title: Promoting Respectful Maternity Care by Undergraduate Nursing Students in Nepal: A Multi-Method Research Approach
Creators: name: Dhakal, Prativa
Publisher: name: Griffith University
Year: 2022
Subjects: subject: respectful maternity care
subject: Nepal
subject: undergraduate nursing students

description: Background Respectful maternity care (RMC) is a fundamental human right and has been shown to increase utilisation of maternity services and improve maternal and neonatal outcomes. The original intent of this doctoral program of research was to investigate midwives’ understanding of RMC and women’s experiences of respectful care. Due to sudden global COVID-19 restrictions on travel and the health care system, the program of work changed to focus on students’ understanding and practice of RMC. Obstetric nurses are the main maternity care providers in Nepal. Aim This program of research aimed to assess undergraduate nursing students’ perceptions of RMC and measure any potential change in their perceptions after an education intervention. Methods A multi-method design was used. A series of five studies was conducted and included two systematic reviews of the literature; tool development and testing using cross-sectional surveys; and a quasi-experimental pre-post-test educational intervention study with a qualitative evaluation. Findings A systematic review (Study 1) was commenced pre-COVID-19 to critique the quality of tools that measure women’s experiences of respectful or disrespectful maternity care during labour and birth. Methodological quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. This published review identified six tools without ‘sufficient’ high quality evidence to adequately measure women’s experience of RMC. The search was subsequently updated to identify tools that aim to measure midwifery/nursing students’ perceptions of RMC. The lack of available, reliable tools provided the basis for the next study. Using the approach to scale development by DeVellis (2017), a tool to measure students’ perceptions of RMC was drafted and tested (Study 2). A total of 268 Nepalese nursing students were invited to complete an online survey of the draft tool. The 18-item Student Perceptions of Respectful Maternity Care (SPRMC) scale was developed and published. Survey findings also highlighted the need to improve students’ understanding of RMC. A mixed-methods systematic review to assess RMC educational interventions targeting midwives, nurses, or students was conducted (Study 3). There was relatively little research in this field. Of the nine included studies, most had been conducted in low-income African countries. Variation in content, delivery method, duration, timing of pre-post-test evaluation methods, and findings from multiprong interventions hindered robust conclusions. This review was published. In order to use the SPRMC scale as an outcome measure of the educational intervention, the validity of the scale was determined by comparing perceptions of RMC between Nepalese and Jordanian midwifery and nursing students (Study 4). This published paper reported on survey findings with 276 Bachelor’s degree or diploma level students. Perceptions of RMC were more positive among Jordanian students (t (199.97) = 6.68, p &lt; 0.001). However, most students in both countries reported witnessing disrespect and abuse towards childbearing women. Nepalese students were more likely to observe poor adherence to women’s privacy and confidentiality. Subsequently, an online education intervention was developed, implemented, and evaluated in Nepal (Study 5). This published paper reported on a non-randomised quasi-experimental pre-post study with 89 undergraduate nursing students from three medical colleges. Students from site A (n = 40) were recruited to the intervention group and site B and C (n = 49) to the control group. The intervention group completed six hours of online (synchronous) education (2 hours x 3 weeks) in addition to their regular classes, whereas the control group attended their usual classroom studies. Both groups completed an online survey consisting of the SPRMC scale before and two weeks post-intervention. The intervention group also completed a survey on quality and relevance of the intervention. Independent t-test, paired t-test, and ANCOVA were used to analyse the quantitative data, and inductive thematic analysis was used for the qualitative data. Students in the intervention group reported a significant increase in perceptions towards RMC (F(1,86) = 28.1, p &lt; 0.001, ηp2 = 0.25). Thematic analysis identified three themes: empowerment through RMC, motivation to initiate change, and becoming a respectful clinician (second revision submitted). Conclusions This program of work is novel in developing the SPRMC scale, providing evidence about students’ perceptions of RMC and witnessing of disrespect and abuse from two countries, and developing and evaluating a RMC education intervention. Attention now needs to be directed towards improving the practice of RMC among midwives/nurses to enhance women’s experience of care. Several avenues for further research include: further testing of the SPRMC tool with a large diverse sample of maternity professionals in different contexts, incorporation of RMC components into midwifery/nursing curricula, assessment of changes in students’ practice, and longer follow-up. This thesis consists of nine chapters. Notably, Chapter 2, the literature review, presents one published systematic review, and Chapters 4 – 8 present five published/submitted research articles reporting on other studies to promote RMC. The final chapter discusses the main findings, strengths, and limitations, as well as implications for future practice, education, and research.