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A Delphi Study of Self-Competence for Childbirth. Tanya Tanner, PhD, MBA, RN, CNM Faculty Frontier Nursing University Nancy K. Lowe, PhD, CNM, FACNM, FAAN Professor and Chair University of Colorado College of Nursing. Background & Significance.
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A Delphi Study of Self-Competence for Childbirth Tanya Tanner, PhD, MBA, RN, CNM Faculty Frontier Nursing University Nancy K. Lowe, PhD, CNM, FACNM, FAAN Professor and Chair University of Colorado College of Nursing
Background & Significance • Increasing intervention and technology, even in “normal” situations. • Maternal Child Health goals are not being met, maternal and neonatal morbidity and mortality are increasing. • Women's desires and preferences are markedly different from even a generation ago.
Wondering Why do women make the choices they do? • Primary elective cesarean section • Epidural use • Non-medicated birth In spite of societal pressures to birth technologically, why do some women continue to birth with so much grace and skill?
Study Aims Overall aim: To better understand the defining attributes, attitudes, and beliefs of women who are self-competent for childbirth. Provide conceptual validation and a potential item pool for future instrument development
Research Questions How do expert maternity care providers describe their understanding of women who labor and birth self-competently? What are the defining attributes of the phenomenon of self-competence for childbirth in nulliparous women as identified by expert maternity care providers?
Delphi Method • A multi-round survey process designed to generate consensus among a panel of experts • Effective in cases for which there may be no definitive answer • Chosen for this study because: • Wide range of disciplines were involved • Geographic diversity was desired
The Expert Panel • Comprised of: • Doulas • Nurses • Midwives attending births in homes • Midwives attending births in birth centers • Midwives attending births in hospitals • Family Practice Physicians attending births • Obstetrician/Gynecologists • Maternal/Fetal Medicine Specialists • Inclusion Criteria: • Recommendation • Certification, licensure or registration for last 5 years • Hands- on clinical experience for last 5 years • Consider self to be expert • Be willing to actively participate in study process
Panelist Recruitment and Enrollment Request referrals from boards of directors, other professional recommendations 335 Individuals contacted 398 Nominees identified 224 (56%) Did not reply (11%) Declined 131 (33%) Indicated Interest Contact nominees to inquire about interest in participation Obtain consent 11 (8%) Did not return consent form 5 (4%) Didn’t meet inclusion criteria 1 (1%) Declined participation 114 (87%) Consented to participate Send demographic and first round study surveys 5 (4%) Did not return surveys 109 (96%) Returned surveys and were enrolled
Panel Demographics (N = 109) Age Gender Ethnicity Education Years certified, licensed, or registered M = 47.9, SD = 9.08 Female: 87% Male: 13% Caucasian: 93% African American: 3% Asian: 2% Other: 2% Some College: 6% Associates/Vocational: 8% Bachelors: 18% Masters: 34% Doctorate: 34% M = 15.6, SD = 8.6
Panel Practice Characteristics (N = 109) Births Attended per Month Mode of Birth Birth Location Labor and Birth Interventions Fetal Monitoring Use M = 10.0, SD = 12.5, range = 1-100 Vaginal: M = 82.2% Operative Vaginal: M = 3.6% Cesarean Section: M = 14.2% Home: M = 12.3%, SD = 27.0 Birth Center: M = 14.4%, SD = 29.5 Hospital: M = 73.3%, SD = 39.9 Induction of Labor: M = 21.4%, SD 20.8 Pitocin Use: M = 32.1%, SD 26.4 Elective Cesarean: M = 5.2%, SD 14.3 Episiotomy: M = 5.9%, SD 11.3 None: M = .17%, SD .8 Intermittent Auscultation: M = 27.3%, SD 23.3 Intermittent EFM: M = 27.3%, SD 33.3 Continuous EFM: M = 52.0%, SD 39.5
Round One Study Survey • Contained five open-ended, qualitative questions • Characteristics • Outcomes • Rationale • 97.2% Response rate • Content analysis of comments resulted in the identification of: • 54 Outcomes Statements • 59 Rationale Statements • 72 Characteristics Statements • 185 Total Statements
Round Two Study Survey • Contained 195 statements to be ranked on Likert scale of 1 - strongly disagree to 6 - strongly agree. • 95.4% response rate • Consensus was reached for 49 (25%) of the items: • 21 Outcomes Statements (39%) • 14 Rationale Statements (21.5%) • 13 Characteristics Statements (10.7%) • 1 Miscellaneous Statement (10%)
Round Three Study Survey • Contained 147 statements to be ranked on same Likert scale • 88.9% Response rate • Consensus was reached for 13 (8.8%) of the items: • 5 Rationale Statements (11.1%) • 4 Characteristics Statements (6.8%) • 3 Outcomes Statements (9.1%) • 1 Miscellaneous Statement (11.1%)
Round Four Study Survey Served as “member check” for final retained statements and to evaluate the experience of participating in the study. Contained the 62 consensus statements, 5 survey experience statements and 60 consensus statements to be applied to panelists’ nulliparous patients. 88.9% response rate Mean agreement ranking: 5.07 Mean disagreement ranking: 1.67
Results • Internal Characteristics of women who are self-competent for childbirth • Personal Characteristics • Beliefs • Supportive factors affecting self-competence for childbirth • Behaviors of women who are self-competent for childbirth • Outcomes associated with women who are self-competent for childbirth • Positive Feelings and Emotions • Acceptance of Outcomes
Implications • Practice • Panelists exposure to the concept influenced practice • “framing things in terms of self-competence is helpful in how I tweak certain teaching points for different patients.” • Help women achieve their goals • Provide a supportive environment • Policy • Support women’s self-competence and self-determination
Implications • Research • Accomplished construct validation • Need to create instrument to measure self-competence for childbirth • Intervention research to increase women’s self-competence for childbirth • Investigate women’s experiences with self-competence for childbirth • Investigate the role of birth team members on women’s self-competence for childbirth
Strengths and Limitations • Strengths • Strong theoretical foundation • Large, diverse panel • High response rate • “Member check” reflected agreement with results • Results reflected related extant literature • Limitations • Delphi expert panel is inherently biased • Limited ethnic representation • Did not directly address women’s experiences
References Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: WH Freeman. Csikszentmihalyi, M. (1991). Flow: The psychology of optimal experience. New York, NY: HarperCollins. Csikszentmihalyi, M. Abuhamdeh, S., & Nakamura, J. (2005). Flow. In A. J. Elliot & C. S. Dweck, (Eds.), Handbook of competence and motivation (pp. 598- 608). New York, NY: Guilford Press. Dweck, C. S. (2006). Mindset: The New Psychology of Success. New York, NY: Random House. Foster, J. C. (1981). Utah test for the childbearing year: Beliefs and perceptions about childbearing. (Doctoral dissertation). Retrieved from ProQuest. (AAT 8121979).
References Lowe, N. K. (2007). A review of factors associated with dystocia and cesarean section in nulliparous women. Journal of Midwifery and Women’s Health, 52(3), 216-228. Parratt, J. & Fahy, K. (2003). Trusting enough to be out of control: A pilot study of women’s sense of self during childbirth. Australian Midwifery Journal, 16(1), 15-23. Reed, P.G. (2008) The Theory of Self-Transcendence. In M.J. Smith & P.R. Liehr (Eds.), Middle Range Theory for Nursing (2nd ed.) (pp. 105-130). New York, NY: Springer Publishing.