The argument that ‘research is boring’ is one that greets me most days when trying to introduce research to undergraduate student midwives. The role of research in midwifery has become well established and, as a lecturer, I believe that it is important for student midwives to appreciate the importance of research, and to be able to understand and analyse it. However, determining how to achieve this, when student midwives do not always immediately see its value, has not been an easy journey. This article will discuss how research has become embedded in midwifery practice and education, and how midwifery educators can begin to engage student midwives in research and evidence.
Midwifery and research
Research has not always played a role in midwifery care and education. Memories of common midwifery practices that were not evidence-based, such as routine shavings, enemas and episiotomies, remain vivid in the memories of both midwives and women (Steen and Roberts, 2011). During the 1980s, however, the concept of evidence-based practice began to emerge in medicine, through the work of David Sackett at McMaster University in Canada (Spiby and Munro, 2010). Medical professionals were encouraged to act on available research, and eradicate care that was based purely on a health professional's personal preference and tradition (Rees, 2012). This same ethos was transferred into midwifery care through the work of the National Perinatal Epidemiology Unit (NPEU) in Oxford, which was established in 1978 and comprised researchers from various backgrounds, including midwifery. The NPEU was led by Iain Chalmers and was developed after Archie Cochrane, a leading British epidemiologist, made disparaging remarks about the lack of evidence in the care of pregnant women (Renfrew, 1997). The following years saw the development of research within midwifery; in 1985, the Midwives Information and Resources Service (MIDIRS) was created, a journal dedicated to the dissemination of midwifery knowledge (Anderson, 2006), and research by NPEU led to the publication of Effective Care in Pregnancy and Childbirth (Chalmers et al, 1989) and a subsequent guide (Enkin et al, 1989). This is one of the first examples of evidence in childbirth being collated and synthesised for use in midwifery care (Renfrew, 1997). It was also at this time that midwives began to undertake research themselves, and Clark (2000) highlights revolutionary midwifery research into shaving (Romney, 1980), enemas (Romney and Gorden, 1981) and routine episiotomies (Sleep et al, 1984). The Cochrane Pregnancy and Childbirth Database, a collection of the latest research and evidence, followed in 1993 (Chandler et al, 2017), and for the first time, provided every midwife with easy access to the latest research and evidence-based knowledge (Renfrew, 1997). Research was also introduced into the midwifery curriculum in the 1980s (Macdonald, 2004). When midwifery education was assimilated into higher education institutions in the 1990s, it cemented the concept of midwifery as an evidence-based profession (Clark, 2000).
Research and evidence-based practice developed in popularity throughout the 1990s, with the Department of Health and the NHS stating that research was the central tenet of the NHS (Department of Health and NHS Executive, 1995; Department of Health, 1997; NHS Executive 1999) and the creation of the Midwives Association and Evidence-Based Midwifery Network in 1998, enabling midwives to collaborate and share research (Spiby and Munro, 2010). Stakeholder consultations and midwifery involvement in the creation of guidelines from the National Institute for Health and Clinical Excellence (NICE) (2014), and the Royal College of Midwives (RCM) (2012), which have provided more opportunities for midwives to become involved in research, while reports such as Changing Childbirth (Department of Health, 1993), Midwifery 2020 (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010) and Better Births (National Maternity Review, 2016), have used research to respond to issues most important to midwives and women. This brings us to today, where there are more midwives undertaking PhDs than ever before (Steen and Roberts, 2011) and research is championed as fundamental to the role of the midwife (Department of Health, 2012; 2014; Nursing and Midwifery Council (NMC), 2015).
Is evidence-based midwifery a good thing?
Despite the increase in research in midwifery, it has not always been welcomed. The dominance of randomised controlled trials has been criticised (Walsh, 1996; 2008), and it has been suggested that care cannot be individualised when mass guidelines are enforced (Drife, 1995). The result of research on midwives' autonomy has also been questioned (Rees, 2012), and Jefford et al (2010) have argued that evidence and research cannot be used in the same manner in midwifery as they can in medicine, as in midwifery the woman, not the guidelines is the decision-maker. However, as Sackett (1996), the creator of the concept of evidence-based practice, states, research findings should not replace experience, but rather work alongside it. Similarly, Walsh (2010) has concluded that midwifery research must be allied with a social model of childbirth, acknowledging that, above all, birth is a normal, physiological process. However we approach research, it is an inextricable part of midwifery today, as working to the best available evidence, and ensuring all advice is evidence-based, is a key component of The Code (NMC, 2015). Studying new research, and adapting practice accordingly, is also part of continuing professional development, which is necessary for revalidation and maintaining midwifery registration once qualified (NMC, 2017). It is therefore crucial that students interact meaningfully with research throughout their midwifery careers, beginning at undergraduate level. Midwifery educators and practitioners must provide opportunities to help students to value research, to learn about it and to gain the necessary research skills to become lifelong learners and seekers of information.
‘However we approach research, it is an inextricable part of midwifery today, as working to the best available evidence, and ensuring all advice is evidence-based, is a key component of The Code’
Research in the midwifery curriculum
Since 2008, programmes providing a midwifery qualification have been delivered at degree level by Approved Education Institutions (AEIs) (NMC, 2009). Although the NMC standards for pre-registration midwifery education are under review, to maintain AEI status, universities must follow NMC regulations, one of which is the need to teach research to undergraduate midwifery students (NMC, 2009).
Research and the philosophy of evidence-based midwifery have been introduced into undergraduate programmes to reflect the needs of the qualified midwives. By analysing research, students develop the ability to think critically, evaluate, reflect, and make decisions. These are essential skills for the competent practising midwife (Power and Ridge, 2017), and ensure that students develop the ability to adapt their practice in the rapidly changing healthcare environment and in the light of new information (NMC, 2009). It is therefore not surprising that the NMC (2008) stipulates not only that an accredited midwifery course should teach research philosophy and criticism in the classroom, but also that midwifery students must be assessed in the clinical environment in their use of evidence-based practice. This weaving of research throughout all aspects of academic and practice-based midwifery education reflects the importance and omnipresence of research in midwifery.
How to teach research in midwifery
Make the connection between evidence-based practice and research clear
Why educators should teach research has always been clear to me, but the ‘how’, I feel, has often been elusive. The first issue that became evident when I initially started teaching research, was that many students were familiar with the term evidence-based practice, and accepted that the work they did as a midwife must be grounded in evidence, yet they did not always make the connection between evidence and research, which caused some students to panic when research was introduced. Students felt that research was a completely new, abstract topic, bearing no relevance to the role of the midwife they had been taught previously in class, or to the work they had experienced in clinical placement. My advice is simply to make it clear, from when the concept of evidence-based midwifery is first introduced to students, that it is research that generates the evidence. At the University of Nottingham, the research aspect of evidence-based practice is emphasised in the first year. Then, when research is introduced as an independent topic later in the programme, it is not a scary prospect for the students, nor does it appear to be of no relevance to the other subjects taught.
Applying research to practice
Forgetting the context in which research exists disengages qualified staff from having an interest in research (Walsh, 2010; Jeffs et al, 2013), and I have found the same to be true of students. Knowles et al (2012) state that adult learners are most interested in subjects that are relevant to their lives and that help them solve real issues. Therefore, midwifery research must be applied to student's experiences using a variety of student-centred teaching methods. Discussing with students examples of how research has changed practice, and how the practice they have witnessed has been guided by or has disregarded research, can make research a tangible, real-world subject with which to interact.
To truly engage students and emphasise the relevance of research in clinical practice, we have also developed an online, interactive, multiple-choice quiz. For example, one of the questions is: ‘If midwifery research did not exist and I went into labour, what would I experience?’. The answers students have to choose from are: (a) Have my perineum shaved; (b) Experience ‘bowel prep’; (c) Have an episiotomy with my first birth; (d) Give birth in an obstetric ward. Of course, all the answers are correct, but this allows students to clearly identify the real effect that research has on them, not only as practitioners, but as women and/or carers of women.
The application of research to midwifery is also embedded into student assessments, by creating assignments where students explore the research relevant to a midwifery subject, rather than having an assessment on a purely academic topic. This ensures that, throughout the research module, students are encouraged to reflect on how research is an inherent part of midwifery practice.
Identify how research can help students and their careers
For the adult learner, motivation and a desire to fulfil one's own potential can be a strong impetus to engage in learning (Rogers, 2002). Therefore, highlighting to students the importance of research to them as individuals can encourage them to become immersed in research. We have achieved this by discussing how research can strengthen the midwives' role as an advocate for women, as the knowledge it provides can be a source to challenge others to support women's choice (Rees, 2012), and can be a tool with which to question obstetric-led decision-making (Spiby and Munro, 2012). One example discusses how it was research that empowered midwives to stop performing routine episiotomies (Bick, 2011). Being involved in research also enhances an individual's job satisfaction, by creating possibilities for further career progression, and provides opportunities for different interests and perspectives within midwifery practice. The need to discuss this with students is supported by O'Byrne and Smith (2011), who found that emphasising the importance of research activity to the individual and their career, rather than to the organisation, encouraged research activity in qualified staff.
Make research real and attainable
Research can also be made more interesting and engaging by inviting experienced midwifery researchers, working either at the University or in clinical practice, to talk to the students about their research. This helps students to realise that research is attainable: it is not something that ‘other people’ do in lab coats far away, but it is something that real midwives are involved in close to home. This allows students to see that research—whether it is understanding and critiquing it, or pursuing it as a career—is within their reach.
Acknowledge different levels of experience
It is important to recognise that midwifery students have different backgrounds, life experiences and levels of education. In one class it is possible to have a student with a PhD and one who has not been in formal education for 20 years; therefore, acknowledging this and finding ways to present knowledge that is both accessible and interesting to all is important. Knowles et al (2012) believe that adult learners' previous experiences can be a resource for learning, and a recent report by Health Education England (Jones et al, 2015), states that healthcare education must adapt to the differing generations and demographics among healthcare students. At the University of Nottingham, we have achieved this by basing our programme on the ‘Flipped Learning’ model. Flipped learning involves the student investigating a topic outside the classroom to gain a basic understanding of the subject before coming to class to expand on that knowledge and explore the topic in more depth (Williams and Coolin, 2015). Through this model, we have been able to facilitate learning at varying levels of complexity via an online learning platform, offering introductory knowledge or more in-depth exploration. For example, we have created ‘research plus’, an online package where students who wish to have more information can access additional work to be able to challenge themselves.
Show your belief in research
Research is crucial for the survival of midwifery. It is only by actively generating research in the topics important to us, as midwives, that we can stand independently from other professions with our own specialist knowledge and expertise. This is not to suggest that other professions' knowledge should be discounted; merely that without engaging in research, midwives risk relying on the knowledge of others, which may prioritise aspects of care that do not support the core values of midwifery. For example, following obstetric-led research may lead to a medical model of care, rather than the social, physiological understanding of birth to which most midwives subscribe (Walsh and Newburn, 2002). Although McNeill and Nolan (2011) warn of the possible bias that can arise when midwives research their own social environments, Rowland and Jones (2013) argue that midwifery researchers ensure that research remains woman-centred, as they have witnessed the effect of research on women and their families. Similarly, Rees (2012) states that the future of midwifery will be decided by those that have the ability to take it further. I believe that this is the core message that must be conveyed to student midwives. If student midwives can be engaged in research, they can be empowered to create their future and enhance the care of women and their families.
Practise what you preach
Finally, the midwifery educator must be an active researcher. It goes without saying that the topic they teach should be evidence-based, but in addition, their teaching practices must be built on a solid foundation of educational research—a challenge for educators working in today's busy higher education settings.
Conclusion
Midwifery has not always embraced research as a crucial element of its practice—only since the 1980s has midwifery research underpinned all aspects of childbirth care. However, teaching research to midwifery students is not simple, as students often question the relevance of research in their role in clinical practice. They can see the midwife as purely a practical, skills-based worker and research as an academic activity that takes them away from the ‘real work’ of clinical practice; yet, applying research to practice and identifying how research can help them as individuals encourages them to see its relevance. Making research attainable; acknowledging different levels of experience; and demonstrating commitment to research can also encourage students to engage with research in a meaningful and more interesting way.