The development of a survey instrument to evaluate women’s experiences of their maternity care in Ireland
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Introduction The value of survey instruments in measuring the quality of maternity care from the perspective of service users is well recognised. Many countries, including, for example, the UK, USA and Australia use large scale national and regional surveys to explore women’s experiences of their maternity care with the results informing national maternity policy and practice. Prior to the commencement of this project, there was no such survey used within the Irish maternity services. The aim of the work presented in this thesis is to develop a survey instrument to evaluate women’s experiences of their maternity care in Ireland. In line with the recommendations of the Irish National Maternity Strategy, the purpose of this instrument is to identify areas for improvement within maternity care in Ireland to facilitate the provision of safe, effective, high-quality care. Methods This thesis includes five papers. The first paper (Chapter 2), a discussion paper on concept development methodology, was developed in response to the challenges faced in attempting to develop the concept of ‘women’s experiences of their maternity care’. This paper presents a review of concept development in nursing and midwifery and explores methodological considerations in concept development specific to nursing and midwifery. Paper one informed the concept development strategy and method used in paper two. Paper two (Chapter 3) presents an analysis of ‘women’s experiences of their maternity care’ using the principle-based concept analysis method by Penrod and Hupcey (2005). Following the development of the concept, the remainder of the study was completed using an adapted two-phase exploratory sequential mixed methods design as reported in papers three, four and five. A protocol for a systematic review of self-report instruments used internationally to measure women’s experiences of their maternity care was developed and has been presented as paper three (Chapter 4). A systematic review was then completed in line with the protocol, the findings of which are presented in paper four (Chapter 5). The purpose of the review was to identify self-report survey instruments available internationally to measure women’s experiences of their maternity care, evaluate the methodological quality of each survey instrument and evaluate the criteria for good measurement properties using quality criteria and to categorise items included within each identified instrument. Paper five (Chapter 6) reports the identification and prioritisation of items for inclusion in the survey instrument. This consisted of the systematic review (Chapters 4 & 5), focus groups and one to one interviews, and a gap analysis. An exhaustive item pool was then developed based on items identified. Items were prioritised for inclusion in the final item bank through a Delphi study and consensus review. Results Paper one presents an overview of the methodological considerations of commonly used concept development strategies and methods within nursing and midwifery. The methodological considerations discussed provides guidance in determining the most appropriate strategy and method of concept development. Paper one informed the choice of the principle-based concept analysis method by Penrod & Hupcey as being the most suitable conceptual development framework for the analysis of women’s experiences of their maternity care. Using the principle-based method of concept analysis, the concept was analysed under the epistemological, pragmatic, linguistic and logical principles. The outcome of the concept analysis is a theoretical definition that highlights the subjective nature of the concept, its dependency upon a woman’s individual needs, expectations and circumstances and the influence of the organisation and delivery of maternity care. Citations were identified (n=4,905) from database searches as part of the systematic review. Additional records were obtained via reference checking and by expert suggestion. Following stepped screening, 40 papers related to 20 instruments are included in the review. Findings indicate that published evidence of the methodological and psychometric quality of self-report survey instruments to measure women’s experiences of their maternity care is lacking. Focus group and one to one interviews were completed with 82 participants from key stakeholder groups, i.e., women as service users as the Irish maternity services, midwives, public health nurses, obstetricians, neonatologists, anaesthesiologists, General Practitioners, policymakers and funders. These interviews enabled exploring aspects of care that stakeholders consider to be of most importance for inclusion within this survey instrument and identify any further potential outcomes of importance to each stakeholder group not identified in the concept analysis & systematic review. A hybrid approach to the analysis of the data arising from the interviews was adopted. The analysis was guided first by an inductive approach (Braun and Clarke's recursive thematic analysis approach) and subsequently influenced by a deductive approach (framework approach) (see Chapter 6). The gap analysis mapped the suite of international items against the findings of the focus group and one to one interviews in addition to Irish policy documents, i.e., (i) National Maternity Strategy (Creating a Better Future Together) (ii) HIQA National Standards for Safer Better Maternity Services and (iii) the background document supporting the development of National Standards for Safer Better Maternity Services. The purpose of the gap analysis was to identify items for inclusion within the survey instrument that had not been identified within the suite of items arising from the systematic review. An item pool for inclusion in the pilot survey was drawn up. It included items identified in the international analysis, as per the results of the focus group and one to one interviews and gap analysis. Various formats were also determined at this stage; for example, the selection of the number of scale points to be used. Refinement of the item pool was completed via an online two-round Delphi study with key stakeholder groups, i.e., women as service users as the Irish maternity services, midwives, public health nurses, obstetricians, neonatologists, anaesthesiologists, General Practitioners, policymakers and funders. Twenty-two participants completed round one of the Delphi study and 127 participants completed round two of the Delphi study. Following the Delphi study, all items judged suitable for inclusion in the survey instrument were reviewed by experts in the areas of survey development and maternity care in Ireland. The purpose of additional reviews was to assess for areas not included, inclusion of irrelevant areas and to identify if a relevant part of the construct may have been missed. Integration of the use of the survey instrument within the Irish maternity services; The National Care Experience Programme (NCEP) is a partnership between the health service regulator (Health Information and Quality Authority (HIQA)), the national healthcare provider (Health Service Executive (HSE)) and the national policymaker (Department of Health). It was launched in Ireland in 2019 to evaluate service users’ experiences across the public acute healthcare services with the results informing care improvement actions nationally. A formal agreement was reached in 2018 with HIQA, who oversees the programme, that the bank of items developed within the project reported here will be the basis for the National Maternity Experience Survey (NMES). The NMES was launched nationally on February 4th 2020. Conclusion A bank of 95 items have been prioritised and grouped within eight sections; care during your pregnancy, care during your labour and birth, care in hospital after the birth of your baby, specialised care for your baby, feeding your baby, care at home after the birth of your baby, overall care and you and your household. As per the National Inpatient Experience Survey development process, HIQA will now use this bank as the basis for the survey with the remainder of the questions acting as a reserve list for possible inclusion in future iterations of the survey.