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Title Page MIDWIFERY KNOWLEDGE AND THE MEDICAL STUDENT EXPERIENCE An exploration of the concept of midwifery knowledge and its use in medical students’ construction of knowledge during a specialist obstetric rotation Fiona Ellen MACVANE PHD DIVISION OF MIDWIFERY & REPRODUCTIVE HEALTH UNIVERSITY OF BRADFORD 2010 1 Abstract Midwifery Knowledge and the Medical Student Experience An exploration of the concept of midwifery knowledge and its use in medical students’ construction of knowledge during a specialist obstetric rotation Author: Fiona Ellen MacVane Key Words: Midwifery knowledge, knowledge construction, interprofessional education (IPE), clinical learning, professional socialization, problem based learning (PBL), informed choice, medical model, social model, holistic care The literature concerning what medical students learn from midwives during specialist obstetric rotations is scarce. In the UK, despite a long tradition of providing midwifery attachments for medical students, it is almost non-existent. Working with midwives is arguably the only opportunity medical students have to experience holistic or social models of maternity care, focusing on normality rather than on the medical concept of risk. This study sought to discover how medical students constructed their knowledge about childbirth during a six week specialist rotation in obstetrics in a Northern English teaching hospital (NETH), with particular emphasis on whether participants assimilated any concepts from midwifery knowledge (MK). A Delphi Study, done as the first phase of the research, focused on MK, utilizing an international sample of experienced midwives. Resulting themes were used to develop the data collection tool for the second phase of the research. The research employed a qualitative case study method with students from a single year cohort comprising the case. Data were collected using a tool consisting of three problem based learning (PBL) scenarios. These were presented to the students in consecutive interviews at the beginning, the middle and the end of their obstetric rotation. Following analysis, five main themes were identified which illuminated the medical students’ construction of knowledge about maternity care. These were explored and discussed. The thesis concludes with recommendations for increasing opportunities for IPE in the medical and midwifery curricula. 2 Acknowledgements 3 Abstract 2 Acknowledgements I would like to thank the following people: Professor Rob Newell, my PhD Supervisor for his support and encouragement during the entire research process. Professor Gwendolen Bradshaw, my second PhD Supervisor for her confidence in the validity of my work, to which she contributed invaluable midwifery and clinical education perspectives Professor Neil Small who joined my supervision team during a period of restructuring and rewriting and provided calm reassurance and pertinent guidance. My HOD, Julia Pansini-Murrell who rearranged the Division’s workload so that I could take a much-needed sabbatical for writing up my thesis. My colleagues who cheerfully shared my workload while I was away and always demonstrated an unwavering belief in my ability to complete my PhD. Thanks are due also for their help with the Delphi analysis and with the development of the PBL scenarios used as the data collection tool in the second phase of my research. Among them, special thanks go to: • Dr. Diane Barrowclough who provided advice about methods of data analysis and who interrogated my data, enabling confirmation of my thematic analysis. • Elizabeth Whitney who encouraged creative thinking and acted as a critical reader. • Stephanie Cowell for offering to proof-read my final draft. Many thanks also to: My husband, Reginald John Phipps for his continuing love, patience and support. The midwives and obstetricians of ‘NETH’ who assisted in the process of student recruitment and provided me with space for interviewing, particularly the Consultant Obstetrician with responsibility for medical student placements, the Matron with overall responsibility for the labour ward and the Practice Educator who taught clinical skills to medical students during their obstetric rotation. The Delphi Survey panel members who explored the concept midwifery knowledge. The medical students who shared their narratives with me, and without whom this study would not have been possible. 3 Dedication 4 Acknowledgements 3 Dedication In Memory of Uncle Bil Dr. Wiliam Lesley MacVane Jr. 12 June 1915- 1 August 2010 (MacVane family film clip 1949) I dedicat tis PhD Tesis t te memory of my uncle, Dr. Wiliam Leslie MacVane Jr. of Portland Maine whose atributs included: intligence, common sense, kindness, humour and detrminaton. Al of tese made him bot a renowned medical practtoner in his field of toracic surgery and a very special uncle. His years as Directr of Medical Educaton at Mercy Hospital ( 1965-1978) contibutd t his life-long intrest and involvement in educaton. Fiona Elen MacVane 2 August 2010 4 Table of Contents 5 Dedication 4 Table of Contents Title Page.……….. 1 Abstract ………... 2 Acknowledgements.……….. 3 Dedication ………... 4 Table of Contents.……….. 5 Chapter 1: Introduction to the thesis Introduction ……….. 11 Justification for the project ………. 12 Clinical education ………. 14 Interprofessional education.………. 16 Constructing a data collection tool ……….. 18 Aims of the research ……….. 18 Using PBL as a research methodology.………. 20 Theoretical components ……….. 24 Personal constructs ……….. 26 Concluding discussion ……….. 27 Chapter 2: Interprofessional education and professional socialisation in the context of clinical education Introduction ………... 33 Reviewing the literature on multiprofessional, interprofessional and interdisciplinary learning ………... 35 The development of interprofessional learning.……….. 37 Testing assumptions about IPE ………... 38 Better working relationships through IPE.……….. 38 Interdisciplinary teaching in the community ………... 41 Differing objectives of midwives and medical students.……….. 43 Creating successful IPE.……….. 43 Team working.……….. 45 5 Table of Contents 6 Table of Contents 5 Table of Contents Uni-directional interdisciplinary teaching as the norm.………. 47 IPE as a catalyst for change.………. 47 Professional socialisation.………. 48 Clinical education.………. 52 Conclusion.………. 54 Chapter 3: Midwifery in the shadow of medical obstetrics Introduction.………. 56 Risk assessment and decision making: obstetricians and midwives.……… 56 The complementary nature of midwifery and obstetric medicine.……… 58 Historical conflicts between medicine and midwifery ……….. 61 The 1910 Flexner Report.………. 62 The 1902 Midwives Act and the concept of professionalism ……….. 63 The sociology of power. ……… 67 Comparing midwifery and obstetric care ………. 68 Midwives as the invisible carer.………. 72 Lack of autonomy.………. 73 Emancipation strategies ……….. 77 Conclusion.………. 78 Chapter 4: PBL in health professional education. Introduction.………. 81 Learning to ‘do’ PBL.……… 81 Educational theory underpinning PBL.……… 83 Evaluating the effectiveness of PBL ……….. 85 Conclusion.………. 91 Chapter 5: Considerations of methodology and rigour. Introduction.………. 94 Issues of ontology and epistemology.………. 94 The social construction of knowledge ………. 97 Women’s Ways of Knowing and the unique voice.……… 98 Precepts of qualitative research ………. 99 6 Table of Contents 7 Table of Contents 6 Table of Contents Modified Delphi survey.………. 103 PBL case study exploring knowledge construction.………. 104 Issues of rigour. ……….. 108 Conclusion.………. 115 Chapter 6: Research ethics Introduction.………. 118 Ethical principles.………. 118 Ethics and qualitative research.………. 121 Conclusion.……….. 123 Chapter 7: Delphi methods The Delphi survey method.………... 125 Situated knowledge.………... 125 The electronic Delphi survey.………... 127 The Delphi sample.………... 129 The interview schedule.………... 130 Using the findings to plan the second stage of the research.………... 130 Chapter 8: Delphi findings Introduction.………... 133 The Delphi survey.………... 133 Evidence based midwifery.………... 136 The invisible nature of medical power.………... 140 Differences between the medical and midwifery models.………... 140 Conclusion.………... 142 Chapter 9: Methods of the case study research Introduction ………… 145 The importance of midwifery knowledge.………... 145 Developing the data collection scenarios.……….. 146 Sampling.………... 150 The interviews.……….. 154 Field notes.………... 158 7 Table of Contents 8 Table of Contents 7 Table of Contents Data analysis.……….. 161 Using template analysis.……….. 165 Conclusion.……….. 169 Chapter 10: Presentation of the data and initial discussion Introduction.……….. 172 Medical student attachment to midwives.………. 172 Medical students’ learning styles.……….. 180 Understanding an holistic social model of birth.……….. 182 Witches or wise women? ………... 184 Medical students’ clinical allocations.……….. 186 Data from the PBL scenarios.……….. 187 Conclusion.……….. 212 Chapter 11: Analysis & discussion Theme 1: Witches or Wise Women.……….. 215 Theme 2: valuing the concept of normality.……….. 222 Theme 3: Communication for persuasion.……….. 227 Theme 4: Communication to develop rapport.……….. 234 Theme 5: Authoritative knowledge and medical hegemony ………... 235 Conclusion.……….. 239 Chapter