether
the correct
approach
had
depends
(Table 5). Sixty nine respondents stated that the information was satisfactory. Some of the first
who is informed
to make these contacts were dissatisfied
with the information staff, regarding inadequate ward;
provided
for labour
a letter in the woman’s notes as
to alert midwives
in a busy labour
this view was prevalent
who had not been informed in labour.
This
problem
placing a coloured
among
students
that the woman was
has been remedied
by
sticker in the ‘special features’
section of the notes and by speaking ward midwives
ward
during
January,
to the labour in advance
of
woman
because
of willing and suitable of students’
ties, the success or otherwise
been used in written and verbal communication
students
difficult,
of
women
personali-
of the relationship
very much on the efforts of the student, of this prior to the introduction.
Comments
were
Women’s
comments
tive, including the element
made
on
a range
were almost
of
issues.
entirely
posi-
the value of this form of contact, of continuity
it provides
and the
pleasant personality of the student. Those GPs who replied would have appreciated being including
more one
opportunity
involved who
in the programme;
would
to discuss
the
have
liked
woman
more
with
the
when the women are due to give birth. Some students, was unclear
having found that the woman
about what was involved,
suggested
that the woman be allowed more ‘thinking prior to agreeing; and almost Further
this is an offer which is made
invariably
evidence
time’
refused
at recruitment.
of this problem
is provided,
first, by the tendency of some woman to seek health advice from the student, a situation for which she is prepared and, second, one mother’s apology that she failed to demonstrate any medical haps
problems
not
Table 6 Did you encounter any problems with the implementation of this scheme?
to interest
surprisingly
they were repeatedly
the student!
students required
None Calling student
Personalities Don’t know
Per-
reported
that
to explain
their
Total
Women
Students
Total
30 83.3% 2 5.5% 1 2.7% 3 8.3%
31 83.8% 0 0 2.7% 5 13.5%
61 83.6% 2 2.7% 2 2.7% 8 10.9%
36 100%
37 100%
73 100%
234
NURSE EDUCATION
student.
Maternity
ably, perceiving learning.
TODAY
unit staff responded great
All students
favour-
value in this method
reported
that
for
they found
a range
of
of this
experience
valuable
reasons,
particularly
for the insight that it gave them on
the progress
of pregnancy
and the interaction
between
the
woman
the
student
stated:
and
‘I found it a very worthwhile experience.
Gaining including
emotional
and informative
emphasised
what
experience
woman, husband
As one
first hand knowledge
the events of pregnancy aspects,
carers.
a
personal
it could
be
of
various and
for
the
and relatives.’
SUMMARY A fully integrated been introduced Continuing contacts
valuable students, mothers
2)
has
experience
heavy burden
The value of the experience
the
on the women/
student.
to the student
to have been influ-
enced by the commitment the
for
a
or on the health care providers.
and its success appear of
provided
it does not appear to have placed
an unduly
a familiar
of the
programme
that a large majority
are
provides
a basis for ‘fine tuning’
gramme.
Certain
materialise, unexpected Whether
satisfied
able
and
of the pro-
problems
failed to
there appear
to be certain
this or a similar form
of Maternity
benefits.
Care Experience deserves
of
of those
with its operation
anticipated
whereas
has
problem.
is suitable for wider application
consideration.
DNS
to accommodate unpredictable
nursing the
students
irregular
and
timing of the contacts
by virtue
of the flexibility
Teaching
schedules
of their
timetable.
which are more structured
than those used in the university environment may reduce the freedom which permits the
programme
learning
evaluation
Component
principles
involved
are
CONCLUSIONS this
Care
educational
to remedy
indicates
sometimes
1) While
Maternity
based on established
and enthusiasm
Unfortunately
students who were very enthusiastic disappointed at the outcome of experience.
certain were their
3) The recruitment of parous women to participate in this programme is appropriate, as there appear to have been relatively few serious obstetric problems. The penalty to be paid for the involvement of parous women is that a number
student to fit in with the woman’s arrangements. It is for nurse advantages
teachers
to decide
of a programme
weigh the disadvantage
whether
the
such as this out-
involved in introducing
a more flexible timetable.
Acknowledgements I acknowledge the help of all those who were involved in planning, organising and implementing this programme. I would like to thank particularly the former Directors of Midwifery Services in Lothian Health Board, Miss Bess Jamieson and Miss Nora Stephen, and also the current DMSs, Miss Nina Taylor and Miss Sheila Fleming. I am grateful to the former and current officers of the statutory bodies, Miss A S Grant OBE and Miss V Pope respectively, whose foresight facilitated the implementation of this programme. and to the latter for her help in the preparation of this paper. I recognise the contribution of my colleagues in DNS and record my gratitude to the women, students and staff who made the programme both successful and enjoyable.
(six) have had very
rapid labours which prevents the student being with the woman in labour. 4) Women report that there have been certain advantages in being involved in this programme, which were not anticipated during the planning phase.
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NURSE EDUCATION
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