Otago Polytechnic

The Effective Representation of Midwifery Care in Documentation: A Delphi Study

Bridget Kerkin
9 February 2021

Kerkin, B. (2021). The Effective Representation of Midwifery Care in Documentation: A Delphi Study. (A thesis submitted in fulfilment of the degree of Master of Midwifery at Otago Polytechnic) [PDF 1575KB]

Abstract

The documentation of midwifery care is widely accepted as a critical component of midwifery practice. This documentation serves a variety of purposes. At a minimum it represents the care provided to a woman, childbearing person and/or baby, by the midwife. It may enhance coordination of care provision, highlight the priorities and decision-making of the woman or childbearing person and the midwife, and promote communication between them, and with other health professionals. Effective health records will support audit and practice review processes and contribute to research and education. However, optimal practice in relation to the documentation of midwifery care is not clearly defined in Aotearoa New Zealand, or elsewhere in the world. Evidence is lacking to support midwives to understand the most effective approach to documenting the care they provide. Therefore, clarification of midwifery practice priorities for documentation is warranted.

The research question, developed from initial exploration of the existing pool of literature, was “What content should be included in midwifery documentation to effectively represent the care provided?” A modified Delphi methodology was used to explore the opinion of expert midwives in relation to this research question. Three survey rounds were completed, with the data from the first two surveys analysed to develop consensus-seeking statements which were presented to participants in the third, and final, survey.

Consensus was achieved on 70 of these 93 individual consensus-seeking statements. The rich commentary contributed by the participants also developed understanding of the complex factors contributing to the practice of midwifery documentation. The opinions of these expert midwives emphasised that the impact of the context of care provision cannot be underestimated. Prioritisation of the provision of safe, individualised care, and autonomous midwifery decision-making to achieve this, was identified as a principal focus.

Key words: Midwifery; Documentation; Record keeping; Quality care.

Bridget Kerkin's thesis was supervised by Sally Baddock, Jean Patterson and Vicki van Wagner.

License 

This thesis is available under a Creative Commons Attribution-NonCommercial licence CC BY-NC 4.0 International.

Creative Commons License