A CLINICAL GUIDELINE FOR THE MANAGEMENT OF A WOMAN DURING LABOUR

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CHAPTER 2 LITERATURE REVIEW

  INTRODUCTION

Chapter 1 explained the general orientation of the research study. In this chapter, a literature review is discussed. Literature review is regarded as a critical summary of research on a topic of interest (Polit and Beck 2008:757). The purpose of conducting a literature review in qualitative research has been stated by De Vos et al (2006: 263) as the following:

• To demonstrate the underlying assumptions behind the general research questions. Furthermore, Parahoo (2006:127) indicates that literature review is conducted to put the current study into context, to stimulate the researcher’s thinking, and to identify, refine and formulate questions.
• To demonstrate that the researcher is thoroughly knowledgeable about related research and the intellectual traditions that support and surround the study.
• To show gaps in previous research studies, and that the proposed study may fill a gap in midwifery practice.

Literature review was conducted in order to provide a rationale for the study, formulate questions for interviews, and explain concepts relevant to this study, which include clinical practice guidelines and the partogram. The researcher conducted the literature search using University of South Africa Library facilities, reference list from the librarian and other useful articles from the Internet, and relevant documents from the National Department of Health in South Africa. 

CLINICAL GUIDELINES

Clinical practice guidelines are defined as systematically developed statements to assist practitioners and patient decisions about appropriate health care for a specific clinical circumstance (Waters 2008:1; Parahoo 2006:427). A number of terms such as protocols, procedures and standards have been used interchangeably to mean a set of instructions that are intended to guide clinical decisions by providing practitioners with procedures to follow when faced with clinical problems. Moreover, Graham, Mancher, Wolman, Greenfield and Steinberg (2011:4) define guidelines as statements that include recommendations that are intended to optimise patient care, which are informed by a systemic review of evidence and an assessment of advantages and disadvantages of alternative care options.
In this section on clinical guidelines, the importance of clinical guidelines, development, dissemination, implementation, benefits and legal implications are discussed.

Importance of clinical guidelines

The partograph is of little use without management protocols that give clear directives about the actions that need to be taken. Hence, clinical practice guidelines are commonly used to support midwives so that they can improve practice including patient outcomes, the process of care, standardise practice and to reduce costs. Filed and Lohr (1992) in Van der Wees and Mead (2004:5) described the key characteristics of guidelines as:

• Presenting a clear picture of the best available evidence of effectiveness for a particular condition or set of clinical circumstances which, in turn, reduce variations, enhance consistency and stimulate collaboration in midwifery practice. The tasks and responsibilities that a midwife needs to perform in case there are deviations from normal are clearly indicated on the partogram.
• Providing recommendations for the most effective interventions in particular circumstances in the context of clinical practice.
• Providing a resource for decision-making for health care professionals and for patients about the most effective care in a particular clinical circumstance. According to Turner (2009:3), guidelines should be clear, well written, short and provide a quick answer to clinical decisions of interest. The hospital needs these set of rules to guide decision-making in the health setting so that midwives know what action to take when the partograph shows that a woman needs additional care including the need for referral.
• Standardised protocols that are developed in a rigorous and systemic way in order to minimise bias and maximise the validity of their recommendations.

The clinical guideline in this research study refers to the partogram that has been developed by the National Department of Health in consultation with experts in the field for presenting a clear picture of a woman in labour. The most effective interventions that are indicated on the partogram guide midwives on clinical decisions when managing a pregnant woman in labour. Nevertheless, clinical guidelines have been viewed as having disadvantages such as oversimplifying decisions, failing to identify variations in individual needs of patients and reducing practitioners’ autonomy (Graham, Brouwers, Davies and Tetroe 2006:607). In addition, Parahoo (2006:427) indicated the potential limitation of guidelines being the wrong interpretation of evidence on which the guideline is based.
In addition, Turner (2009:3) revealed that clinicians rely too much on guidelines without thinking. Over and above that, Van der Wees and Mead (2004:5) argue that clinical guidelines are not to be regarded as recipes for practice that must be followed in all circumstances, hence the need for midwives to use their reasoning skills.

 Development of clinical guidelines

Clinical guidelines need to be developed systematically in order to be clear, simple and usable. Onion and Whalley (1998) in Parahoo (2006:427) indicated that there are two schools of thought on guideline development. First, there are those who think guidelines should incorporate only the best evidence. Secondly, there are others who believe that guidelines should be simple and practical, taking into account local resources, priorities as well as local opinion and experience. This section discusses the development of guidelines at national, regional and local level including the South African context.

Guideline development at national, regional and local level

The development of guidelines is a complex process requiring skills, resources and time, and involving a multidisciplinary team. Guidelines are developed at local, regional and national level to ensure that expertise of a wider range of professionals can be drawn to participate in the process.
Local team members are important in adapting the guidelines to the local circumstances (Parahoo 2006:427). Furthermore, Worrall et al (1997) in Parahoo (2006:407) state that local guidelines have produced significant improvements in practice as compared to national guidelines, hence the importance of adapting national guidelines to local use. End-user involvement increases ownership and improves the implementation of clinical guidelines.
The validity of guidelines can be checked by making use of focus group discussions, postal questionnaires, peer group consensus and literature review. Van der Wees and Mead (2004:6) recommend that there should be a certain degree of central coordination in developing guidelines even if individual groups are involved in the process of development and should be endorsed by the relevant professional body.
Graham et al (2011:5) summarised the most important aspects to be considered if the guideline is to be trustworthy, which include:

• systematic review of existing evidence
• involvement of knowledgeable, multidisciplinary panel of experts and representatives from key affected groups
• consideration of important patient subgroups and patient preferences as appropriate
• explicit and transparent process that minimises distortions, biases and conflicts of interest
• a clear explanation of the logical relationships between alternative care options
• a revision when important new evidence warrants modifications of recommendations

The team that is involved in the process of guideline development should consider these aspects in order to ensure that quality guidelines are developed. A document on guideline implementation that has been developed by Nuffield Institute for Health (1994:4) at University of Leads described the desirable attributes of clinical practice guidelines as indicated in Table 2.1.
The characteristics and attributes of guidelines are important in ensuring that the guidelines are of quality and are acceptable to end-users such as midwives and doctors.

Development of clinical guidelines for maternity care in South Africa

The South African government demonstrated its commitment to improving maternal health by making maternal death a notifiable condition and by formation of the NCCEMD. One of the ten key recommendations made by the NCCEMD in the Saving Mothers Report 2002-2004 is to update and strengthen the guidelines on the management of conditions which may commonly result in maternal deaths. The correct use of the partogram as a norm in each institution conducting births was recommended in order to improve quality of care and pregnancy outcome. The purpose of developing guidelines on maternity care was to give guidance to health care workers providing obstetric and anaesthetic services in clinics, community health centres and district hospitals.
A vast review of literature was conducted before the development, and guidelines were reviewed by many experts and programme managers in the field. The South African Nursing Council support the partogram as a guideline in monitoring a woman during labour, hence its inclusion in the curriculum of all midwifery courses that are offered in South Africa.

Disseminating guidelines

After the guidelines have been developed, they need to be disseminated to those for whom they were intended. There are a number of strategies to distribute guidelines as indicated in Parahoo (2006:407) and Van der Wees and Mead (2004:12) such as:

• Distributing hard copies of guidelines to practitioners. Printing and distributing is one of the most commonly used methods to disseminate clinical guidelines.
• Computer-generated reminders in patients’ notes. Computerised or automated reminder systems were discovered to be more effective than clinician’s recall.
• Educational initiatives that focus on the guideline. Apart from printing hard copies, lectures or training sessions were the most commonly used method of disseminating guidelines to the users.

In this research study, midwives indicated their experiences on the use of the partogram as a guideline in monitoring a woman during labour, which includes how the partograms were disseminated at Vhembe District hospitals.

Implementation of guidelines

The involvement of staff in the process of development is important to ensure that the guideline is implemented. Davis and Tailor (1997) in Parahoo (2006:407) indicate that the development of guidelines without taking into consideration their adoption waste intellectual and human resources. The dissemination and implementation strategies are regarded as interdependent and are graded as

• weak interventions which consist of educational and distribution of guidelines in paper form;
• moderately effective interventions that include audit and feedback as well as the involvement of peers and opinion leaders; and
• strong interventions include the use of reminder systems that are available in patients’ notes, educational initiatives and multiple interventions.

These strategies confirm the relationship between the dissemination and the implementation stage of clinical guidelines. In this research study, midwives described their experiences on how the partogram is being implemented in the maternity wards of the three hospitals at Vhembe District.

Benefits of using guidelines

Benefits of using the partogram need to be highlighted to motivate clinicians to have an interest in using them. Grimshaw and Russell (1993) in Parahoo (2006:431) reviewed 59 articles on guideline dissemination and implementation and found that in most of the guidelines, there was an improvement in the process of care that was measured by

• a change in the practice of doctors, especially compliance with the recommendations of guidelines;
• in the 11 of the studies reviewed, there was an improvement in terms of fewer admissions, fewer complications, reduction in symptoms or more patient compliance with treatment; and
• Organisational change, which may include provision of equipment and human resources.

However, there is little evidence that clinical guidelines are effective in improving patient outcomes in primary care settings. Cheater and Closs (1997) in Parahoo (2006:431) reviewed studies on dissemination and implementation of guidelines in nursing practice, and none was readily available, which further prompted the researcher to conduct research in midwifery practice.

Legal implications for guideline users

Clinical guidelines that are developed systematically are regarded as legal documents. Van der Wees and Mead (2004:13) indicate that nationally approved clinical guidelines become a recognised source of evidence of best practice and can be used in court by an expert witness as the benchmark of good practice. According to Van der Wees and Mead, clinicians (midwives) are expected to use their experience and clinical reasoning skills to consider the relevance of a guideline (partogram) to a particular patient, taking into account the patient’s condition and circumstances. It is recommended by Van der Wees and Mead that if a highly recommended guideline such as a partogram is not implemented for a particular patient, a rationale for failure to do so should be documented.

CHAPTER 1 ORIENTATION AND OVERVIEW OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 THE PURPOSE OF THE RESEARCH STUDY
1.5 THE RESEARCH OBJECTIVES
1.6 SIGNIFICANCE OF THE STUDY
1.7 DEFINITIONS OF KEY CONCEPTS
1.8 PARADIGMATIC PERSPECTIVES
1.9 RESEARCH DESIGN AND METHOD
1.10 THE SCOPE OF THE STUDY
1.11 STRUCTURE OF THE RESEARCH STUDY
1.12 CONCLUSION
CHAPTER 2 LITERATURE REVIEW 
2.1 INTRODUCTION
2.2 CLINICAL GUIDELINES.
2.3 THE PARTOGRAM AS A CLINICAL GUIDELINE FOR THE MANAGEMENT OF A WOMAN DURING LABOUREmerging Management Development Programme (EMDP)
2.4 CONCLUSION
CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
3.2 RESEARCH SETTING
3.3 RESEARCH DESIGN
3.4 RESEARCH METHODS
3.5 CONCLUSION
CHAPTER 4 DATA ANALYSIS AND DATA PRESENTATION 
4.1 INTRODUCTION
4.2 FINDINGS ON DOCUMENTS REVIEW
4.3 PHASE 2: FACE-TO-FACE SEMI-STRUCTURED INTERVIEWS WITH MIDWIVES
4.4.1 Theme 1: Benefits experienced by midwives on implementing the partogram
CHAPTER 5 DISCUSSION OF FINDINGS
5.1 INTRODUCTION .
5.2 DISCUSSIONS ON THE REVIEW OF PARTOGRAMS
5.3 DISCUSSION OF RESEARCH RESULTS ON FACE-TO-FACE INTERVIEWS
5.4 ALIGNMENT OF RESULTS TO THE GUIDING THEORY OF PLANNED BEHAVIOUR
5.5 Correlation of findings from document analysis and face-to-face interviews
5.6 CONCLUSIONS
CHAPTER 6 .IMPLEMENTATION STRATEGIES TO SUPPORT MIDWIVES ON THE USE OF THE PARTOGRAM 
6.1 INTRODUCTION
6.2 STRATEGIES TO ENHANCE IMPLEMENTATION OF PARTOGRAM BY MIDWIVES
6.3 CONCLUSION
CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS 
7.1 INTRODUCTION
7.2 RESEARCH DESIGN AND METHOD
7.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS
7.4 STRATEGIES THAT WERE DEVELOPED TO IMPROVE THE USE OF THE PARTOGRAM
7.5 EVALUATION OF THE STRATEGIES
7.6 CONCLUSIONS
7.7 RECOMMENDATIONS
7.8 CONTRIBUTIONS OF THE STUDY
7.9 LIMITATION OF THE STUDY
7.10 CONCLUDING REMARKS
LIST OF REFERENCES
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