Research and evidence-based midwifery practice are essential in order to drive the profession forward and deliver safe, effective, women-centred care. Evidence-based practice is not a new concept, but it is evolving, and curriculum models need to be dynamic and flexible to allow for changes in midwifery practice, delivery of services and the continued development of evidence-based practice.
Midwives work in ever-changing care environments, and changes in policy, technology and the demography of society all affect how midwifery care is delivered. Various high profile public inquiries, such as the Francis Report (2013), the Morecambe Bay investigation (Kirkup, 2015) and the Nursing and Midwifery Council (NMC) (2014) in Guernsey have increased scrutiny of midwives' work, and clinical negligence claims relating to maternity care represent 50% of the received claims to NHS Resolution (formerly NHS Litigation Authority) (NHS Resolution, 2017). As a result, midwives are increasingly required to use evidence to justify the decisions they make and the care they have provided, rather than relying upon experience and intuition.
This article will define evidence-based practice, discuss its use in midwifery, provide examples of evidence and demonstrate how a philosophy of evidence-based practice can be embedded within a pre-registration midwifery curriculum and beyond.
Elements of evidence-based practice
There has been some debate about what evidence-based practice actually means. There are a number of terms used interchangeably in the literature, including ‘evidence-based practice’, ‘evidence-based medicine’, ‘evidence-based healthcare’ and ‘research-informed practice’. The term ‘evidence-based practice’ derives from medicine and has been defined as ‘the integration of best research evidence with clinical expertise and patient values’ (Sackett et al, 2000: 1). This acknowledges that the best available research evidence available should be used, but that it should be applied discerningly in the context of individual patient- or woman-centred care.
McKibbon provides an explanation of evidence-based practice that recognises the importance of the patient, client or woman in decision-making and is perhaps particularly relevant to midwifery:
‘[Evidence-based practice] involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristic, situations and preferences.’
Evidence from the different types of research design are graded in a hierarchy (Table 1), with the highest quality evidence at the top of the table, and those requiring greater critical assessment at the bottom. Research knowledge is only one source of information, however, and there is a growing understanding that various forms of evidence have to be acknowledged, as different problems or circumstances call for different types of knowledge and skills (Rolfe et al, 2008). This challenges the concept of a hierarchy of research evidence, because each type of evidence has its own strengths and applications. Evidence derived from randomised controlled trials, perceived by medicine to be towards the top of the hierarchy of evidence, has been criticised for limiting and controlling women's choices, for example in relation to length of second stage and place of birth (Fahy, 2008). In order to work in partnership with women, midwives therefore need to take into account research evidence, clinical experience, and information from women and their families. Moule (2015) has developed a five-step process that enables midwives to identify evidence and put it into practice (Box 1).
| Level 1a | A well-conducted systematic review of randomised controlled trials |
| Level 1b | One good quality randomised controlled trial |
| Level 1c | ‘All or none’ studies |
| Level 2a | Systematic review of cohort studies |
| Level 2b | Individual cohort study (including low-quality randomised controlled trial) |
| Level 2c | Outcomes research (i.e. the effect of an intervention) |
| Level 3a | Systematic review of case control studies |
| Level 3b | Case series |
| Level 4 | One case study |
| Level 5 | Qualitative studies and expert opinion |
Embedding evidence-based practice within the pre-registration curriculum
The NMC (2015: 7) stipulates that midwives must ‘always practise in line with the best available evidence’. There are numerous examples of the integration of evidence-based practice in midwifery, such as the routine use of episiotomy for uncomplicated vaginal births, and routine use of enema in first stage of labour. These studies were instigated by midwives seeking to question the inefficiency or harm of ritualised and accepted medical obstetric practices. Midwifery academics have a role and responsibility to prepare pre-registration students to become evidence-based practitioners, delivering excellent women-centred care. The Standards for Pre-registration Midwifery Education (NMC, 2009: 5) specify that education programmes must be designed ‘to prepare students to practise safely and effectively’ and that ‘students must demonstrate competence … underpinned by appropriate knowledge’. Education programmes must also reflect the emphasis on evidence-based practice and learning according to the components of evidence-based practice, defined as searching the evidence base; analysing, critiquing and using evidence in practice; disseminating research findings; and adapting and changing practice where appropriate (NMC, 2009: 7). One of the challenges for education providers is to incorporate evidence-based practice across the curriculum so that student midwives see it as an integral part of their role, rather than a separate concept.
The components of evidence-based practice are essential elements of lectures, workshops and directed activities in the University setting, and students are taught how to search the evidence base; how to analyse and critique evidence; the importance of disseminating research findings and the variety of ways through which this can be done; and how to implement research findings into practice using change management theories. A spiral curriculum model (Figure 2) was chosen, since it supports a developmental constructivist process that allows learning to take place over a long period and be repeatedly revisited (Bruner, 1960; Russell and Williams, 2018). The student progresses from simple understanding of key concepts to the development of a rich depth and breadth of information, knowledge and competence. This is a curriculum in which there is an iterative revisiting of topics, subjects or themes throughout the course, with each successive encounter building on the previous one, so that the theme of evidence-based practice is organised in a simple-to-complex, general-to-detailed, abstract-to-concrete manner. This model takes into account that prerequisite knowledge and skills need to be mastered first, with sequencing that provides linkages between each session as students spiral upwards through the pre-registration programme. In the spiral curriculum model, evidence-based practice is not viewed as a specific module or topic, but as a central tenet of midwifery.
Year one
Surprisingly, while students acknowledge the importance of evidence-based practice in midwifery, not all students view research as integral to the role of the midwife, with expectations that unless a midwife wants to be a ‘researcher’, then only a basic understanding of evidence-based practice is required. However, considering some experiences they have in the practice areas (discussed below), this finding should not be unexpected. The concept of midwives and research being inextricably linked is therefore introduced early in the programme. Students are also taught the importance of service user involvement, not just in students' clinical experience, but also through public participation in research to help direct and improve maternity care (National Institute for Health Research (NIHR), 2017). As students progress through the 3-year programme, they can see how every midwife has a role in evidence-based practice, whether they research empirical evidence, instigate change, or use their skills and knowledge to ascertain the quality of guidelines and research. In the first year, students are directed towards examples of midwives who are performing primary research alongside their day-to-day clinical role. Thereafter, students learn how to search for and evaluate evidence. Key face-to-face lectures are supported with timetabled small group sessions in the library with the subject librarian using a variety of databases and directed activities supported by digital online technology. This blended learning approach is creative and flexible, and designed to support learning (Garrison and Kanuka, 2004). Rather than being a specific discrete module, the components of evidence-based practice are delivered throughout the year within other modules so the student can see the evidence and referencing skills that underpin other year one modules.
Year two
Students revisit the theme of evidence-based practice when they look at analysing and critiquing evidence and dissemination in year two, building upon their understanding of searching the evidence base from year one. All modules throughout the second year explicitly require students to search and critically appraise the literature. In order to link their university taught knowledge to their clinical practice, students identify a clinical problem or issue from placement, for example the management of physiological third stage of labour in low risk women, or postnatal depression, and use the problem to work through the evidence-based practice steps that they have learned.
The assessment of the research module in year two requires students to formulate a question using the PEO (population and their problems; exposure; outcomes or themes) (Table 2a) or PICO (population, patient, problem; intervention; comparison; outcome) format (Table 2b) (Bettany-Saltikove, 2012). They then demonstrate how to search for relevant literature from evidence-based sources by developing a list of search terms and devising a search strategy, and search for a research article and a clinical guideline in order to answer their research question. Students disseminate their findings by creating and presenting a poster.
| Population/patient/problem (P) | Exposure (E) | Outcomes/themes (O) |
|---|---|---|
| Mothers with postnatal depression | Postnatal depression | Experiences, daily living |
| Patient/population/problem (P) | Intervention (I) | Comparison (C) | Outcomes (O) |
|---|---|---|---|
| 3rd stage of labour | Physiological management | Active management | Postpartum haemorrhage |
Year three
In year three, students apply theory to practice in the development of a research proposal, defining their research question and providing a clear rationale for their proposed study. The research proposal provides a basis for students to investigate their research questions as part of post-registration research degrees.
Learning environments
Pre-registration midwifery students spend between 50-60% of time in practice learning (NMC, 2009). Learning opportunities and placements span antenatal, intrapartum and postnatal environments, in addition to community, case-holding, non-midwifery placements (in medicine, surgery, gynaecology, mental health) and in a ‘standalone’ or ‘alongside’ midwife-led unit where possible. One of the challenges for pre-registration midwifery education lies in the interaction between the University setting and the practice environment, which is never more evident than in relation to evidence-based practice.
Students report mixed experiences of evidence-based clinical practice, ranging from mentors and other practitioners who are clearly engaging with the principles and practice of evidence-based practice, to witnessing clinical practice that contradicts the evidence base. Students also report difficulties if they attempt to apply current evidence during their placements. This is perhaps not surprising, given that midwifery care has previously been described as being based more on tradition and clinical experience than research evidence (Hunter, 2013). Students should be encouraged to challenge the poor practice and demonstrate courage, one of the 6Cs advocated by the Department of Health and Social Care (2012). However, the Code (NMC, 2015) and the Royal College of Midwives (RCM) (2015) state that it is each practitioner's duty to speak out if they have concerns about the quality of care, whether they are qualified or a student, and should be supported and protected when doing so.
This can be more difficult than it sounds: students worry about fitting into the clinical team, and whether there will be repercussions in terms of grading in practice. The importance of challenging poor practice is therefore discussed with students during preparation for each placement, and students are taught that challenging poor practice needs to be undertaken with respect to the ongoing relationship with the mentor and the placement area. The link lecturer or personal teacher can provide support and discuss strategies for questioning poor practice in a constructive manner. It should be remembered that it is not only as a student that you may need to challenge a colleague's poor practice.
These incidences should reduce as new and existing mentors are required to meet the NMC Standards to support learning and assessment in practice (NMC, 2008). These standards cover eight domains, specifically identifying the responsibilities of mentors to update their knowledge and skills required to effectively meet the needs of healthcare students. Placement providers are responsible for maintaining a ‘live register’ of mentors. In order to stay on the live register mentors need to meet with a designated supervisor for a ‘Triennial review’ to provide evidence that they have (NMC 2008: 15):
The seventh of the eight domains for mentors is specifically relevant to supporting students in their appreciation of the importance of research in midwifery NMC (2008: 26):
As mentors consider this domain, their mentoring skills to supporting students in embedding research in to their role are strengthened.
Conclusion
Evidence-based midwifery practice aims to ensure that women receive the care that fits their needs, facilitates sound decision-making, reduces unnecessary and ineffective interventions, provides student midwives and other health professionals with the skills and knowledge to justify their practice, and minimises risk. Therefore, at University of Nottingham, evidence-based practice is threaded across all modules, from teaching evidence-based practice methodology to its application in clinical practice. Students need to see the relevance of evidence to midwifery practice, and have the confidence and conviction to challenge when practice is at odds with the evidence base. The aim is to instil principles of lifelong learning, so that midwives do not rely solely on experience and intuition, but on their research knowledge and skills. The aim is to equip midwives with the confidence and ability to evaluate the research that underpins national and local guidelines so, rather than being confined by ‘others’ research, they can influence the care they deliver to the ever-changing needs of childbearing women and their families.