Memorandum by Dr Angie Hart and Dr Valerie
Hall, Centre for Nursing and Midwifery Research, University of
Brighton (MA5)
This memorandum describes the relevant findings
from two research projects and also draws on our own experiences
as midwifery educators. Dr Hall is also a practising midwife.
The research projects, both of two-years duration
were conducted with other colleagues in our department. The first
was an English National Board for Nursing, Midwifery and Health
Visiting funded research project entitled Addressing Inequalities
in Health: New Directions in Midwifery Education and Practice.
This research was completed in 2001. The purpose of the research
was to examine how midwifery education and practice met the needs
of disadvantaged clients.
The research was carried out in three stages.
The first was a national survey of midwifery educators. The second
was a curriculum analysis of midwifery education regarding inequalities
and disadvantage. The third was in-depth case studies in three
different UK locations. One had a large ethnic minority population,
and two had high levels of social deprivation. Research was undertaken
on (a) delivery of midwifery care to disadvantaged clients and
(b) preparation of midwifery students in relation to inequalities
and disadvantage. To obtain perspectives from all relevant stakeholders
we interviewed a variety of disadvantaged clients, their midwives
and health advocates. We have published widely on the results
of this research in academic and practice journals.
The second project, The use of Electronic
Patient Records (EPRs) in the maternity services: professional
and public acceptability, was funded by the Department of
Health (DH) under its initiative on Information and Communication
Technologies. The purpose of this research was to explore the
professional and public acceptability of Electronic Patient Records
(EPRs) however some of the findings have a bearing on issues of
inequalities in access to maternity services.
The research was carried out in two stages.
The first was a national survey of Heads of Midwifery in England.
The second stage was in-depth case studies in four maternity services,
qualitative and ethnographic in approach, involving interviews,
focus groups, observations (with 340 individuals, mainly from
midwifery, medical staff, IT and administrative staff, and clients,
including disadvantaged clients) and analysis of documentation.
A full research report is due for submission
to DH in May 2003. Published articles based on the research projects
which are relevant to this inquiry are listed at the end.
Our research findings from both studies concern
both the delivery of midwifery care and midwifery education. Key
findings from our studies relevant to the enquiry:
1. There is a need to define disadvantage
broadly, and to recognise that many clients experience multiple
disadvantages which affect their access to health care provision.
2. The Inquiry has left out some key groups
from its list of clients who experience disadvantage which our
research suggests should be incorporated into its remit (eg young
people, women with HIV/AIDs, lesbians, drug users).
3. The "Woman-centred" model of
midwifery care addresses the wishes of individual clients. However,
it fails to address issues of structural inequality. Midwives
need to incorporate this issue into their models of care. Our
work, published in Journal of Advanced Nursing 2003 (see
below for reference list), addresses this issue and provides a
teaching model for nursing and midwifery care which addresses
inequalities.
4. The role of the midwife puts her in a
unique position since she often enjoys a greater level of acceptance
by clients than do other professionals such as health visitors
and social workers. Because of this, teams working directly, and
holistically, with disadvantaged clients have much to gain from
incorporating midwives, as recognised by recent government policies.
5. A major finding of our ENB-funded research,
and one which is backed up by that of others, is a very simple
one. Above all, clients welcome being treated with friendliness
and respect by health professionals. Unfortunately, our research
revealed many occasions when disadvantaged clients were not treated
in a friendly and respectful manner. Midwives need more support
and training to enable them to work with disadvantaged clients.
Trusts, supervisors and educationalists need to recognise that
this work is challenging and that it needs extra resources, including
time, training and supervision. In too many Trusts midwives are
expected to undertake training of this sort in their own time
and often at their own expense.
6. In areas where there were few clients
with particular needs, midwives were deskilled and individual
clients often received a poorer service. More sharing of good
practice needs to occur between midwives (and other practitioner
groups) across different socio-economic/geographical areas. This
is vital if National Service Frameworks are to be facilitated.
7. Our research revealed patchy provision
and lack of use on the part of health care professionals of health
advocacy services. In particular, bi-lingual health advocacy is
of fundamental importance to some disadvantaged clients. This
should be readily available on a 24 hour basis, even in areas
where there are few non-English speakers and all midwives should
know how to access it.
8. Maternity departments should identify
a senior member of staff to champion the needs of disadvantaged
clients. There should be a clear plan to enable others to become
competent in working with such clients.
9. Disadvantaged service users should be
involved in planning services and their views taken into account
via mechanisms such as Maternity Services Liaison Committees.
They should be paid for formal participation at Trust meetings
etc.
10. Our research has shown that service
user involvement as expert educators directly in the classroom
greatly enhances student learning, and the development of empathy,
and should be facilitated.
11. The Client Held Record, although seen
by midwives as empowering to women, is rarely adapted to meet
the literacy and comprehension needs of women with learning difficulties
and those for whom English is not their first language. More could
be done within the maternity services to help such clients truly
access their record. The advent of Electronic Patient Records
at least as currently planned, is likely to exacerbate this issue,
rather than alleviate it. This represents something of a missed
opportunity since the potential of such technology cannot be denied.
Our research suggests that in EPR developments across the country
the needs of clients with specific language and literacy needs
are ignored.
12. Findings from our national DH study
indicate that despite government aspirations, EPRs are unlikely
to replace paper records in the foreseeable future. However, if
they do, to avoid a "digital health divide" the needs
of disadvantaged clients should not be ignored. This relates to
women with learning and/or English language difficulties, and
to those for whom issues of confidentiality and privacy are of
particular importance (eg women with HIV/AIDS).
April 2003
SELECTED RELEVANT
PUBLICATIONS
Lockey, R. and A. Hart In Press "Consulting
`disadvantaged' service users: can we get beyond the rhetoric"
British Journal of Midwifery.
Hart, A., V. Hall and F. Henwood. 2003 "Helping
health and social care professionals develop an `inequalities
imagination': A model for use in education and practice"
Journal of Advanced Nursing 41(5), 480-489.
Hart, A., Henwood, F. and Jones, A. 2003 "Views
of Heads of Midwifery on electronic patient records". British
Journal of Midwifery Volume 11, Number 1, 53-57.
Jones, A., Henwood, F., Hart, A. and Gerhardt,
C. 2003 "Resistance at the frontline: The case of Electronic
Patient Records (EPRs) in Maternity Services". Healthcare
2003 Conference, Harrogate.
Jones, A., Henwood, F. and Hart, A. 2002 "Electronic
patient records: the view from maternity." British Journal
of Midwifery Volume 10, Number 10, 635-639.
Jones, A., Henwood, F. and Hart, A. 2002 "EPRs
and maternity services—the challenge of client held records
and the blurring of boundaries" in Healthcare Computing
2002, Guildford: British Computer Society.
Hart, A. and R Lockey. 2002 "Inequalities
in health care provision: Contemporary policy and practice in
the maternity services, England" Journal of Advanced Nursing
37 (5) pp.1-9.
Hart, A. R.Lockey, F.Henwood, F. Pankhurst,
V.Hall and F. Sommerville 2001 Addressing inequalities in health:
New directions in midwifery education and practice English
National Board for Nursing, Midwifery and Health Visiting: London.
Hart, A. and V. Hall. 2001 "Addressing
health inequalities: Implications for curriculum planning and
educational delivery" The Practising Midwife 4(9),
42-3.
Hart, A. and R. Lockey 2001 Addressing health
inequalities: Developmental implications for practice The Practising
Midwife 4(10), 40-41.
Hart, A. 2001 "Addressing Health Inequalities"
The Practising Midwife 4(6) pp.42-43.
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