Co-construire un modèle de continuité relationnelle des soins infirmière-femme en périnatalité

The medicalization of birth is a phenomenon experienced around the world which has consequences for the health system and its organization. In most industrialized countries, the organization of maternity care is mainly provided according to a medical care model (Hatem, Sandall, Devane, Soltani et Gates, 2008). This type of service organization very often contributes to the fact that different care providers offer their services in a fragmented manner. This fragmentation of services leads to a lack of continuity in care (Renfrew et al., 2014). A survey of maternity experience in Canada has shown the lack of continuity of care in almost all hospitals since 50, 6 % of women said they did not have the same provider during their pregnancy follow-up and at birth (Public Health Agency of Canada, 2009). Systematic reviews of continuous maternity care models - continuous prenatal, pernatal and postnatal care given to a woman by a caregiver, in this case the midwife - have assessed the effects of continuity of care on maternal and newborn health (Hatem et al., 2008; Sandall, Soltani, Gates, Shennan et Devane, 2013; Sandall, Soltani, Gates, Shennan et Devane, 2015; Sandall, Soltani, Gates, Shennan et Devane, 2016). The results established that the outcomes are favorable in terms of morbidity / mortality and that women are very satisfied with the care received. Nurses in Canada provide a large proportion of perinatal care to women. However, the prenatal care they provide is not offered according to a care model that promotes continuity along the perinatal continuum. Yet nurses can play a transformative role in improving the quality and safety of maternal and newborn care through the creation of new models of care. However, only one study on the development of a new model of continuous care for the prenatal and postnatal period in hospital context could be identified, but this did not include the pernatal period (Wan, Hu, Thobaben, Hou et Yin, 2011). It is recognized that the creation of new models of care must include the participation of women so that they can make their voices heard about their needs and expectations (Green, 2012). The patient-partner approach would make it possible to engage women in the process of co-creating new models of care when they are experiencing the maternity experience. This approach generates experiential knowledge that would favor the organization of care according to their real needs (Barello, Graffigna et Vegni, 2012). The objective of the thesis is to co-construct a model of care based on continuity from the relational partnership between the nurse and women during their perinatal care experience, while analyzing the factors - women, caregivers, organization, society - who influence this engagement. A longitudinal qualitative study supported by a collaborative approach was carried out. Twelve pregnant women received prenatal, pernatal and postnatal support offered by the student-researcher according to their needs. Different methods of data collection were used: i) serial interviews in three ways during face-to-face meetings, telephone calls and text messaging; ii) notes of observations made during observing participation at the time of birth; iii) the obstetrical clinical record; iv) organizational and clinical documents; v) exchanges between participants in the discussion forum; and vi) the logbook. Five main results were highlighted: 1- The patient-partner approach has proved to be a promising avenue for better understanding the intensity of the commitment in the partnership relationship between the nurse and the women for this which is direct care, in order to co-create the delivery and organization of perinatal care; 2- The four dimensions of patient-partner engagement in health care have been adapted and co-defined in the context of the organization of perinatal care; 3- A typology of engagement in several themes and sub-themes relating to the typical behaviors of the nurse - informing, consulting, collaborating and exchanging and women - being informed, questioning, sharing, deciding - linked to the components of the model of care in co-construction made it possible to explain the partnership relationship experienced in the context of perinatal care over time; 4- Certain characteristics of the factors - women, organization, caregivers and society - that influence this commitment by promoting or limiting the relational partnership of the nurse and women in the context of perinatal care have been identified; and, 5- The co-construction of the care model and its components - the categories of practices, the organization of care, the values, the philosophy, the care providers and the purposes - were co-defined on the basis of the nurse's and women's commitment behaviors to follow up on the experience of care throughout the perinatal support. This thesis makes a contribution at three levels: 1- at the theoretical level by the development of knowledge in the field of the organization of care by proposing a conceptual framework on the engagement of patients in health care in the context of perinatality; 2- at the methodological level by proposing a framework for carrying out the co-construction approach which drives the research process; and, 3- at the practical level by proposing a new model of nurse-woman relational continuity in perinatal care. The results of this thesis also allow us to demonstrate that it is possible to transform the organization of care and clinical practices with women, which can inspire different actors such as decision-makers and managers as well as providers care in settings.

Keyphrases: Perinatal care model, Relational continuity of care, Partnership, Patient engagement, Woman-centered care, Role of the obstetrics and perinatal nurse