T HE LITERATURE : VALID PRACTICE KNOWLEDGE

Much of the literature from healthcare professional education critiqued in Chapter 1 described the types of knowledge necessary for practice. Table 3.1 shows the types of practice knowledge assessed by the different health professions. If the profession assesses the form of knowledge one can deduce that type of practice knowledge is valued.

Table 3.1 Types of practice knowledge assessed

Type Professions References

Communication and interpersonal skills

Nursing, midwifery, medicine, physiotherapy

Oermann, et al., 2009 ; Smith, 2007 ; Clouder and Toms, 2008 ; Briscoe, et al., 2006 ; Murphy, et al., 2014 ; Imanipour and Jalili, 2016 ; Eggleton, et al., 2016; Fisher, et al., 2016 ; Hanley and Higgins, 2005 ; Meldrum, et al., 2008.

Cognitive/ evaluative abilities (Clinical knowledge or evidence based practice)

Nursing, physiotherapy, medicine, pharmacy, midwifery

Oermann, et al., 2009 ; Clouder and Toms, 2008 ; Briscoe, et al., 2006 ; Manning, et al., 2016 ; Imanipour and Jalili, 2016 ; Lurie and Mooney, 2010 ; Murphy, et al., 2014 ; Eggleton, et al., 2016 ; Fisher, et al., 2016 ; Scammell, et al., 2007 ; Meldrum, et al., 2008. Psychomotor and technical

skills

Nursing, midwifery, medicine Oermann, et al., 2009 ; Smith, 2007 ; Briscoe, et al., 2006 ; Scammell, et al., 2007 ; Imanipour and Jalili, 2016 ; Eggleton, et al., 2016 ; Meldrum, et al., 2008. Values, attitude and

professional behaviours

Nursing, physiotherapy, medicine, pharmacy

Oermann, et al., 2009 ; Clouder and Toms, 2008 ; Briscoe, et al., 2006 ; Manning, et al., 2016 ; Murphy, et al., 2014 ; Susmarini and Hayati, 2011 ; Imanipour and Jalili, 2016 ; Eggleton, et al., 2016 ; Scammell, et al., 2007 ; Meldrum, et al., 2008.

Safe to practice, safety Midwifery, nursing, physiotherapy Smith, 2007; Clouder and Toms, 2008; Murphy, et al., 2014; Amicucci, 2012; Docherty and Dieckmann, 2015; Scammell, et al., 2007.

Self-management physiotherapy Clouder and Toms, 2008 ; Meldrum, et al., 2008.

Skills (but not determined which)

Pharmacy, nursing, physiotherapy, midwifery

Manning, et al., 2016; Susmarini and Hayati, 2011; Lurie and Mooney, 2010; Clouder and Toms, 2008; Fisher, et al., 2016; Scammell, et al., 2007.

The first point to note, from Table 3.1, is the marked similarity between the health professions regarding valid practice knowledge. The types of knowledge can be broadly categorised into Bloom et al’s., (1956) three learning domains: affective, cognitive and psychomotor. Categorisation of types of knowledge can be restrictive so a caution must be stated here. It is also acknowledged that the content of the communication and specific skills used in each profession will change, however, most professional health programmes seem to require students to demonstrate similar generic competencies.

Problems were noted in the studies with assessing practice knowledge (Briscoe, et al., 2006; Smith, 2007; Clouder and Toms, 2008). Six types of practice knowledge were identified and explored to demonstrate their usefulness for assessing medical students (Briscoe, et al., 2006). The survey of medical school directors in the US (n=85, response rate 66%) described discrepancies between types of practice knowledge and their usefulness. In descending order, attitude, professional behaviour, interpersonal skills, communication skills, clinical skills and clinical knowledge were judged to be ‘very useful’ by respondents (34.6-24.7%

respectively). The emphasis was on skills in the affective domain. The main way the affective domain was assessed in the large-scale US nursing survey was through faculty observation of students with patients (67%) or with others (54%) (Oermann, et al., 2009). However, the frequency of observation, by whom, reliability and validity were all questioned in Chapter 1. Therefore, many healthcare professions utilised a range of methods of assessment.

When asked what the perfect clinical assessment tool in medical education would entail, clinical skills, professional behaviour and clinical knowledge were cited most frequently, however there was little agreement between respondents (Briscoe, et al., 2006). The hypothetical question awarded higher significance to clinical knowledge than the usefulness grade of ‘moderately useful’ (Briscoe, et al., 2006). This could be an example of the participants offering socially desirable responses. Clinical knowledge should, one could argue, feature more significantly in the assessment of students but it seems even in medicine the affective domain and the style of the person counts for more. A similar number of medical directors said clinical knowledge was either ‘minimally useful’ or ‘very useful’ (24.7% respectively) in

the clinical assessment. This survey illustrates there is no consensus regarding the usefulness or importance of assessing various types of knowledge and it varies according to individuals.

3.5MIDWIFERY PRACTICE KNOWLEDGE

In Smith’s (2007) qualitative study of 12 midwifery mentors, when asked what the students’ practice grades were based on, communication skills and psychomotor skills were cited most frequently. How well the student related to others and

dexterity were important. However, when asked about research knowledge, mentors were impressed with students’ ability to access it, with no discussion of its

evaluation or application to midwifery practice. Thus, some students were awarded grades for motivation rather than critical appraisal of the evidence. One participant stated ‘we’re not a very good research-based resource- we’re experience based’ (Smith, 2007 p.115). Another participant, however, actively sought discussions with students about research, but most of the grade was from the clinical performance (Smith, 2007). The differing mentor identities with respect to research align with my study.

In the wider midwifery literature, all forms of practice knowledge, discussed above, communication and interpersonal skills, specific competences and using evidence to inform practice are identified specifically in relation to what it means to be a good midwife (Carolan, 2013; 2011; Nicholls, et al., 2011; Byrom and Downe, 2010; Nicholls and Webb, 2006).

First year midwifery students in Australia, like the students in my work, expressed the personal qualities they possessed that were essential for midwifery practice (Carolan, 2011). The 32 direct-entry students questioned after five weeks on the course, considered interpersonal skills were necessary to build relationships with women (Carolan, 2011). When asked again two years later in a separate study, the remaining 30 third-year students identified being a skilled practitioner, interpersonal skills and passion underpinning their perceptions of a good midwife (Carolan, 2013). Clinical competence, based on research supported by continuing professional

development was as important as the affective qualities of caring, compassion and enthusiasm for midwifery. Thus, evidence for midwifery practice was combined with interpersonal skills.

Carolan (2013) observed the third year students seldom discussed the importance of communication skills. Her interpretation of this omission was that communication skills may be so integral to being a good midwife that the students may not have thought they warranted mentioning (Carolan, 2013). Her interpretation differs from my research. I hypothesise students do not seem to value communication skills because they are weakly classified and that they already possess them and this is reinforced by comments in the PAD. However, specific types of communication did need improving including documentation, referring to the multidisciplinary team and planning care.

A limitation of both studies (Carolan, 2011; 2013) is the method of data collection. Although some quantitative demographics are stated and vignettes from qualitative statements are used, it is not clear whether the students were interviewed as one group, several groups or individually. Carolan (2011; 2013) states the data was collected the week after a group information session, so one might assume a group interview was undertaken. However, with 32 and 30 students respectively this might not be the best approach to enable all participants the opportunity to participate. The implications for practice are clear though. Initially students displayed a limited view of the role of the midwife (Carolan, 2011). By the third year, students’ views better aligned with qualified midwives but there was a lack of emphasis on the importance of communication skills (Carolan, 2013).

At the point of registration, Butler, et al., (2008) identified three necessities for student midwives: being safe, having the right attitude and effective communication skills. The emphasis is on the affective domain. In their study of 39 qualifying midwives and assessors and 20 experienced midwives across six universities, less emphasis was placed on clinical skills as some midwives understood the need to develop those once qualified, such as vaginal examinations (Butler, et al., 2008). While the data was collected over a decade ago, before the current changes to pre- registration midwifery education were introduced (NMC, 2009), the work still has some relevance today. The mentors in my research documented in the PADs the

student’s ability to ask for help thereby being safe, and their positive attitude and communication skills. However, there is perhaps a greater pressure for new

registrants to have specific clinical skills as noted by the Darra, et al., (2016) and the participants in my study.

When the qualities of a good midwife are considered in more detail, the need for effective communication skills is more apparent than technical skills (Nicholls and Webb, 2006). In order to develop midwifery curricula an integrative review of 33 research papers on definitions of a good midwife were reviewed by Nicholls and Webb (2006). Eight concepts were identified from the literature, including the attributes of a midwife, what a midwife does and research. The midwives personal qualities and good communication skills made the biggest contribution from the literature which used a wide range different approaches and methods (Nicholls and Webb, 2006). Due to the lack of research on ‘what makes a good midwife’ their follow up study used a Delphi questionnaire (Nicholls, et al., 2011). They questioned 226 postnatal women, midwives and midwifery educators who

collectively deemed good communication skills, lifelong learning and individualised care as the most important features of a good midwife (Nicholls, et al., 2011). The research differentiated between the three participant groups and there was consistency between their perspectives (Nicholls, et al., 2011). However, the recruitment of women to the study was via an email from the National Childbirth Trust so this may have limited participation to those with internet access and the group were self-selecting which means their views may not represent those of other women. A further limitation is the second round of the Delphi had a poor response rate (38%) (Nicholls, et al., 2011). There was no discussion on the communication finding in Nicholls, et al’s., (2011) paper, so its value on what or how

communication is needed is limited. Nonetheless, the implication is that tailoring care to individuals relies on good communication to enable women to make choices informed from the evidence (Nicholls, et al., 2011). Thus once qualified, the

importance of clinical skills seems to reduce, as the registrant presumably becomes accomplished with these.

In a phenomenological study of ten midwives’ views of the characteristics of a good midwife (Byrom and Downe, 2010), personal qualities were valued as much as skill

competence. Skilled competence included clinical skills but it was not stated which specific midwifery skills, rather the generic terms clinical or practical skills were used. The personal qualities encompassed communicating in different ways with different women to form a relationship. The midwives were selected from a random sample of junior and more senior staff so a wide range of perspectives were heard (Byrom and Downe, 2010). However, the study was not wholly focused on being a good midwife as being a good leader was also considered, there seemed to be some overlap between these roles though and both needed practical competence and interpersonal traits (Byrom and Downe, 2010). As the findings support the two previous studies there seems to be consensus on what a good midwife is. When the views of women on what makes a good midwife were collected, great importance was placed on the relationship between the two (Borrelli, 2014). Borrelli, (2014) selected and critiqued six studies, four with a qualitative approach and two surveys with a range of participants including couples, nulliparous and multiparous women (n=19-825 participants) from four countries (England,

Australia, Sweden and USA). Having choice and feeling in control was necessary, and for that women needed appropriate information. This study shows womens’ perspectives do not wholly align with the midwives’ perception. Rather the need for good supportive relationships aligned with the first year students’ perspective presented earlier (Carolan, 2011).

From the literature and my research, what counts as valid midwifery practice knowledge seems to depend. It depends on who is asked, it differs between service users, students and midwives, it is also different between areas such as community or delivery suite. It also seems to depend on the stage of training the student is at (Carolan, 2011: 2013). The reasons why some practice knowledge is valued more than others can be understood using Bernstein’s concept of classification.