Anglia Ruskin University An exploration of student midwives’ attitudes toward substance misusing women following a specialist education programme Claire Hooks August 2016 A Thesis In Partial Fulfilment Of The Requirements Of Anglia Ruskin University For The Degree Of Doctor Of Education Acknowledgements I would like to thank my husband Paul, and children, Charlotte and Joshua for their support and understanding of my absence over the past five years. Without them this journey would not have been possible. I would also like to acknowledge my supervisory team, Dr Geraldine Davis and Professor Sharon Andrew and also my colleague and friend, Dr Susan Walker, for their patience, wisdom, encouraging words and mostly for always making time for me. When I have struggled to stay motivated, they have been there always knowing the right words to say. i Abstract Substance misuse is a complex issue, fraught with many challenges for those affected. Whilst the literature suggests that pregnancy may be a ‘window of opportunity’ for substance misusing women, it also suggests that there are several barriers to women engaging with health care. One of these is the fear of being judged and stigmatised by healthcare professionals, including midwives. Previous research indicates that midwives have negative regard toward substance users and that this in turn may lead to stigmatising behaviours and consequential substandard care provision. Midwives however, stress that they do not have appropriate training to be able to effectively provide appropriate care for substance misusers. Research suggests that education (formal training) is needed in this area to improve attitudes. In this study, the role of education in changing attitude toward substance use in pregnancy was explored using case study methodology. The case was a single delivery of a university degree programme distance learning module ‘Substance Misusing Parents,’ undertaken by 48 final year student midwives across 8 NHS Trusts. The research was carried out in 3 phases, using a mixture of Likert style questionnaires (Jefferson Scale of Physician Empathy and Medical Condition Regard Scale), Virtual Learning Environment discussion board qualitative data and semi structured interviews. The findings of the questionnaires showed that whilst general empathy levels showed no significant change (p=0.539), empathy toward pregnant drug using women showed a statistically significant improvement following the module (p=0.012). Furthermore, exploration of the students’ experiences of the module demonstrated the importance of sharing and reflecting on practice with peers; the experiences of drug users, both positive and negative; and having an opportunity to make sense of these experiences, thus bridging the ‘theory-practice divide,’ as key in influencing their views. Furthermore the findings indicated value in the mode of delivery of such education, suggesting e-learning to be an effective approach, offering not only knowledge gain in terms of the content, but in wider research and critical thinking skills. This research demonstrates the potential of education in this area but also offers suggestions for effective methods of educational delivery to potentially help reduce stigma in other areas of practice. Key Words: Substance Misuse Pregnancy Midwives Attitudes Education ii Contents Abstract ........................................................................................................................ ii Contents ...................................................................................................................... iii Figures .......................................................................................................................... v Tables ........................................................................................................................... v Appendices ................................................................................................................. vi Copyright Declaration ................................................................................................vii Chapter 1 Introduction ................................................................................................ 1 1.1 Overview ..................................................................................................... 1 1.2 Maternal substance misuse ........................................................................ 5 1.3 Researcher background and study context ................................................ 8 1.4 Definition of Terms.................................................................................... 10 1.5 Chapter Summary ..................................................................................... 12 Chapter 2 Literature Review ..................................................................................... 14 2.1 Literature Search Strategy ........................................................................ 14 2.2 Stigma and Shame of drug users.............................................................. 16 2.3 Pregnant women’s experiences of maternity services ............................ 19 2.4 Role of the Midwife .................................................................................. 20 2.5 Midwives’ Attitudes ................................................................................. 21 2.6 Stigma and attitude formation ................................................................ 25 2.7 Attitude Change ....................................................................................... 30 2.8 The role of substance misuse education ................................................. 35 2.9 The nature of substance misuse education ............................................. 37 2.10 Chapter Summary .................................................................................. 42 Chapter 3 Methodology ............................................................................................ 45 3.1 Philosophical Perspectives ....................................................................... 45 3.2 Methodology ............................................................................................ 56 3.3 Data Analysis ............................................................................................ 73 3.4 Ethical Considerations .............................................................................. 89 3.5 Confidentiality and Anonymity ................................................................ 91 3.6 Reliability and Validity .............................................................................. 92 3.7 Trustworthiness ....................................................................................... 92 3.8 Transferability .......................................................................................... 94 3.9 Chapter Summary .................................................................................... 95 Chapter 4 Findings from Phase One and Three ........................................................ 97 iii 4.1 Questionnaires (Phase One) .................................................................... 97 4.2 Conventional Content Analysis of VLE posts (Phase Three) .................. 105 4.3 Chapter Summary .................................................................................. 129 Chapter 5 Findings from Phase Two Interviews ..................................................... 130 5.1 Framework Analysis (interviews) ........................................................... 130 5.2 Attitude of the students toward substance misuse ............................... 131 5.3 Student Practice Experience .................................................................. 140 5.4 Interaction with peers ............................................................................ 153 5.5 Impact of Knowledge gain ...................................................................... 157 5.6 Module Delivery Method ....................................................................... 163 5.7 Summary of Phase Two .......................................................................... 168 5.8 Summary of Combined findings from Chapters 4 and 5. ....................... 169 Chapter 6 Discussion of Findings ........................................................................... 171 6.1 Attitude and practice around substance misuse in pregnancy ............. 172 6.2 Knowledge of Substance Misuse in practice .......................................... 188 6.3 Change .................................................................................................... 195 6.4 Mode of Educational Delivery ................................................................ 199 6.5 Limitations of the Research and Findings .............................................. 206 6.6 Chapter Summary .................................................................................. 210 Chapter 7 Recommendations and Conclusions ...................................................... 212 7.1 Recommendations and Conclusions ...................................................... 212 7.2 Future Research ..................................................................................... 221 7.3 Personal Reflection – Another Brick in the Wall .................................... 223 References ............................................................................................................... 226 Appendix 1 ..............................................................................................................