产科病房分娩共享决策的VIP混合方法研究

E. Annandale, H. Baston, Siân Beynon-Jones, Lyn Brierley-Jones, Alison Brodrick, Paul Chappell, J. Green, C. Jackson, Victoria Land, T. Stacey
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引用次数: 1

摘要

NHS政策强调在分娩和分娩过程中共同决策。然而,关于决策是如何实时发生的证据有限。我们的目标如下:在助产士领导的单位中建立一套分娩和分娩的录像和录音数据;使用对话分析来探讨谈话如何在共同决策中使用;评估妇女的产前期望是否反映在经历中,以及所使用的互动策略(特别是共同决策的程度)是否与妇女的产后满意度有关;并向保健从业人员和服务使用者传播调查结果,为临床实践中的沟通政策提供信息。这是一项混合方法研究。研究的主要方法是对话分析,探讨决策过程中交互作用的细节。根据对话分析,开发了一个编码框架来量化互动,并与有关女性产前期望和偏好的问卷数据以及女性对决策的经历和产后满意度的问卷数据一起进行了探讨。与卫生保健从业人员的半结构化访谈探讨了影响决策的因素。这项研究是在英国两家NHS信托机构的助产士领导的单位进行的。共有154名妇女(年龄≥16岁,低风险怀孕)、158名生育伴侣和121名保健从业人员同意进行记录。在这些参与者中,记录了37名妇女、43名生育伴侣和74名保健从业人员。助产士以不邀请妇女参与(即超出同意)的形式发起大多数决定。助产士提供的选择程度因决定而异。妇女在缓解疼痛和分娩第三阶段的决策中参与最多。据报道,满意度很高。助产士使用不同形式的决策和任何满意度测量之间没有统计学上的显著关系。然而,女性主动做决定,特别是与缓解疼痛有关的决定(例如提出很多要求),满意度较低。我们的数据集中在决策的启动和反应上进行了探索,而对护理的其他重要方面(例如助产士和生育伴侣的互动技术,以促进与疼痛的工作)的探索不足,这可能与决策有关。尽管努力招募多样化的样本,但少数民族女性的代表性不足。强调患者参与决策的政策举措在实践中难以实施。我们的研究结果表明,妇女在决策方面的选择有限,助产士在追求特定决策结果时倾向于指南/标准临床实践。尽管如此,大多数女性还是对自己的经历感到满意。然而,当女性需要做出决定时,尤其是关于缓解疼痛的决定,满意度就会降低。对话分析表明,这种“妇女发起”的决策发生在助产士避免在分娩的特定阶段使用药物缓解疼痛的背景下。我们建议未来的研究解决以下问题-纳入少数民族研究参与者的障碍,产科单位的决策,系统理解如何追求/解决疼痛缓解决策,超越特定决策背景的互动元素的对话分析,情绪劳动的互动“标记”和产前接触的纳入。该试验注册号为ISRCTN16227678,国家卫生与保健研究所(NIHR) CRN组合(CMPS):32505和IRAS:211358。该项目由国家卫生和保健研究所(NIHR)卫生和社会保健提供研究方案资助,将全文发表在《卫生和社会保健提供研究》上;第10卷,第36期请参阅NIHR期刊图书馆网站了解更多项目信息。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Shared decision-making during childbirth in maternity units: the VIP mixed-methods study
NHS policy emphasises shared decision-making during labour and birth. There is, however, limited evidence concerning how decision-making happens in real time. Our objectives were as follows – create a data set of video- and audio-recordings of labour and birth in midwife-led units; use conversation analysis to explore how talk is used in shared decision-making; assess whether or not women’s antenatal expectations are reflected in experiences and whether or not the interactional strategies used (particularly the extent to which decisions are shared) are associated with women’s postnatal satisfaction; and disseminate findings to health-care practitioners and service users to inform policy on communication in clinical practice. This was a mixed-methods study. The principal method was conversation analysis to explore the fine detail of interaction during decision-making. Derived from the conversation analysis, a coding frame was developed to quantify interactions, which were explored alongside questionnaire data concerning women’s antenatal expectations and preferences, and women’s experiences of, and postnatal satisfaction with, decision-making. Semistructured interviews with health-care practitioners explored factors shaping decision-making. The study took place in midwife-led units at two English NHS trusts. A total of 154 women (aged ≥ 16 years with low-risk pregnancies), 158 birth partners and 121 health-care practitioners consented to be recorded. Of these participants, 37 women, 43 birth partners and 74 health-care practitioners were recorded. Midwives initiate the majority of decisions in formats that do not invite women’s participation (i.e. beyond consenting). The extent of optionality that midwives provide varies with the decision. Women have most involvement in decisions pertaining to pain relief and the third stage of labour. High levels of satisfaction are reported. There is no statistically significant relationship between midwives’ use of different formats of decision-making and any measures of satisfaction. However, women’s initiation of decisions, particularly relating to pain relief (e.g. making lots of requests), is associated with lower satisfaction. Our data set is explored with a focus on decision initiation and responses, leaving other important aspects of care (e.g. midwives’ and birth partners’ interactional techniques to facilitate working with pain) underexplored, which might be implicated in decision-making. Despite efforts to recruit a diverse sample, ethnic minority women are under-represented. Policy initiatives emphasising patient involvement in decision-making are challenging to enact in practice. Our findings illustrate that women are afforded limited optionality in decision-making, and that midwives orient to guidelines/standard clinical practice in pursuing particular decisional outcomes. Nonetheless, the majority of women were satisfied with their experiences. However, when women needed to pursue decisions, particularly concerning pain relief, satisfaction is lower. Conversation analysis demonstrates that such ‘women-initiated’ decision-making occurs in the context of midwives’ avoiding pharmacological methods of pain relief at particular stages of labour. We suggest that future research address the following – the barriers to inclusion of ethnic minority research participants, decision-making in obstetric units, systematic understanding of how pain relief decisions are pursued/resolved, conversation analysis of interactional elements beyond the specific decision-making context, interactional ‘markers’ of the emotional labour and inclusion of antenatal encounters. This trial is registered as ISRCTN16227678 and National Institute for Health and Care Research (NIHR) CRN Portfolio (CMPS):32505 and IRAS:211358. This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 36. See the NIHR Journals Library website for further project information.
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