Ali's Proposal
The Theory Practice Gap in Maternal Child Nursing Education:
Childbirth
is a monumental and profound event in the lives of women and their families.
According to the Listening to Mothers II survey, what happens during the birth
period matters deeply and has long lasting implications for the social,
emotional, and physical health of women and their infants. Many women in this
survey described what an incredible challenge and then accomplishment giving
birth to their child was and commented on what a life altering event this was
in their lives. One woman stated, “Childbirth is a trial by fire. It is most physically and
emotionally intense and challenging thing I have ever been through in my life”
(Declerq, E.R., Sakala, C., Corry, M.P., Applebaum, S., 2006). It is important to support and care for women
using evidence based practice to support and encourage them through this most
challenging time in their lives. Women in this survey had much to say about
their childbirth experience and it cannot be forgotten that childbirth is a
personal journey that the nurse and medical staff must do their best to support
and encourage based on the woman and child’s best interest and long term
health.
The overall state of
maternity care that women in this country are receiving is in need of work.
Healthy People 2020 (2012), state as one their objectives to reduce the
occurrence of primary cesarean sections amongst women who are low-risk. Low
risk is defined by Health People 2020 as, “full-term, vertex, and singleton
presentation”. The rate of cesarean
section as an intervention in this country is incredibly high with a rate of 32.8%
as of 2011. This is an increase of almost 53% from 1996-2009 (Hamilton B.E., Martin J.A., Ventura S.J.,2011).
One of the documented reasons for such
as sharp increase is the incidence of repeat cesarean sections after a primary
cesarean section has already occurred. It is important to reduce the rate of
primary cesarean sections being performed on low-risk women. Not only is the
cesarean section rate rapidly increasing but the occurrence of unnecessary
interventions is also increasing. In the Listening to Mothers Survey II, 42% of
all women surveyed reported that their labors were induced. (Declerq et al.,
2006). The mothers reported that their induction was due to both non-medical as
well as medical reasons. The leading
reason for induction was stated to be that the woman was overdue. Overdue was
defined by these women as being 41 weeks
of gestation. (Declerq et al., 2006). Only 19% of inductions were reported to
be due to a medical cause that required the end of the pregnancy (Declerq et
al., 2006). 76% of women were continuously monitored during their labor which
severely restricted their ability to move around freely (Declerq et al., 2006).
Few women were able to walk around during their labor or eat or drink during
their labor. An astounding 57% of women gave birth in the lithotomy position
which is described to inhibit the natural descent of the fetus through the
birth canal. (Declerq et al., 2006). Women described their feelings at the time
of birth to be, “alert, capable, and confident” but also “overwhelmed,
frightened, and weak” (Declerq et al., 2006). The interventions described above
as well as several others not mentioned are in direct opposition to what we
know now is best practice for care during labor and birth.
The rate of these
interventions is on the rise and it is not without consequences. According
to MacDorman, M., Declerq, E., Menacker,
F., Mallow, M.H. (2006), “Since vital statistics on cesarean sections began to
be collected (1989), the infant mortality rate in the United States for total
cesarean deliveries has consistently been approximately 1.5 times that for
vaginal deliveries”. Pregnancy related maternal
deaths have been on a steady climb since collection of the data in 1987 with
the most recent report being 12.7 deaths per 100,000 live births per year as of
2007. This is almost double the death rate from 1989 (Xu J, Kochanek K, Murphy
S, Tejada-Vera B., 2010). These statistics make it clear that the United States
needs to improve its maternity care in order to provide safer and healthier
care to the women and children in this country. Macdorman et al. (2006), state
that “Neonatal mortality rates were considerably higher for cesarean
deliveries, compared with vaginal deliveries”. Cesarean birth done without due
cause puts both the mother and the newborn at greater risk for complications,
including death, then a normal physiologic vaginal delivery.
Albers (2005) states,
“No evidence supports the routine use of electronic fetal monitoring,
epidurals, oxytocin, or episiotomies in low risk women”. We are obligated as
health care professionals to provide evidence based practice that allows for
the best outcomes for both women and child. In order to have an optimal safe
birth Albers (2005) claims that a vaginal birth and an intact genital tract are
necessary features which are becoming rare do the overtreatment and use of
routine yet unnecessary medical interventions.
Nurses are in a
unique position to influence maternity outcomes because they are consistently
present at the bedside of women in labor more than any other health care
professional. They are on the frontlines of care for laboring women. Nurses should and can advocate for their
patients to have the best and most effective care. Edmonds and Jones (2012)
state that, “Nursing care during labor has been shown to be a significant
independent factor in predicting delivery mode”. The way in which nurses think about normal
birth greatly impacts the care they give to their patients. In a study done by
Regan and Liaschenko (2007), women were asked to look at a photograph of a woman
in labor and found that “nurses’ beliefs about childbirth and risk form a logic
of reasoning that directs nursing actions along a trajectory that might be
associated with cesarean section”. Nurses are in a powerful position to
influence the path of labor and birth. Nurses must be aware of best evidence
based practice when caring for laboring women and be able to deliver care that
is based on the best evidence available.
In 2010, 3,999,386
births were reported to U.S. citizens. Of these births, 98.8% took place in a
hospital setting staffed by registered nurses (Martin JA, Hamilton BE,
Ventura SJ, et al,
2012). Due to their sheer numbers, nurses have the potential to influence the
direction and outcome of the birth.
The six care practices identified by the
organization Lamaze International may serve as a strong foundation for nurses
to embrace, support, and promote normal physiologic birth. These care practices
promote the normal physiologic process of labor with limited interventions in
the low-risk population of laboring women. The practices are “1. allowing labor
to start on its own, 2.freedom of movement during labor, 3. continuous labor
support, 4. spontaneous pushing in nonsupine positions, 5.no separation of mother and baby, and 6. no
routine interventions” (Romano and Lothian, 2007). The women surveyed in the
Listening to Mothers Survey II reported minimal use of these care practices yet
these practices have a strong evidence base. There is a gap between evidence to
support best practice during labor and birth as opposed to documented practices of nurses
during labor and birth. This theory-practice gap is astounding and has significant
effects on the health of women and their newborn children. Nurses have the
potential to influence labor and birth outcomes and by putting the six care
practices into effect, nurses can promote and support normal physiologic birth
in order to increase maternal-child health. These care practices have the
potential to decrease the incidence of unnecessary interventions, including
cesarean section, while at the same time promoting normal physiologic birth.
I would like to begin
a search into this theory-practice gap by beginning to study the student nurse
experience during their Maternal Child clinical under the guidance of Professor
Sylvia Ross. I would like to perform in-depth interviews of ten senior level
nursing students at Rhode Island College who have completed their
Maternal-Child clinical rotation in order to explore their experience with the
six care practices outline by Lamaze International. I would like for these
students to describe their clinical experience in relation to these six care
practices. This is of interest to me because I would like to gather evidence
that even though these care practices are considered best practice they are not
used. This is important because women who want to be well supported during
labor and optimize their chances for a non-inventive vaginal delivery need to
know how often and where these practices are being performed. It is also
important because the education that student nurses receive will shape their
practice and impact the health of others. Part of the interview process will
gather data about whether the students attended a teaching hospital or a
community hospital to explore the differences in these experiences in relation
the six care practices.
The method I will be
using to gather my research will be qualitative. The reason for choosing this
research domain is that I am interested in the students’ narratives and experiences.
Polit and Beck (2010) define qualitative research to be “the collection of rich
narratives through a flexible research design”. I believe that it is in the stories of people
that we can gain the most knowledge, true meaning, and rich description to
develop a deeper understanding of the issues at hand. This method of research
also allows flexibility in gathering research so that I can shape my interview
questions depending on the responses. Polit and Beck (2010) describe it to be
“flexible and elastic, and capable of adjusting to what is being learned during
the course of data collection”. My overarching goal is to find out what
students nurses experienced as a part of their maternity clinical and use this
knowledge to develop a deeper understanding of student nurses’ perceptions and
beliefs about normal physiologic birth. These beliefs will shape their future practice
as registered nurses and as a result the health of the women and children they
care for. This research could help to bridge the theory-practice gap. The six
care practices are a part of the curriculum in nursing theory classes at Rhode
Island College and this research will explore in depth whether the students
gained experience with them in the clinical arena and what their beliefs and
perceptions about their experience in relation to the six practices are.
Projected Time Line:
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Time Period
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Projected Activities
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March 20th
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Present research proposal to curriculum
committee
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Summer 2013
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Meet with Professor Ross
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Fall 2013
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Take Honors 390
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Research topic and method
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Being interviews
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Spring 2014
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Take Honors 391
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Complete interviews
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Analyze data and write up data
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Present final project
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