This is the second part of a two-part paper in which a new model of evidence-based decision-making for midwifery is proposed. In part 1, the case was made for a fit-for-purpose decision-making model on which to base personalised care in increasingly complex maternity care systems (Ménage, 2016). Crucially, this model calls for a radical and far broader definition of the evidence on which to base decision-making. Part 2 introduces the new model and explains the different sources of evidence to be considered in partnership with women. A clinical scenario is used to show how this model can be used in practice. This paper argues that the model makes an important contribution to midwifery theory by providing a comprehensive framework on which to base decision-making that reflects the realities of modern midwifery care. In addition, it could be an important tool for use in midwifery education, ongoing professional development, supervision and change management.
In this paper, the word ‘woman’ is used for ease of reading, but always acknowledges and represents the mother–baby dyad. Similarly, for ease of reading the midwife is sometimes referred to as ‘her’ rather than him/her, although it is acknowledged that some midwives are male.
Partnership in decision-making
Working in partnership with women to make decisions is not without its problems. Furthermore, there are many other factors to be taken into consideration, which may potentially conflict with this process. This can mean that the ideal of woman-centred care does not always happen in practice (McCourt, 2006), and women may be denied any sense of control.
Porter et al (2007) identified three conceptual models of organisational control related to midwifery:
Porter et al's (2007) research identified the dominance of bureaucratic decision-making, which has been reinforced by rigid managerial requirements, fear of litigation, workload pressures, and the perception that women are unwilling or unable to participate in decision-making. This position is unsustainable for the midwifery profession, because bureaucratic decision-making is inconsistent with professionalism and the professional standards that guide midwifery. As a result, such a bureaucratic approach threatens to erode the role of the midwife and the reputation of the profession. Midwives are required to make the needs of the woman and baby the primary focus of practice. They should work in partnership with the woman and her family to provide safe, responsive, compassionate care (Nursing and Midwifery Council (NMC), 2012). All practice should be in line with the best available evidence (NMC, 2015). Now, more than ever, midwives are being asked to play a key role in delivering safe, personalised care in partnership (Department of Health and Public Health England, 2014), yet a model to guide this has been missing. The model of evidence-based decision-making proposed here (Figure 1) addresses this shortfall by providing a framework within which to consider and deal with the competing and sometimes confusing demands of modern maternity care.
The four areas of evidence
The broad definition of evidence proposed for this model of partnership decision-making is based on ‘all valid and relevant available information that impacts the person and the situation’ (Hicks, 1997: 8). The model organises the information into four areas: the woman, the midwife, the resources and the research. These areas are set within the environment. Table 1 shows the sources of evidence and lists things that may need to be considered and balanced in the decision-making process. This is not an exhaustive list.
| Consider the evidence from the woman (dyad) | Consider the evidence from the midwife (requires self-awareness and emotional intelligence) |
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| Consider the evidence from and about the resources available | Consider the evidence from research (consider quality, reliability and validity) |
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| Consider the environment in which we live and work | |
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The woman (dyad)
Evidence from and about the woman–baby dyad should be the starting point for high-quality, personalised care. The evidence will emerge from listening to the woman and building a picture of her physical, psychological and social health. Evidence will come from history-taking, observation, examination (which may include auscultation and palpation), the results of ultrasound scans and other clinical measurement test results. Evidence-gathering should take place in the spirit of equal partnership. Nurturing and developing a trusting relationship is key to obtaining quality evidence. This partnership also promotes safer, better care and high levels of satisfaction with care (Sandall, 2014). Developing such a relationship may seem difficult in a busy clinic or ward situation, but it is the cornerstone of good midwifery care and job satisfaction (Kirkham et al, 2006; Deery and Hunter, 2010). Continuity of carer will support this process, making it easier for the midwife to get to know the ‘person behind the patient’ (Goodrich and Cornwell, 2008): the woman's family, cultural and social circumstances, ideas, hopes and expectations.
Resources
Evidence regarding what resources are available has the potential to enhance decision-making and care. Within this model, members of the multidisciplinary team are vital resources. At any point, the midwife may need to facilitate access to the team's expertise as part of a woman's care. Therefore, knowledge about the team, their different skills, clear referral pathways, and lines of communication play an essential role in good quality maternity care (Kirkup, 2015).
Knowledge about the different services, facilities and equipment available is another important part of the evidence required. Time (that fundamental resource we all feel short of) will also need to be considered in any realistic decision-making process. When looking after two or three women in labour, decision-making will be different than when providing one-to-one care. One of the strengths of considering evidence about resources is the opportunity to highlight insufficient resources and the impact on care, and to identify resources that may be underused. By engaging in discussions with women about how their needs and choices match available resources, this model could assist in guiding resource allocation and changes to services.
The midwife
Evidence from the midwife herself is perhaps the most radically different aspect of this model, as midwifery has a tradition of being outwardly caring, rather than introspective. Although reflecting on practice and making necessary changes is a competence standard for all midwives (NMC, 2009), these skills are usually seen as separate from the business of decision-making in practice. They are considered more of an add-on activity after an adverse incident, for example. This model proposes that decision-making requires the midwife to consider herself and her role within the woman–midwife partnership, and to reflect on her own knowledge and skills, including any gaps. This provides a tool for her to identify situations where she can be confident in her skills and experience to deal with a situation, as well as situations where a different approach or additional expertise may be required. Self-awareness plays an important part in this process and is part of continuing professional development. Self-awareness also serves to build resilience, wellbeing and morale, and improve retention (Hunter and Warren, 2013). A model that seeks to incorporate evidence from the midwife will support better decision-making and will help to facilitate and strengthen self-awareness in midwives.
The research
Research is what has traditionally been thought of as evidence. Within this new model, research continues to be a significant part of the evidence used in decision-making. However, this type of evidence needs to be balanced with evidence from the other areas presented in the model. Research evidence comes from appropriate quantitative and qualitative research trials. While it is unrealistic to expect midwives to be aware of all of the research pertaining to every clinical scenario, peer-reviewed journals play an important role in informing midwives about new research. Online databases and libraries are invaluable for their ability to accommodate huge numbers of research papers and reviews and to make them searchable. All midwives need to be competent at searching for research evidence. They also need to be able to appraise the evidence, because the quality and thus the reliability of research can vary. Evidence-based guidelines assist clinicians by providing statements that help decision-making for specific clinical circumstances. Ideally, evidence-based guidelines are created using an unbiased and transparent process of systematic review and appraisal, drawing on the best clinical research findings to make recommendations regarding the delivery and effectiveness of clinical care. When created in such a way, guidelines can improve outcomes and the consistency of care (Kirkpatrick and Burkman, 2010). Midwives have an indispensable role to play in the process of the multidisciplinary production of evidence-based guidelines and evaluation, and the development of midwifery-led guidelines (Royal College of Midwives (RCM), 2012).
The National Institute for Health and Care Excellence (2014) produces national evidence-based guidelines on a range of specific conditions, as well as on how to improve health and manage medicines in different settings. Guidelines may also be developed by specialist groups and organisations, and locally at the Trust or department level. High-quality guidelines that are up-to-date and based on reliable evidence from well-conducted research can certainly improve care, but they can be potentially harmful if based on an incomplete or flawed data set, biased, based on opinion, or out-of-date. Other ‘research’ activities that focus on service evaluation or service improvement, including the collection and analysis of birth statistics, clinical audits, and service-user feedback, could also be used to inform decision-making under some circumstances.
The impact of the environment on the decision-making process
The environment in which we live and work can have an impact on both the woman and the midwife. Therefore, all the evidence that is considered when decision-making in partnership will also be influenced by environmental factors. These include the law of the land, political influences, culture and social values. For example, the Human Rights Act 1998 protects the individual's right to autonomy, which means that consent must always be sought before performing any procedure. European law (European Union Directive 2005/36/EC Article 40) dictates the professional activities of the midwife (NMC, 2009) and the Children Act 1989 sets out the key role of the midwife in acting on child protection concerns (HM Government, 2013).
National and local policies may also affect the decision-making process, for example, through a policy decision to centralise services and close small rural units. Organisational culture can have powerful positive or negative influences on teamwork, innovation and change (O’Neill, 2008; Kirkup, 2015). Sadly, too many decisions are made on the basis of ‘that's the way we do things here’ (Dixon-Woods et al, 2013).
It is not only the legal, political, and organisational environments that influence decision-making; the physical environment affects us all—perhaps none more so than the birthing woman. Women's sensitivity towards their physical, emotional and spiritual birthing environment and its impact on their feelings of safety, the birth process and birth outcomes has been well documented (Hodnett et al, 2012). The physical environment will, therefore, frequently be a significant factor in women's decisions regarding birth.
Any decision-making model must be user-friendly. The clinical scenario in Box 1 and Table 2 will demonstrate an example of the proposed model's use in decision-making. Names have been changed to ensure confidentiality.
| Evidence to consider | Scenario example |
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From the woman
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From the midwife
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From resources
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From research (and other empirical data)
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Environmental factors
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Decision-making in partnership with Jo at her appointment, following consideration of the above evidence:
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Discussion
Decision-making in midwifery is unique and is grounded in a philosophy of normality and working in partnership with women. The case has been made for a model of evidence-based decision-making for midwifery care in part 1 of this paper (Ménage, 2016), while part 2 has outlined the proposed model in more detail and provided an example of its use in a practice situation. The development of a professional model of clinical decision-making for midwifery is a critical step in articulating the profession's philosophical principles as they are applied to the complexity of today's maternity services. This model has the potential to make an important contribution to midwifery as it addresses the gap in theory and practice about how partnership decision-making works, and it provides a valuable teaching aid.
The model presented expands on traditional models of clinical decision-making by incorporating a radical, far broader definition of evidence that includes evidence derived from the woman, the midwife, research, resources and the environment. It recognises that partnerships with women are central to the quality of care and therefore a foundation for all decision-making. Uniquely, the model considers the midwife herself as a source of evidence to consider. Drawing on self-awareness and reflecting on her own knowledge and skills—and identifying any gaps—supports safe and effective practice and promotes authentic midwife–woman partnerships.
This model has been used by midwives mainly in community settings, particularly with women who are choosing care options that deviate from those dictated by the guidelines. In these settings, this model has provided a comprehensive framework for making decisions in partnership with women. Further formal evaluation is needed. The next step is to extend its use to more women and midwives in a variety of settings, to assess its efficacy. Through publication, it is anticipated that further application will be possible and may create opportunities for further testing in hospital settings, midwifery-led units and community settings. Further refinement of the model is welcomed, and will be achieved through professional evaluation, critique and discourse. Methods of evaluation might include looking at the various outcomes of care and assessing women's experience of care and the extent to which they felt part of the decision-making process. Quality of record-keeping concerning how and why decisions are made should form part of the evaluation, as should midwives’ views on the model's use.
Developing a model is an iterative process (Davidson et al, 2006), and the model may need to be developed further after evaluation. While its use in clinical practice has been the prime concern of this paper, its role in education, professional development, supervision and service management should also be explored.