It began with a course run by LIRG Writing research proposalsOf interest for Arts Council bidsIt transpiredTwo sessions, the first was theory/advice/introduction to the LIRG annual award for information professionals conducting researchSecond day would involve our presenting bids for the award and critical examination of these My response was mild panic – but the advice they had given was very practical almost offering a model for the desired bid
My hunch was that a library-only study such as a service evaluation would not set the LIRG heather on fire; also the experienced researchers I know are in the DNM so I needed to persuade someone here to be involved, but first I needed my study idea.Replicating an existing study sounded the panicked not-really-wanting-to –become-a-researcher’s simplest option. It needed to use a simple methodology (that is, one that I could easily understand and copy), have some relevance to librarianship and also to nursing or midwifery.
A look in the librarianship and healthcare literatures found this one.Kirkwood and Wales are well known to me and Ann Wales is now the most senior health librarian in the country heading up the team that delivers The Knowledge Network to NHS Scotland.Essentially this study aimed to derive a consensus of opinion from nurses in their Trust on the research that required to be done to best inform their practice. In fact, this study failed to achieve a consensus and only the most generic of topics moved towards attaining this status due to the diversity of the nursing workforce and their wide ranging professional interests – clearly a similar study would work better with a narrower professional group. Midwifery began to look like a potential target.It gained further impetus given that I attend the NMAHP research group that is chaired by Helen Bryers – lead midwife for NHS Highland and got the final seal of approval when Wendy enthusiastically agreed to become involved.So I set about writing my proposal exactly as the LIRG team had suggested and submitted it in advance of the follow up session and then...
Why this study is of concern to librarians.
The snow came, a train crashed, the line was closed and Glasgow might just as well have been on Mars.However, I was sent feedback on my proposal by email. I adjusted my bid and submitted it to LIRG. Job done.But be careful what you wish for...
It is essential that midwifery practice is based on a robust knowledge and research base (NMC 2004). much of midwifery research is University based, driven by RAE agendas and published in academic rather than practice-focused journals. Consequently, dissemination to practising midwives may be poor or findings of limited relevance in clinical contextsThere is a push to encourage practitioners to engage with research. However, without a strategic research direction specifying research priorities, initiatives are likely to be ad hoc, inappropriately targeted and poorly disseminated, and limited resources wasted. Currently NHS Highland research efforts are top-down a practitioner-derived strategy has distinct advantages, principally its propensity for deriving practical, service-driven questions of local relevance and the encouragement of local practitioners to engage with research.midwife involvement may engender a sense of ownership of the strategy, encourage innovation, support change management and reduce the theory-practice gap
The Delphi technique is a well-established methodology that has frequently been used to identify research priorities in many areas of healthcare, including midwifery. It has also been used within librarianship.It was designed as a method of predicting the future or forecasting trends (was used during the cold war to forecast the impact of technology on warfare) but has since often also been used to derive a consensus on priorities (for research, in design e.g. Of curricula or policy)The Delphi is a method of aggregating the knowledge of experts that does not require face-to-face contact. It is considered reliable by virtue of its anonymity and its consequent equalising of participants. Focus groups suffer from the potential skewing of results by a the dominance of the group by a strong personality and of quieter peoples’ views or ideas not getting an airing.
Iterative process involving three rounds of questionnaires and analysis – usually postal but could be done by email – with feedback.The entire process was outlined to invitees at the outset with a timetable. This gave the process a dynamism and momentum that was very useful to the research team.
Conventionally a Delphi study recruits a panel of experts. We followed the model used by Kirkwood and colleagues in their study of Glasgow nurses who invited all nurses employed in their Trust to participate.All practising midwives in NHS Highland (n=280) were invited to participate as they were expected to have expert knowledge of the midwifery issues (both local and general) that might be addressed through research. One advantage of this is that it offered us a bottom-upapproach that potentially gives us a more useful picture.
For our results to be reliable we needed a good response. Kirkwood and Wales’ study achieved only 15.8% participation at the first round: our challenge was to better that.My immediate thought was to encourage buy-in from midwives, this study should be seen as their own, not something that was being done on their behalf either by the University or by their managers. To that end, I decided to recruit a practising midwife onto the team. We ‘advertised’ the vacancy via Dr Bryers, NHS Highland’s consultant midwife, and received a good number of applicants – most of whom were quite senior staff. We chose Ali Felce: a staff midwife at Raigmore, not just because she came recommended as bright and reliable, but because a hands-on practitioner was likely to encourage buy-in. It was the ideal project for a first-time researcher to become involved with: the methodology had been chosen for its simplicity.We had the support of Dr Bryers in publicising the project and offering her support. The ethics committee would not let her actively encourage midwives to participate (that might have been seen as coercion) but to have the invitation letter come from her was certainly useful.We used every method communication we could think of and feedback showed that the awareness of the study was very good, even among midwives working in very remote areas.Our response rate was 23% - disappointing but in line with similar studies and better than our model study.
Simple? We thought so but...Up to 5 was lost on some who saw five lines and immediately thought they needed to come up with five research topics.Lesson one: people do not read documents you send them fully or carefully.Once we realised this we put out publicity stressing that even a single question would be of interest to us.We asked additionally for some demographic information.
We asked about where they worked. NHS Highland is broken into four Community Health Partnerships (CHPs). The responses from each CHP were roughly in line with the numbers of midwives working in each area. Six respondents failed to give us this information, and one stated that she worked in all CHPs.
Asked how long qualified and how oldThe age distribution of respondents closely reflects that of the midwife population.How interesting that older midwives seem just as interested in research as their younger colleagues.
This diagram shows the distribution of responses by age and the National (Scottish) and local (Highland) figures.Midwives who have retired have an average length of service of 31 years (Scotland)The average age of a midwife at retirement is 58 (Scotland)The average age of a midwife is 42-43 yearsAge distribution similar to Scottish Figures
Thematic analysis was practical and fun. The questionnaires were photocopied and the individual questions cut out. The 329 pieces of paper were moved around to form subject groups with debate and discussion among the three researchers until agreement on the categories was reached.Questions that could not be themed (outriders) were excluded. Themes that were populated by fewer than four questions were also deemed to have insufficient interest to progress for consideration as research priorities so were excluded.Some of the themes had obvious sub-themes and we sought to reflect this in the second questionnaire.
Some confusion over sub-themes, mostly remedied. A very acceptable rate of return (84%), though we did have to issue reminders and extend the deadline.Our attrition rate was very low, in contrast to the model study that reported disappointing retention of round one participants.
You can see we have 84% response rate from rounds one to two and 98% in the final round (in fact was 100% but one response was received too late for inclusion).
Mean, median and interquartile range was calculated. Consensus on priority status was deemed to have been achieved when the inter-quartile range was 1 (or lower) and the mean score was 4 or 5; effectively when 70% of respondents rated the theme ‘important’ or ‘very important’. This method was slightly different from our model study which used Standard Deviation rather than IQR but we felt this could easily lead to skewing by deviant returns so adopted this method used in at least one other study. This is very basic arithmetic easily done via an Excel spreadsheet: statistics for non-statisticians.
Lists the 25 remaining themes and the rating each midwife gave them in the previous round, offering them the opportunity to change their mind. Again, some confusion as to why. We put out publicity requesting that even if they remained firm in their conviction they should return the form and ultimately an excellent (98% - 100% if we had permitted the last very late return) resulted.
The same analysis as in the previous round saw two additional consensus topics
Identifying evidence – extensive search across a range of bibliographic databases, guideline collections and point-of-care tools looking for systematic reviews and large RCTs. Papers are sourced.Evaluation done using CASP methodology (Centre for EBM)
But the best laid plans....The themes we derived were very broad – we recognised that and had identified sub-themes in many cases - but when we came to search for evidence we found we sometimes needed to go down to question level for our searching so we would find strong evidence in some aspects of our themes but weaker evidence in others.This has led us to conclude that our ‘dissemination booklets’ will include notes about the gaps in the evidence (our priority topics).
One further problem with our simplistic view of how we would disseminate evidence failed to anticipate was this question that came up again and again in the questionnaire responses.Of course, there are few, if any, published studies, let alone large RCTs on aspects of Highland midwifery practice so it is impossible to answer such questions from the literature but not every question can be prioritised just because of a lack of local evidence.It has led us to ask what is really behind this:Lackof trust of the evidence? Genuinely different working conditions?Could it be that midwives are made aware of best practice via guidelines and protocols but are less aware of the evidence behind such recommendations? Follow up research with focus groups might throw interesting light on these questions.
We are planning to produce booklets and electronic versions summarising what the literature says and does not say regarding the top six topics.I will be writing a paper on the project for the LIRG journal, presenting my research here and at other conferences and my midwifery colleagues will be doing the same in their literature. I am also submitting a paper on the Delphi technique and its use and potential in librarianship.There will be a formal project report sent to the NHS Highland Health Board and the consultant midwife and made available via the University repository.I am keen to follow up my study with focus group work to answer some of the questions it raised.
But will any of the midwives’ priorities reach research status or influence the research agenda? That is out of my hands but I hope midwives will consider conducting their own research to answer some of the questions they have raised.I hope it will encourage local researchers and clinicians to see the potential value of including a librarian in their research team or at least consulting a librarian during the course of their research.
As health librarians we see our role as assisting researchers and practitioners build and use evidence. Being involved in research about research reinforces that idea. If any midwives still view us as mere custodians of the date stamp and the silence notices, they will have been challenged in that view by my extended role. It is a useful topic of conversation at the issue desk that opens up the topic of how we might assist research teams and practitioners in their work.
Prioritising research and dissemination: the Highland midwives' story
www.is.stir.ac.uk/nhs<br />Prioritising research and dissemination<br />The Highland Midwives STORY<br />
Kathleen Irvine*, Wendy Jessiman¥ and Alison Felce+<br />*Subject Librarian, Highland Health Sciences Library,<br />¥ Lecturer in Midwifery Studies, University of Stirling and Supervisor of Midwives, <br />+ Staff Midwife, NHS Highland. <br />
Photo: John Paul Photography<br />Photo: Alison Felce<br />So what’s a librarian doing hanging out with a bunch of midwives?<br />
Advice for beginners<br />Collaborate with an experienced researcher<br />Use a tried and tested methodology (even consider replicating an existing study)<br />
Analysis<br />Analysis identified those themes where a consensus on their importance had been reached.<br />Consensus on priority status was deemed to have been achieved when the inter-quartile range was 1 (or lower) and the mean score was 4 or 5<br />Consensus was achieved on four themes: workforce issues, labour second stage, obesity in pregnancy and women’s expectations.<br />
Round 3<br />Round three questionnaire<br />3<br />4<br />
Analysis<br />Two additional themes achieved consensus: breastfeeding and place of birth<br />
Evidence-based methodology<br />Identifying the evidence<br />Selecting the best evidence<br />Evaluating the evidence (critical appraisal)<br />Reporting the findings and quality of supporting evidence<br />Photo: Joost J. Bakker IJmuiden<br />
Research and dissemination<br /> Topics may be considered on three levels: themes, sub-themes and questions.<br />Strong evidence <br /> Dissemination<br />Weak evidence <br /> Research priority<br />
Photo: Alison Felce<br />But does it work here?<br />
What next?<br />Dissemination of existing evidence<br />Dissemination of research findings<br />Project report<br />Further research<br />