Background

The negotiations about pay and conditions between queensland health, and nurses and
midwives

Working in the public health sector in queensland (represented by the queensland nurses
union), resulted in the acceptance of the sixth enterprise bargaining agreement (eb6) in 2006.
A number of issues arose from the negotiation process, including the adoption of an interest-
based bargaining (ibb) approach (developed by the harvard business school) to oversee the
implementation of the agreement’s five priority areas:

1. Workforce recruitment and retention

2. Nursing and midwifery workloads management

3. Modelling contemporary nursing and midwifery

4. Education and staff development

5. Work life balance

The nurses interest based bargaining implementation group (nibbig) was formed to
investigate these five areas and provide recommendations for their effective management.

The focus of nibbig was to include, but not be limited to:

• the advancement of expanded or new nursing roles (eg. Extended practice-nurse

roles, nurse practitioners)

• midwifery models of care used by or for midwifery

• multidisciplinary team models of care

• the appropriate use of assistantsin nursing (ains)

• the use of evidence to inform professional practice ensuring continuity of patient

care.

Five subcommittees were established. The responsibility for ‘the adoption of a consistent
approach to models of contemporary nursing midwifery practice’ (eb6 priority area 3) was
undertaken by the models of contemporary

Nursing practice committee (mocnpc). :in order to achieve a consistent approach, the mocnpc
decided to develop a flexible user-friendly tool that recognised the diversity of settings in
which nurses and midwives practice and gave them information and a structured approach to
help them design, implement and evaluate a model of care using agreed foundation
principles.

The five foundation principles are:

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1. Patient-centred care

2. Best use of nursing and midwifery resources

3. Safe practices

4. Quality care – judicious use of evidence

5. Trends in contemporary healthcare

They were identified by the mocnpc as the key elements of nursing and midwifery practice.
From nightingale onward, nurses and midwives have developed models and theories that
examine the relationships between four key elements: person, nurse (and midwife), health,
and environment (fitzpatrick & whall, 1983; pearson, vaughan, & fitzgerald, 1996; marriner
tomey & alligood, 1998). Within the overarching relationship with health, the
foundation .principles (fps) have been derived from the four key elements. For example:

• person is associated with fp-1

• nurse (and midwife) is linked to fp-2

• environment (physical, societal,legal and organisational aspects)

The foundation principles are also similar to those used in queensland health’s business
planning framework: nursing resources (2005), namely:

the patient/client

The nurse

The organisation.

Other articles such as transforming care at the bedside (institute for healthcare improvement,
2007) list four ‘key design themes’ for improving bedside care:

• safe and reliable care

• vitality and teamwork

• patient-centered care

• value-added care processes.

These are closely allied to the [Link] constantly changing nature of our world (the
environment) required the mocnpc to develop a framework that was contemporaneous,
therefore the document modelling contemporary nursing and midwifery: a framework for
shaping professional practice and fp-5 reflect the need for nurses and midwives to ensure
their practice models are capable of managing current and future healthcare.

aim

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Using a consistent and logical approach, the aim of the modelling contemporary nursing and
midwifery: a framework for shaping professional practice document (this framework) is to
challenge nurses and midwives to assess the effectiveness, efficiency and efficacy of their
current practice model in meeting the foundation principles and, if required, to assist them to
design, implement and evaluate a suitable contemporary practice model in their workplace.

Purpose

There are a number of models that influence the delivery of patient care in our healthcare
system. These include nursing and midwifery practice models, the biomedical model used by
doctors and some allied health professionals, and a managerial model that focuses on
business planning and resource allocation. It is also necessary to consider societal
expectations and patient beliefs that may be influenced by religious and cultural
considerations. Nurses and midwives need to be aware of the unequal power of these models,
therefore it is important for them to consider the control that each model exerts through key
stakeholders, legislation and systems that affect the delivery of healthcare. Nurses and
midwives need to focus on the pivotal coordinating role that their practice plays in this
complex matrix. This framework is a comprehensive guide and resource that provides nurses
and midwives with a process that helps them identify and develop an understanding of the
factors that should be considered in contemporary nursing and midwifery practice. It provides
direction as to how a ‘new’ practice model may be implemented and how the effectiveness
and outcomes of a practice model can be evaluated. It is an instrument that can also be used
to support and promote the importance of nurses and midwives within the healthcare system.

Definitions

This section discusses the definitions used in this framework. There are several meanings
related to ‘models of care’ and often terms are used interchangeably. While ‘models of care’
inform practice about ‘what is being done’ (the approach to, and underlying beliefs about the
care that is provided), ‘models of practise’ provide direction as to ‘how it is done’. The
discussion below attempts to provide clarity by examining these interpretations in order to
help the user make sense of the terminology.

Model

A practice model is ‘…a descriptive picture of practice which adequately represents the real
thing’ (pearson, vaughan, and fitzgerald, 1996, p. 2). A model is formed when an idea is
explained by using symbolic and physical visualisation. It can be used ‘to facilitate thinking
about (abstract) concepts and the relationships between them . This framework assists in the
development and application of models that assist professional practice by linking the
abstract concepts of the foundation principles to the reality of providing the best possible
healthcare. It provides an ‘action’ map and resources that nurses and midwives can use to
further develop their professional practice.

Model of care

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A literature review undertaken by queensland health for the development of the changing
models of care framework found that there was no consistent definition of ‘model of care’
and determined that ‘a model of care is a multifaceted concept, which broadly defines the
way health services are delivered.’ tierney noted that ‘ambiguity exists in the literature, with
the terms model of care, nursing model, philosophy, paradigm, framework and theory often
used interchangeably despite referring to diverse, yet parallel concepts.’ davidson et al.
(2006, ) define a model of care as ‘…an overarching design for the provision of a particular
type of health care service that is shaped by a theoretical basis, ebp (evidence-based practice)
and defined standards. It consists of defined core elements and principles and has a
framework that provides the structure for the implementation and subsequent evaluation of
care.’ they suggest that it should be clearly articulated ‘… to ensure that all health
professionals are all actually ‘viewing the same picture’, working towards a common set of
goals, and are able to evaluate performance on an agreed basis’ (davidson et al. 2006, ).
Fowler, hardy, and howarth (2006,) refer to a model of care as a ‘nursing practice model’ and
define it as ‘…an operational model for redesigning nursing practice for the provision of
patient care in an organisational setting, specifically at a clinical services unit level (ward)…it
governs the manner in which nurses organise work groups, communicate with work group
members and other disciplines, interact, make decisions, and create an environment within
which nursing care is delivered among care providers, and specify communication and
coordination patterns necessary to support (patient) care.’ these definitions are similar in that
they relate the theory of the ‘model’ to the provision of patient care by nurses and midwives.
The purpose of professional practice by nurses and midwives is patient-centred healthcare,
and this framework, with its use of foundation principles and structure, guides them toward
building a healthcare practice model that best meets the needs of their workplace.

Nursing model of care

The nursing model of care – toolkit for nurses (queensland health, 2003, ) defines a nursing
model of care as the ‘organisation and delivery of nursing care’ within diverse work units and
settings that range across the continuum from acute to community, in metropolitan, regional,
rural and remote areas. Davidson et al. (2006, ) defines a ‘nursing model’ as pertaining
‘solely to the practice domain of nursing’. The patient is central to the nursing model of care.

Midwifery model of care

The queensland nursing council (no date) defines midwifery care as being woman centred
care that ‘…occurs in an open and interactive environment in which the woman and midwife
negotiate a partnership to achieve the best possible health outcomes.’ the international
confederation of midwives notes that ‘a midwife may practice in any setting including the
home, community, hospitals, clinics or health units.’ despite the differences between nursing
and midwifery ‘models of care’, there is enough flexibility within this framework for it to be
useful in the development of a model of care that assists both nurses and midwives with their
organisation and delivery of optimal patient care. Models of nursing and midwifery (see
below) provide the concepts from which this framework’s foundation principles were derived
and they guide the decisionmaking process for the setting of goals. This framework differs

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from them in that it provides direction and resources that facilitate the achievement of those
goals.

Models of nursing

Models of care should not be confused with ‘models of nursing’ or ‘nursing theories’ that
comprise the beliefs and values that guide nursing practice. The four elements or concepts
that comprise most (if not all) nursing theories are: the person (patient, resident or client);
health (wellness–illness, physical, mental, spiritual); environment (physical, social, cultural
and political); and nursing (nurses and midwives). Pearson et al. (1996) suggest that while
beliefs and values are the foundations upon which the rest of the model of nursing is built, it
is essential to have goals in order to provide a common or agreed purpose, and systems of
care delivery that result in the delivery of the agreed service, namely healthcare.

Models of midwivery

Recent research by kennedy, rousseau and low ) into the essence of midwifery care identified
four elements that comprise ‘midwifery’: the woman as the central focus, the midwife as the
provider or ‘instrument’ of ‘midwifery care’, the professional partnership or ‘alliance’ that
forms between them, and the environment in which this occurs. These components are
similar to the four features of nursing models: patient, nurse, health and environment.

Models of practise

These ‘models’ could be more accurately described as ‘systems of work’ as they relate more
to care delivery processes and the organisation of nursing work than the explication of the
ways that ‘models of care’ guide the practices of nurses and midwives toward providing the
best possible patient care. Traditionally ‘nursing work’ was based on task allocation, however
patient allocation, team nursing (and midwifery) and primary nursing (and midwifery) are
other approaches to the contemporary organisation of healthcare [Link] suggest that
‘practise models’ are an adjunct to care delivery (as was the nursing process) with models of
care providing the underlying principles and goals that have guided nursing practice. Other
care delivery strategies have focused on management practices such as key worker, case
management, managed care, and nursing beds examples of nursing care delivery models
defined by fowler et al. Include patient-focused care; model of professional accountability;
primary or total nursing care; individualised care; team or functional nursing care; magnet
hospital environmental/shared governance; quality-caring model (acute care); and model for
promoting process engagement (chronic illness). This framework is founded on the key
beliefs and values of the models of both nursing and midwifery (as its foundation principles)
and uses the contributions of both models of care and models of practise to guide the practice
of nurses and midwives so that they can provide the best possible healthcare in the most
efficient and effective way.

Framework

A framework shapes and guides the implementation and evaluation phases of a model’s
development, it is the ‘brace and girders that support the model’ (davidson et al. 2006. P. 49).

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This framework provides guidance for assessing the quality of care that results from current
service delivery, and a process whereby clinicians are guided through the steps whereby a
‘new’ practice model can be implemented. It contains resources that inform the different
practice models that could be used in a variety of clinical and community settings. The value
of this framework extends beyond just guiding the implementation and evaluation phases of a
model’s development; it delivers a strong foundation upon which the selected model can be
assessed for its validity. The logical structure that guides the decisionmaking processes of
clinicians provides justification for the modification of workplace practices. Furthermore, it
provides guidance for assessing the quality of healthcare that results from current service
delivery methods and a process whereby clinicians are guided toward setting goals and
implementing a ‘new’ (or changed) practice model.

The purpose and benefits of a model of care

Because nursing models of care have been poorly defined, fowler et al. (2006) suggest that
they have been variously seen as a governance structure, a compensation scheme (where
guidelines that direct practice are lacking) or a strategy for allocating patients to staff (or staff
to patients). This has contributed to confusion about the meaning of the terminology. The
lack of clarity about the purpose of nursing models of care has added to this uncertainty.
Various reasons have been given for developing and introducing nursing models of care; they
include increasing work satisfaction and staff retention, cost containment, service
efficiencies, quality improvement, and improving patient outcomes (in terms of health status,
number of attendances and duration of stay)

Davidson et al. Argue for the need to define the term ‘model of care’ and propose that it
‘describes the delivery of health care within the broader context of a health system.’ girard
(1993) emphasised the practical application of models of care when she used the term
‘nursing care delivery models’ when referring to new practice models for delivering nursing
care in the perioperative setting. The nursing worklife model of manojlovich and laschinger
(2002) also identified the importance of a nursing model of care in informing and directing
nursing practice. They suggest that it directly influences the organisational factor of staffing
and resources, and the personal accomplishment of staff. The benefits of using an agreed
practice model include:

•consistency of patient care and continuity of care patterns and management (treatment)

• reduction in disagreements and conflict within the ‘patient-care team’

• understanding of the aims, goals and interventions of nursing by all stakeholders (nurses,
patients and other health professionals)

• providing direction to nursing care by defining its ‘fit’ or place within the practice setting

• guiding decisions about practice and policy because the selected components of the model
guide the interventions and outcome evaluation

• focus the criteria for team-member selection.

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Having determined the advantages of using an agreed practice model as a conceptual tool that
provides ‘a standard or example for imitation or comparison, combining concepts, belief and
intent that are related in some way’ it is essential that the chosen practice model meets the
required needs and standards. Several authors including davidson and elliott and

Girard have suggested that the essential criteria for a practice model include:

• a basis in evidence that is clearly identified and documented and/or a grounding in

theoretical propositions (a professional knowledge base)

• a foundation derived from assessment of patient and health-provider needs

• evaluation of health-related and intervention outcomes (for patients, nurses, other health
professionals, and organisations)

• the identification of nursing competencies and defined nursing roles

• professional autonomy and accountability

• consideration of the safety and wellbeing of nurses

• respect for legal and ethical positions, including equity of access for all members of society
and interventions that are culturally sensitive and appropriate

• consultation and collaboration between key stakeholders and, where applicable, involve a
multidisciplinary approach

• endorsement of self-determination and health promotion

• optimal and equitable utilisation of health care resources including financial and budgetary
impacts and quality-management factors

• currency (they need to be contemporaneous), with flexible application, practicality,and

‘repeatability’.

In summary, practice models serve a number of functions. These include the provision of a
‘common’ language that supports communication between nurses and/or midwives, they
permit others to ‘see what nurses and midwives see’ (and therefore gain an understanding of
nursing and midwifery), enable review by other stakeholders (eg. Patients, health
professionals, managers, lawyers) so that their suitability and legality can be assessed, and
allow for accountability because the ideas that have been selected can be tested (theoretically)
before they are applied to the practice setting. They should be based on the best available
evidence (tried and tested), support the delivery of quality patient care, and through their
involvement in selecting, implementing and evaluating a practice model that best suits the
specific needs of their workplace, increase nurses’ work satisfaction.

Midwifery model care

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The existence of two separate approaches to the care of pregnant women began in ancient
history; ultimately it led to the development of the two professions of midwifery and medical
obstetrics. Each of these disciplines is based on a different understanding of the nature and
significance of pregnancy and childbirth. Midwifery developed out of the social,
informational, physical, and material support women have traditionally provided to one
another in times of need. Midwives view pregnancy as a critical, vulnerable, but normal part
of women’s lives. Obstetrics developed from within medicine for the purpose of dealing with
the pathologies of pregnancy and childbirth. Each of these perspectives calls forth a different
approach to the care of pregnant women—the midwifery model and the medical model .

Difference in philosophy and focus

Midwifery and medical obstetrics are separate but complementary professions

with differentphilosophies and overlapping but distinct purposes and bodies of knowledge.
Physicians are experts in pathology and should have primary responsibility for the care of
pregnant women who have recognized diseases or serious complications. Midwives are
experts in normalpregnancy and in meeting the other needs of pregnant women— the needs
that are not related to pathology. In most countries, midwives have primary responsibility for
the care of women with uncomplicated pregnancies.

Midwifery focuses on the normalcy of pregnancy, and its potential for health. Birth is viewed
as a natural process that has profound meaning to many people and should be treated as
normal until there is evidence of a problem. The possibility of complications is not allowed to
preempt all other values associated with the woman’s experience of bearing and giving birth
to a child. Midwives are experts in protecting, supporting, and enhancing the normal
physiology of labor, delivery, and breast-feeding.

The medical management model focuses on the pathologic potential of pregnancy and birth.
As a specialty of medicine, the main focus of obstetrics is diagnosis and treatment of
pregnancy complications and management of diseases that affect pregnant women and the
fetuses they carry. Attention to the pathologic potential of pregnancy is vital because,
although most pregnancies would proceed healthfully without any medical intervention,
serious complications and diseases are not uncommon and can be deadly. The importance of
medical care for pregnant women with serious complications was dramatically shown by a
study that documented extremely high mortality among well-nourished american women who
belong to a religious sect that does not allow any kind of medical treatment (eg, deaths
equaling a maternal mortality rate of 872/100,000 births among members of the faith
assembly in 1983) . Acknowledging the essentialness of medical care for women and
newborns with serious complications, the american college of nurse-midwives (acnm)
requires all certified nurse-midwives (cnms) and certified midwives (cms) to maintain a safe
mechanism to obtain medical consultation, collaboration, and referral .but, physicians have
expanded the proportion of pregnancies considered abnormal or pathologic by using
monitoring devices that over-diagnose complications , basing diagnoses on overly narrow
definitions of normal, and treating variation from those definitions as evidence of pathology .

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The desire to identify complications early has led to use of a sequence of preemptive
interventions (to prevent complications or to treat them before there is evidence that they
exist) and a focus on “risk factors” (conditions that are not pathologic but are associated with
an increased incidence of complications). In many instances, the distinction between risk
factors and actual pathology has been lost, and women with “high-risk factors” are treated as
though they have actualcomplications .

Since an unexpected complication can happen to any woman at any time, the medical
management model prepares for the worst. For example, an intravenous infusion (iv) or “hep-
lock” (placement of an iv cannula to ensure rapid access to a vein) are often provided just in
case the woman needs blood or drugs in an emergency. And, substantial oral intake is
discouraged or not allowed just in case she needs anesthesia for an emergency cesarean
section. Although an iv is not necessary for a woman having a normal birth , establishing an
iv early in labor is a routine practice in many united states hospitals . In contrast, ivs are used
relatively rarely in birth centers , which were specifically designed for the midwifery model
of care .

Common ground between midwifery and medical obstetric practice

Although there are important differences between these models, there is also much common
ground. The knowledge and skills of midwives and obstetricians overlap. Midwives read
books and articles written by obstetricians and use information based on their research.
Midwives do their own research and write their own articles and books, which are available
to obstetricians. In addition, nurse-midwives teach management of normal childbirth to
medical students and residents in many academic medical centers .many important
improvements in obstetric practice during the past 15 years have resulted from obstetricians
adopting some of the beliefs and methods associated with midwifery. When a physician
practices them, they become part of his or her medical practice. Cnms and cms have also
incorporated some aspects of the medical management of pregnancy into their practices—as
demonstrated by data showing that women whose births were attended by cnms were as
likely as women whose births were attended by physicians to have had some kind of
electronic fetal monitoring (efm) in 1997, based on birth certificate data .the birth certificate
item used to collect this information provides for only a “yes” or “no” response. Thus, the
national center for health statistics (nchs) natality data cannot distinguish between internal
versus external placement of the monitoring equipment or between continuous versus
intermittent use of efm .

The midwifery model is consistent with the purposes, philosophy, and knowledge base of
midwives, but it is practiced, to varying degrees, by others, including some obstetricians and
family physicians. Yet, an important part of the practice of both obstetricians and midwives is
not fully accessible to the other. Even though no definitive line can be drawn between the
care provided by midwives and physicians, there are important general differences between
the midwifery model and medical management.

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Differences in the relationship between the care provider and the woman

The midwifery model establishes the pregnant woman as an active partner in her own care
and recognizes her as the primary actor and decision-maker. A major part of the midwife’s
role is providing the information and support the woman needs to make her own decisions. A
midwife helps the woman identify problems and gives her information, options, and the
authority to make her own choices . Many midwives avoid saying that they “deliver babies”;
rather they “attend” the laboring woman and “catch” the baby, recognizing that the woman
herself, through her labor, delivers her own child into the world. Physicians are more likely to
see themselves as the key decision-makers, and most say that they “deliver” babies.

The main focus of prenatal care

The midwifery model of care makes the woman and her life the central focus of prenatal care.
A large part of the midwife’s attention focuses on the pregnant woman as a unique person, in
the context of her family and her life. The midwife is interested in the woman’s expectations
and experience of her pregnancy—her perceptions and beliefs; her knowledge and opinions;
her questions and worries; her satisfactions and dissatisfactions; her comforts and
discomforts; her desires, decisions, and actions; and the effect of all these on her pregnancy,
fetus, labor, delivery, breastfeeding, postpartum recovery, and development as a mother.

Pregnant women need a lot of information, and some need help and support to recognize and
change aspects of their lifestyles or circumstances that put them or their babies at increased
risk. Midwives emphasize helping women make changes conducive to a healthy pregnancy,
baby, and family.

Prenatal care within the medical management model focuses primarily on the fetus and
screening for pathology. Medically oriented prenatal care often fails to give enough attention
to the problems embedded in the lives of pregnant women, such as smoking and domestic
abuse. Nearly 20% of low birth weight has been attributed to smoking , and the national
ambulatory medical care study (namcs) found that more than 80% of office-based physicians
determine whether their pregnant patients smoke ; however, the doctors provided counseling
to help women who smoke quit or cut down on their smoking during only 22% of the
pregnant smokers’ visits. In another study based on a nationally representative sample, only
71% of white women and 64% of black women said that they had received advice about
smoking during prenatal care . A survey based on a random sample of obstetricians in texas
found that most do not understand the seriousness of maternal smoking. Although most asked
their patients if they smoked, one third of the doctors did not counsel the women who said
they smoked .

In contrast, a 1994 study that queried a stratified random sample of active acnm members
about their practices reported that 93% of the cnms indicated that they assessed the smoking
habits of “most to all” of their prenatal patients (81%–100%), and 86% of the cnms indicated
that they provided smoking cessation counseling to “most to all” of the pregnant women

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whosmoked . A study of care provided to low-risk pregnant women in washington state
found that cnms were more likely than either obstetricians or family physicians to record
information on smoking at the first prenatal visit . In a study of women who had obtained
prenatal care at a facility that offered care by either cnms or obstetricians, the nurse-
midwives’ clients believed that their care providers held significantly stronger opinions about
the importance of health-promotion behaviors, including abstinence from smoking, and
offered more support to help the women conform to those behaviors, as compared to the
women who obtained their prenatal care from obstetricians .

Domestic violence is another example of the need for prenatal care to focus on the lives of
pregnant women. Approximately one of every 20 pregnant women is physically hurt by her
husband or another man at some time during her pregnancy . When the oregon medicaid
program converted to managed care, many high-risk women left special maternity-care
programs to enter the care of private physicians. In order to facilitate this change, the health
department developed a guide to help private doctors identify women with problems such as
drug abuse and domestic violence. Although some physicians welcomed this help, many
refused, saying they did not have time to ask women these questions, they were not willing to
pay a nurse to do it, and they did not consider these problems to be any part of their business.

Continuous presence and hands-on assistance during labor

The midwifery model of care is time-intensive and relationship-intensive. Midwives use their
own physical and emotional energy to encourage, support, and comfort women during birth;
the medical management model, in contrast, tends to substitute more use of medical
technology for more use of professional time. Researchers studying the impact of caregiver
support for women during childbirth have noted that nurses who work in obstetric units with
a high use of technical obstetric interventions may have little time to provide support to
women in labor . That description seems to fit american obstetric care in general. More than
80% of women who gave birth in the united states in 1997 had efm during labor (whether
internal or external, continuous or intermittent), more than a third had their labors either
induced and/or stimulated by oxytocin and more than 40% had epidurals .use of both
oxytocin and epidurals is increasing rapidly. Recent studies have reported a doubling in use
of both interventions during the previous 10 years ,and there are anecdotal reports of epidural
rates of 90% or higher in specific hospitals . Nurses in many hospitals watch fetal monitor
tracings from several patients at a central nursing station. Careful observational studies
conducted at some hospitals have found that labor-and-delivery-unit nurses spend only about
one-fourth of their time in a room in which there is a patient .

Use of obstetric interventions

The midwifery model of care is based on respect for the intricacy of the natural physiology of
childbirth and belief that women’s bodies are well designed for birth. Midwives try to protect,
support, and avoid interfering with the normal processes; thus they try to avoid unnecessary
use of obstetric interventions. The medical management model, in contrast, views women’s

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bodies as very imperfect at giving birth and calls for close monitoring and control of the
process.

Physicians tend to manage labor using relatively narrow criteria for what is normal and
intervene when a woman’s labor falls outside those criteria. Midwives may accept greater
variation as within the range of normal, so long as both the woman and fetus tolerate labor
well. Labors that deviate from these norms are cause for increased vigilance for early signs of
actual complications, but not for automatic use of interventions.

Medical management often calls for applying treatments as preventive measures. The
midwifery model recommends waiting until there is evidence that the intervention is needed.
Treating more labors as normal may help them stay normal; some of the interventions applied
because a woman is high-risk cause actual complications. For example, using oxytocin to
increase the frequency and strength of contractions can interfere with the supply of blood
going to the placenta and thus cause fetal distress . Oxytocin also tends to increase the pain
oflabor (, sometimes making it necessary to give an epidural to a woman who would not have
needed it if she had not had the oxytocin. Epidurals, in turn, tend to increase the need for
either a cesarean section or use of forceps or vacuum extraction to actually deliver the baby .

Most cnms and cms use some obstetric procedures, including electronic fetal monitoring
(efm), and some of their clients have episiotomies or receive oxytocin, epidural analgesia, or
anesthesia, and other procedures that are needed sometimes . But, except for efm, midwives’
clients are less likely to have these procedures, in part because midwives specialize in the
care of women without serious complications, in part because women who want to avoid
unnecessary procedures seek the care of midwives ,and in part because midwives have other,
less invasive methods to assist women, such as warm water baths and counter-pressure as
measures to relieve and help women cope with pain.

Goals and objectives of care

The health and safety of the mother and baby are of paramount importance in both the
midwifery and medical models. But, they are not the midwife’s only goals. Midwives value
childbirth as an emotionally, socially, culturally, and often spiritually meaningful life
experience—something to be experienced positively, with potential for making women feel
stronger, and be stronger, and for strengthening bonds between the mother and father, as well
as the other siblings and the newborn.

In addition, the baby is not the only important outcome of the pregnancy. Pregnancy,
especially every first pregnancy, is a critical developmental process for a woman. Pregnancy
results in a mother as well as a baby. It is important that the woman’s transition into
motherhood is a positive experience, that she and all members of her family make
emotionally healthy adjustments to each pregnancy and birth, and that she has the means to
acquire the necessary information, skills, support, and self-confidence needed to successfully

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assume the roles and responsibilities of motherhood. Breastfeeding and mothercraft are part
of the focus of midwifery.

Summary

The midwifery and medical models are based on particular perspectives of pregnancy and
birth. Both of these perspectives are valid and important; the extent to which one or the other
should be given priority varies with different women. Conceptually, the two approaches are
complementary rather than competitive, and the experience of midwives and physicians
working together in hospitals and practices throughout the united states and europe shows
that they are compatible. Although these perspectives have sometimes competed, midwives
and physicians work together and share information, and the two models have merged, to
some extent. Most midwives acknowledge the importance of medical treatment for women
with pregnancy complications, and most physicians acknowledge the importance of the social
and emotional aspects of pregnancy and childbirth. Hospitals and physicians who at first
resisted women’s requests to have their husband or another support person with them during
labor now “allow” it, and the practice is widespread. Instead of two mutually exclusive ways
of managing birth, there is a wide continuum, with some examples of more extreme or pure
renditions of each model at the ends of the continuum, but most practices falling towards the
middle. If childbirth practitioners were placed on this continuum and plotted on a frequency
curve, the curve might be bimodal—with relatively few examples of the pure expression of
each model, most practices incorporating some elements of both, and two distinct peaks in
the curve, one reflecting practices that adhere more to the midwifery model and one reflecting
practices that adhere more to the medical model.

The process of building midwifery theory

Theory building is incremental. To provide an idea of the current extent ofliterature on

midwifery theory, we undertook a database search in 2010 ofpapers on midwifery theory
generation and midwifery theory testing. To dothis, we contacted the chief librarian at the
royal college of midwives and thesubject librarian at ulster university to support us as we
undertook a comprehensive and systematized review of the literature on midwifery
theory,midwifery concepts, midwifery models and midwifery theorists.

Cinahl

‘midwifery’ was not a mesh or a subject heading. Searches for key words‘midwifery theory’,
‘midwifery concepts’ and ‘nurse-midwifery theoreticalconstructs’ produced no results; this
did not change using smart searchingtechniques. We also undertook a key word search using
‘theory generation’ combined with ‘nurse midwife’, and the result was zero. Mesh ‘nurse
midwives’ was a subject heading in cinahl and produced 1292 [Link] was added and
exploded to include all terms resulting in 76,000 hitsthat were reduced to 58 when we added
‘theory testing’ and ‘theory generation’. The abstracts were downloaded and read, and it was
found that 10 papers were relevant to midwifery practice.

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Ovid medline

‘nurse-midwifery’ was a mesh, but ‘midwifery’ was filed under ‘nurse specialties’. The
search was replicated and a potential pool of 5407 papers was identified. This was reduced to
82 when the key words ‘midwifery theory’, ‘midwifery concepts’ and ‘nurse-midwifery
theoretical constructs’ were [Link] was further reduced to 37 when ‘theory generation’,
‘theory development’ and ‘theory testing’ were added.

British nursing index

‘nurse midwifery’ was not a mesh, and a key word search revealed no papers under this
umbrella term. A key word search for ‘midwifery’ and ‘nursemidwifery’ revealed 189 papers.
The terms were exploded and a pool of 2472 papers became available. However, when
‘theory generation’ and ‘theory development’ and ‘theory testing’ were added, this was
reduced to [Link] this search generated a small number of papers, it was encouraging
that many have been published in recent years – demonstrating, as do theauthors in this book,
the continuing growth and development of midwifery theory building and testing.

We believe that the art and science of midwiferymust be equally valued and evidence-
supported for post modern “y” generation women to make truly informed choices about their
birthing experience, inpartnership with midwives and doctors. This poses considerable
challenges:

• asking answerable and appropriate questions about our knowledge base

• keeping our focus on searching rigorously for the ‘truth’

• assembling new knowledge into meaningful explanations and laws or theories

• applying, testing and evaluating these theories and their relationships topractice education
and research, prior to building foundational models for‘midwifery’.

A concrete foundation needs to be built with proportionate amounts of theright ingredients

and, in midwifery, we require three key substances: education, research and practice. Each of
these must be equally balanced and carefully monitored in order to produce the desired
outcome – a solid evidencebase on which to build midwifery practice with pillars of
knowledge. Theevidence in the book demonstrates theory derivation, theory
generation,theory application, theory development, theory testing, theory evaluation
andtheory synthesis. However, it is important to remember the purpose of atheory and its
limitations. A theory should provide auditable and transparentdata on its concepts, attributes
and empirical referents, as well as proposedtentative relationships or theoretical assumptions.
Describing a theory and itsapplication is similar to the production of a map in which the
cartographerhelps the navigator to visualize the journey and see the dimensions, connections
and boundaries. This is very helpful, but it is mostly of ‘extrinsic ‘[Link] is only after
experiencing the journey equipped with your own personalknowledge, skill and attitude that

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you really know and understand the ‘intrinsic’ value of ‘doing’ and move more towards
becoming enlightened. It is ourhope that, through your experience of doing, of engaging with
this book andthe exercises, you will develop your abilities in the critical analysis and
evaluation of theory, and be confident and competent to question the value, relevance and ‘fit
for purpose’ contribution of any theory for midwifery practice.

Bibliography

1. [Link]
2. [Link] health

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