15. The challenge of the future
Key points
• Midwifery research is on the point of entering a new era of maturity. The challenge is to increase the amount of quality research produced, critically evaluated and, where appropriate, implemented. The credibility gap between the amount of research produced and the amount put into practice must be reduced. Emphasis must be placed on developing a supportive midwifery research culture.
• More midwives need the practical skills of undertaking research. There is no shortage of clinical problems that need examining, and new developments that need evaluation. More encouragement is needed for midwives to develop these skills, and support given to undertake research, underpinned by an efficient system of funding.
• Once complete, midwifery research should be communicated by means of conference papers, posters and published articles. These should be seen as a crucial part of the research process and be clear, unambiguous and action orientated.
• One of the largest areas of deficit is the number of midwives who can critique research articles and produce critical reviews of the literature. When these activities are undertaken they should contribute to the wider research culture of the clinical area as clinical developments or clinical-effectiveness initiatives.
• The suggestions made in this chapter require someone to accept the challenge of the future. Let it be you.
The last chapter of a novel usually reveals all, and brings the plot to a resolution. It often has a happy or at least intriguing ending, so that the reader puts down the book with a feeling of contentment, perhaps mixed with a tinge of regret that the characters will no longer be a feature of their life. Non-fiction books are not like that. The aim of this chapter is to emphasise that what has gone before in the previous chapters is only the beginning. This chapter challenges you to continue absorbing and applying the information in this book on an increasingly regular basis as part of your clinical practice. It will also encourage you to make a vital contribution to evidence-based practice by helping to establish a research culture in midwifery. This is the last chapter but it is not goodbye.
The future of maternity care is likely to be demanding as well as challenging for the midwife. For example, a report by the King’s Fund (2008) identified the following changes that are likely to have future implications for maternity services:
• The number of births has risen since 2002 and is projected to increase.
• There is an increased number of older mothers, with higher rates of complication.
• There is more fertility treatment, leading to a higher rate of multiple births.
• There are more obese women, who are less fit for pregnancy.
• There are more women surviving serious childhood illness going on to have children, and needing extra care in pregnancy and childbirth.
• There is a rising rates of intervention in labour, in particular in rates of Caesarean section.
• An increasing social and ethnic diversity sometimes leads to communication difficulties and other social and clinical challenges in maternity care.
Such changes will require an even greater emphasis on an efficient midwifery service in order to cope with the complexity of demands. Despite successes with such developments as models of midwifery-led care (Hatem et al. 2009) there is still more work to be done in maintaining high levels of normality in women. The danger is that in stressful situations such as increasing demands and shortages of staff, workable solutions for reducing the problems can sometimes be rejected as a reaction to the situation (McKellar et al. 2009). So, although evidence-based practice offers practical ways of introducing improvements, the production and use of good-quality research may be seen as too demanding by those involved. In this situation, how can we build a culture that embraces evidence-based practice?
One option when looking at the future is to examine the past and previous aspirations for midwifery’s future in research. This may provide a clue to how far we have come and what still needs to happen. Here is the ‘10 year wish list’ for midwifery research made by Lavender et al. (2003: S22). See how many have come true.
• All midwives will have the confidence, ability, desire and opportunity to be involved in research.
• Access to appropriate resources in each clinical area, e.g. libraries, databases and research support staff, will be available.
• Multidisciplinary collaboration, which generates professional respect and equal status, will be encouraged. Multidimensional perspectives can only benefit the women and their families.
• External funding bodies will recognise the importance of midwifery research.
• Trusts will fund and support permanent midwifery research posts.
• Midwives will hold positions of high status to ensure midwifery research is a priority.
• Clinical and managerial leaders will all have research skills and the ability to support and facilitate and generate research in the clinical area.
• Dissemination of findings will be valued and midwives will be supported to attend appropriate forums.
• Local strategies will be developed to ensure the implementation and evaluation of research findings.
You do not always get everything you wish for, so we should acknowledge these as aspirations or directions in which we needed to go. Looking at the list, it is striking that many are now developing, but we are not there yet and the extent of successes of some of these will vary locally. None of the above has dropped completely off the wish list, although some progress has been made in most if not all of them. However, it is now time to consider where we set our sights for the next 10 years so that we can plan how we arrive at that destination. The remainder of this chapter will consider some of the themes where we need to focus attention.
Closing the credibility gap between producing and using research
If we are to close the credibility gap between the amount of research evidence generated and the extent to which it is used in practice, all midwives need to share the same philosophy and emphasis on continually moving professional knowledge forward. To achieve this we must constantly challenge the basis for activities and seek new evidence to support clinical decision making. This will be demanding, as midwives have been regarded as fairly passive in their engagement with the evidence-based agenda (Lavender 2010). The use of information requires the generation of that knowledge so we need to increase the amount of new midwifery research. This book has cited large numbers midwifery research, which would suggest that midwifery does regularly produce research. So where is the problem? The answer is that although the amount of midwifery research has increased, it is still more of a trickle than a steady stream. There are still only a small number of midwives producing research. In other words, there is a lack of research capacity, that is, a shortage of midwives who are actively engaged in producing high-quality research.
The challenge for the future, then, is to answer the following questions:
• Why is there so little midwifery research produced on a regular basis?
• Why don’t midwives make more use of the available research?
• How can we improve the situation?
Why is there so little midwifery research?
Just as in nursing, research in midwifery is a comparatively new phenomenon where techniques and skills of research are still being refined. Research role models are just beginning to emerge in the form of consultant nurses, and midwives working as full-time researchers, often in academic or research units. However, in the case of consultant midwives, their workload does not always allow them to pursue and promote the research aspect of their role and so inspire and encourage the number of midwifery researchers to expand. The conclusion is that at the moment there is a lack of midwives developing practical skills in carrying out research.
If more research is to be produced we must develop acceptable ways of acquiring high-level skills in research design, data gathering and data analysis. These do not come from assignments that require midwifery students to produce a literature review or design a research proposal. Although these activities develop useful skills, isolated from the experience of undertaking research they merely serve to produce a new research theory–practice gap.
How can we increase the opportunities for midwives to gain research skills? This could take a variety of forms. Schools of Midwifery need to provide courses and study programmes where these skills can be developed. These courses should balance the theory of research with engaging with research activity. This means there should be more ‘hands on’ and practical elements in the teaching, such as design workshops and data collection and analysis in a ‘safe’ and ‘coached’ environment.
There should also be opportunities for midwives to shadow midwifery researchers both in clinical areas and to gain secondments to research units where these exist. More midwifery research scholarships should also be considered for trained staff. It is beyond the scope of this chapter to explore all the problems of funding, but this is a crucial area that has to be developed if midwifery is to gain the same level of experience as other health professional groups.
Why don’t midwives make more use of research?
Care for women will stagnate unless we apply available evidence to practice, but before research can support practice it must first be accessed (Chapter 6), then critically evaluated (Chapter 5). Lavender (2010: 114) suggests that midwives fall into the following five categories when it comes to their use of the research literature:
• non-users,
• reluctant users,
• selective users,
• rigid users,
• thoughtful users.
Each of the first four groups is in some way problematic, and will have implications for the type of care provided. The non-user is unlikely to be open to change and so may be practicing in ways that could be outdated and dangerous. The reluctant user is likely to maintain old systems of care and only use research occasionally as a way of avoiding criticism. Selective users are likely to use research that supports their way of doing things and ignore research that disagrees with favoured methods. The rigid user will not adapt research recommendations flexibly to local situations even though they may vary considerably from conditions and contexts in which original studies were undertaken (Amelink-Verburg et al. 2010). The ideal goal would be to move all of the former closer to the final category of the ‘thoughtful user’, which Lavender (2010) characterises as a midwife who can identify relevant evidence and apply it to an individual woman in a particular context.
What are some of the main barriers to research implementation? If you consider your own clinical area, or those you have encountered as a student, what prevents a greater use of the available research that could improve care? Numerous studies both in the UK and the USA have identified barriers to applying research to practice, and these have been grouped by Gerrish (2010)
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