The development and testing of a co-designed distance learning programme to improve the knowledge of trained auxiliary nurse midwives in normal midwifery practice in central India

Abstract

Background

In the Indian State of Madhya Pradesh maternal health is poor, and women’s social status is low. For some women, autonomy and decision-making within the family is limited as they seek medical treatment through their husband or father-in-law. The then state government identified a need to strengthen midwifery care given by auxiliary nurse midwives to improve maternal and neonatal health.>*

Methods

This cross-cultural, two phase study was designed in partnership with an Indian non-governmental organisation, utilising Elliot’s action research model within the paradigm of critical theory. Phase 1 investigated the then current situation and established a potential solution to strengthening midwifery practice within Madhya Pradesh. This comprised an educational approach using a specifically designed self-directed distance learning programme focussing on normal pregnancy and childbirth. The distance learning programme was a hard copy workbook supported by a multimedia resource informed by the Rowntree and Analysis Design Development Implementation Evaluation models of educational material development. Phase 2 involved the use and evaluation of the distance learning programme with an initial primary group sample of 28 comprising auxiliary nurse midwives (22), lady health visitors (4) and staff nurses (2) in Madhya Pradesh. Fourteen auxiliary nurse midwife participants completed knowledge tests using a pre- and post-programme multiple choice question paper. This primary group negotiated a 3-day workshop to cover identified gaps within their original 12-week study period. Nineteen additional auxiliary nurse midwife participants joined this workshop (group 2).

Results

The multiple choice question test results indicated that the first group had poor knowledge of the normal process of pregnancy and childbirth. After the workshop, they marginally improved their personal performance scores. The second group demonstrated greater change, which suggests that coupling self-directed guided study material with an enabling, face-to-face environment can be successful.

Conclusions

Distance learning among auxiliary nurse midwives in central India may be enhanced when accompanied by face-to-face workshops. Partnership working – at organisational, team and individual levels, was a crucial, and empowering, component of this cross-cultural action research study. Both points have relevance for others undertaking similar studies.

Keywords

action research international collaboration primary/community care public health women’s health

Background

The work described in this paper was undertaken between 2004 and 2014 in the central Indian state of Madhya Pradesh (MP). At the time of the study’s inception (2004) the state’s birth rate was high, and so were infant and maternal deaths, but the number of qualified midwives was minimal. Women’s social status was low and their autonomy and decision-making within the family was limited, with medical treatment only being accessed through their husband or father-in-law. Care during pregnancy, childbirth and post-partum was undertaken by an array of different people ranging from doctors, nurses with or without extra training, and dais (an Indian traditional birth attendant), to family members, but rarely qualified midwives (see note). In addition, the Federal Government of India was striving to achieve the Millennium Development Goal (World Health Organization, 2002a) of reducing maternal and child mortality by 2015. In 2000 the maternal mortality rate reported for the whole of India was 390:100,000 (United Nations Population Fund, 2011). Neonatal and maternal mortality rates in MP were unacceptable, the maternal mortality was 269:100,000 (Government of India, 2011a) in 2009, higher than the national average of 212:100,000 (Government of India, 2011b), and maternal health was poor, so to ameliorate this the state government of MP identified the need for improvement.

This paper describes one non-governmental organisation’s (NGO) response to this initiative. The first named author, Mary Foss, worked alongside this NGO to design, implement and evaluate a structured educational programme in the care of women experiencing normal pregnancies and childbirth largely for auxiliary nurse midwives (ANMs). ANMs are women who have undertaken 18 months’ training in nursing and midwifery. Although they are not qualified nurses or midwives they often work independently in hospitals and in urban and rural communities. This project formed Foss’s PhD which was awarded in 2015, le May and Gobbi were Foss’s doctoral supervisors and as such, worked with her on this project.

Structure of the paper

This research used an iterative, phased, action research design which was complex and messy to implement – writing up such work for academic journals can sometimes appear disjointed. To help prevent this and to enable readers to grasp the totality of the work we initially provide a summary of the project’s origins and timelines before moving on to a more detailed description of what occurred. Although we present the work in a largely linear form it contained many iterations, discussions and refinements as it progressed to its conclusion.

Origins, timeline, and context

The impetus for this study started to build in 2000 during a UK Department for International Development funded study focusing on developing better care for pregnant women and infants in India. During 2000 a workshop, held in Bhopal, recommended the instigation of a national direct-entry midwifery preparation programme – this did not come to fruition, so attention was diverted in 2004 to improving ANMs’ education, role and position (Pallikadavath et al., 2004). Analysing and reflecting on the data collected during this work resulted in the identification of a need for an educational strategy to address the significant deficits in ANMs’ knowledge of maternal healthcare but did not determine the methods through which this could be achieved. This then became the focus of the action research, using Elliot’s (1991) model, described in this paper. Funding for the reported study was secured in 2009, prior to that a general exploration of the literature related to distance learning and educational material development was undertaken. Development of the educational programme was guided by Rowntree’s (1994) four-stage design framework and the Analysis Design Development Implementation Evaluation (ADDIE) model (Dick et al., 2001). A distance learning method was selected using multimedia including a written workbook and a film. The film was made in India (2010–2011) to provide support for the written text. The programme was implemented and evaluated within the Shivpuri district of MP in 2011 with an initial primary group of 28 ANM-level trained women who provided support and care during pregnancy and childbirth (22 ANMs, four lady health visitors and two staff nurses). At the end of the distance learning programme a group of participants negotiated an extension to the initial study period to include an additional 3-day workshop. Data collection ceased in 2013. On completion of the study a review of ‘partnerships’ was explored within a cross-cultural action research study, the salient findings of this conclude this paper.

The aim

To design and evaluate the effectiveness of a co-designed distance learning programme to improve knowledge concerning normal pregnancy and childbirth for ANMs in MP.

To achieve this the following objectives were devised:

Develop a distance learning programme to advance the knowledge of the ANMs;

Translate and publish the educational programme for the use of Indian participants;

Film and produce a multimedia package to support the participants’ learning;

Pilot the educational programme;

Evaluate the usefulness of this method of education for health staff development.

The design

One of the principles fundamental to this study was to work in partnership with women to improve care and implicitly, through this partnership, their status. Underpinned by the values of empowerment through involvement, and equality between researchers and participants promulgated by Kurt Lewin (1946) and his followers, action research was deemed a good fit between adopting a rigorous, relevant research design and making change. Using action research enabled the fusion between the process of learning on and in practice (Schon, 1983), initiating social change (Lewin, 1946) and utilising a problem-solving, context-specific approach (Hart and Bond, 1995; McNiff et al., 2003; Meyer, 2010) to practice improvement.

A two-phase action research design was therefore adopted for this study guided by the Elliot’s (1991) framework (Figure 1). The first phase outlined the development of the educational materials, while the second focused on testing the materials with a group of ANMs. Throughout Foss took the role of participant researcher (Hart and Bond, 1995; McNiff et al., 2003; Waterman et al., 2001) working closely with the participating NGO at an organisational level and the ANMs and their supervisors at an implementational level.

Figure 1.

Elliot’s (1991) model as applied to the development and evaluation of a co-designed distance learning programme to improve midwifery knowledge concerning normal pregnancy and childbirth for auxiliary nurse midwives in Madya Pradesh. (Elliot’s principles are denoted in bold text, the study-specific actions are italicised next to the principles and the phases of the study are set out to the right).

Identifying frameworks for the study

Action research combines various methodological approaches to data collection and analysis to achieve a research study’s aim(s) (Drummond and Themessi-Huber, 2007) but this agility, while a cornerstone of its success in achieving ‘action’, has also led to confusion as to an exact definition (Costello, 2003, le May and Lathlean, 2001) and the identification of precise design-related methods of data collection and analysis. Flexibility gives action research its dynamism and enables it, as a design, to have the potential for the generation of sustainable yet tailored impact, but it can also cause problems with ‘accounting’ and replicability. Therefore, to minimise this it is important to adopt and delineate the framework of action research used in any action research study. This study adopted Elliot’s (1991) model of action research because of its previous use in educational research, its fit with the selected educational development models and its clarity of approach. Elliot’s (1991) framework, although portrayed as a linear process, is a series of cycles, all of which include identifying the issue (reconnaissance), planning, identifying actions and implementation, monitoring, evaluation and review and adjustment then starting the cycle again (Figure 1 shows these steps in bold).

Completing the initial reconnaissance (Figure 1) resulted in the recognition that distance learning was the preferred educational approach, largely driven by the local rural geography, telecommunications and educational infrastructures. In response to this, a review of literature was undertaken (Foss, 2014) and Rowntree’s (1994) model for the development of distance learning materials (Figure 2) and the ADDIE model (Dick et al., 2001) (Figure 3) were selected. They were then blended with Elliot’s model (see phases below).

Figure 2.

Overarching steps in Rowntree’s (1994) model for open, distance and flexible learning.

Figure 3.

Overarching steps in Dick et al’s (2001) iterative Analysis Design Development Implementation Evaluation (ADDIE) model with a central core of ongoing formative evaluation.

The phases of the study and how the frameworks were integrated

Phase 1

Identifying the issue: this represented the initial exploration of the issues surrounding strengthening midwifery within the state of MP. Initial discussions started by considering midwifery direct-entry training but then moved to the development of a distance learning programme for trained ANMs.

Reconnaissance: this incorporated the situational analysis (the first stage (Rowntree, 1994) and needs assessment/analysis ADDIE (Dick et al., 2001)). This was achieved following field visits to three Indian states (Rajasthan, Uttar Pradesh and MP) and a range of interviews with state ministers of health and family welfare, doctors, teachers of ANMs, ANMs in practice, student ANMs and women. An analysis of the findings was undertaken and led to the next steps.

Action step 1: development of the self-directed distance learning material – the workbook (the second stage (Rowntree, 1994), design: ADDIE (Dick et al., 2001)).

Action step 2: development of the multimedia (film) support for the self-directed distance learning programme (including formative evaluation in development: ADDIE (Dick et al., 2001)).

Phase 2

Action step 3: plan implementation.

Action step 4: test and evaluate (the third stage (Rowntree, 1994), implementation: ADDIE: (Dick et al., 2001)).

Monitor implementation and effects: evaluation and reflection (the fourth stage (Rowntree, 1994), evaluation: ADDIE (Dick et al., 2001)).

Reconnaissance (for cycle 2): explanation of any failure of implementation and effects (Elliot, 1991), summative evaluation: ADDIE (Dick et al., 2001) and reviewing plans for further actions.

Review plan and commence cycle 2.

Data collection and analysis

Data from the reconnaissance were collected through visits, attending meetings and interviewing key stakeholders and were recorded in field notes (Table 1). This work was particularly important to the co-design of the educational programme and in establishing ongoing relationships that enabled its implementation. The field notes were analysed using PESTLE and SWOT techniques to identify the issues that would affect the development of the programme.

Table 1.

Reconnaissance visits and data collection.

Visits	Interviews
Policy-makers: 1 National Department and 3 State Departments of Health and Family Welfare (Rajasthan, Uttar Pradesh and Madhya Pradesh)	3 Ministers of Health and Family Welfare
Organisations and service providers: 3 district hospitals, 2 primary health clinics, 2 sub-stations, 1 private hospital	3 Chief Medical Officers, 2 Medical Officers, 4 Auxiliary Nurse Midwives
Education providers: 6 Schools of ANMs	6 Teachers of ANMs, 2 groups of ANM students
Rural communities: 3 villages	3 Women with permission from their husbands or fathers-in-law

ANM: auxillary nurse midwife.

Data for the evaluation of the programme were collected through two individually completed questionnaires – a pre- and post-programme knowledge test in the form of a 44-answer multiple choice question (MCQ) paper (see below), and an evaluation form given at the end of the course. Pre- and post-programme MCQ paper scores were analysed descriptively, due to a small sample size, to determine any increase in knowledge. Data from the end-of-course evaluation were reviewed for positive and negative comments regarding the programme. It was not our intention to compare data with variables such as age, time in post, educational level. The key aim was to improve midwifery knowledge, influence their decision-making and therefore improve maternal care.

Field notes were taken throughout the study to record meetings and discussions: they helped contextualise data and guided reflection on the study’s progress.

The findings

Phase 1: context and situational analysis

The initial reconnaissance and situational analysis provided extensive information about the education and practice of the ANM and the context within which this was, and could be, provided (Table 2). It also exposed some of the wishes of women in the community. In terms of state policy, initial discussion with the Minister of Health and Family Welfare in MP in 2004 confirmed that there were approximately 90,000 ANMs working in MP. Most worked in community settings and were isolated from professional medical support. At the time of this discussion the minister was a woman interested in improving the knowledge and skills of the ANMs. As the study progressed this role was taken later by a male medical doctor who was not as interested in the proposal. This perception may have been because of his cultural view of women or his professional view of ANMs or the possibility of financial implications, or all of these; it was difficult to identify a reason, but he did not obstruct the continuation of the study. The SWOT analysis undertaken during reconnaissance (Figure 4) directed the development of the educational programme.

Figure 4.

SWOT analysis of possible educational strategy.

Table 2.

The results of the situational analysis using PESTLE.

Category	Factors (in no particular order)
Political	• Federal government policy to reduce maternal mortality in line with MDG5
	• Ministers who are innovative and who embrace change
	• Lack of fiscal funds available to support any development
	• Ministers who have traditional social views and not supportive of any improvement
	• Professional dominance by the medical profession
	• No post-qualification education
Economic	• No fiscal support for training
	• Poor pay for ANMs
	• Poor healthcare infrastructure
Social	• Geography of the population impacts on service provision
	• Health facilities too far away
	• Poor roads and transport
	• Low status of women who have no power to make decisions
	• Woman’s role within the family
	• ANMs are required to fulfil family requirements and may not have the power to make decisions regarding professional needs
	• Poverty
	• Need mothers and ANMs to work
	• Desire of health service workers for further education
Technological	• Poor educational standards in training schools
	• Lack of teaching resources including books and clinical models
	• No post-qualifying education
	• No access to computers and internet
	• Lack of competence-based education
	• Lack of clinical experience
Legal	• Limitations on the role of ANMs
	• No professional standards
	• Dai legally a midwife
Environmental	• Medical dominance
	• Lack of clinical resources
	• ANMs working alone
	• Poor clinical skills acquisition
	• Teachers not trained to high standard and may have no clinical experience
	• Total number of ANMs equals approximately 90,000

ANMs: auxillary nurse midwives; dai: an Indian traditional birth attendant; MDG5: Millennium Development Goals.

Phase 1: developing the educational programme

Selecting the approach

From reviewing the factors set out in Table 2 and Figure 4, it became clear that a distance learning method of delivery could be employed. Although at the time this method had not been used before in nursing and midwifery professional development within India or in MP, it had several educational and implementation advantages and minimised the need for the ANMs to leave their workplace and families to study while retaining maximum flexibility for the participants. Distance learning is also relatively inexpensive when compared to the need for residential accommodation associated with traditional face-to-face courses favoured in India at the time, travelling and backfill at the workplace. Indeed, backfill was not always possible.

Development of educational materials

Drawing on Foss’s personal professional experience, discussions with key stakeholders held at the outset of the project (Table 1) and a review of the literature, a print-based workbook (translated into Hindi) and an accompanying skills-based film, also in Hindi – set in an Indian location, were developed. This learning programme was delivered over 12 weeks. Both Rowntree’s (1994) model for developing distance learning programmes and the ADDIE model (Dick et al., 2001) informed this process. The film was a critical way to show how techniques should consistently be applied – something a workbook alone could not achieve.

On completion of the programme it was envisaged that the ANMs would be able to:

Explain the normal anatomy and physiology of the female reproductive system;

Explain the normal changes in pregnancy;

Describe normal labour and its mechanism;

Explain the use of the partogram;

Describe infection control methods;

Explain normal postnatal physiological changes;

Describe thermoregulation in the newborn;

Use the standardised skills shown in the film.

To conclude the development phase, two evaluation tools were designed. A pre- and post-programme knowledge test in the form of a MCQ paper in Hindi, and an evaluation form to identify areas of success and those for adjustment.

The MCQ test comprised 25 questions covering topics from the workbook, each question had several possible answers (44 correct answers in total), and the participants had to indicate their answers on an answer sheet provided. As this was a new method of assessment for the participants the number of questions was limited, and one or two questions that participants should have been able to answer from their everyday practice were included, such as the calculation of the expected date of delivery, so participants were not demoralised by zero scores. The test was designed specifically for the programme and the target audience (taking account of information gleaned through the situational analysis phase, e.g. their maternal health literacy, the identified knowledge gaps and routine practices – many based on out-of-date textbooks).

Phase 2: implementing and evaluating the educational programme

Implementation

Once the materials had been completed a convenience sample of 30 primary healthcare workers was selected by the Chief Medical Officer of the district of Shivpuri, 28 of whom attended. The group comprised 22 ANMs, four lady health visitors and two staff nurses (lady health visitors supervise ANMs). ANMs, lady health visitors and staff nurses traditionally covered similar content related to pregnancy, childbirth and the immediate postpartum period in educational activities, the lady health visitors differed from the ANMs largely in length of time practising.

A briefing day was held at the beginning of the 12-week study period to explain the use of the hard copy workbook and the film (on a DVD). The initial pre-programme knowledge test (MCQ) was completed by all the participants at this meeting. This MCQ assessment was repeated at the end of the programme with those returning to the final day (n = 14); they also completed the evaluation form.

Evaluation

As outlined above, traditional knowledge and satisfaction tests were applied, and descriptive comparisons made between knowledge scores.

Only 14 participants, all ANMs, sat both the pre- and post-programme MCQ papers. The range of the pre-test performance scores of this group was 8–32 (mean 22, standard deviation (SD) 6.73). At the end of the 12-week study period the post-test performance scores were remarkably similar, ranging from 16 to 31 (mean 23.7, SD 5.09). Three individual’s results stood clear from the majority, showing greater improvements in their scores; however, it is important not to devalue participants’ scores that did not change because they already had acquired an appropriate level of knowledge (Figure 5). Lower and unchanged scores may be linked to contextual factors which inhibit or prevent learning, such as finding that managing self-directed study conflicts with family and work commitments, lack of access to a DVD player, or fluctuating power supplies. This meant that some of the programme was not accessible, and that the visual ‘interacting’ film element was more central to understanding the workbook than recognised. Any similar future work needs to investigate such practical issues to understand better the place and context of education within the boundaries of usual family and work life.

Figure 5.

Group 1 pre- and post-intervention multiple choice question test scores at the end of 12 weeks. Pre-intervention scores to the left-hand side of each participant’s number.

Although slight improvements had been made to many scores, these results were disappointing. During the final evaluation the group reflected that although they found the workbook acceptable and particularly liked it being in their own language, they found it difficult to manage their time to make space for study, and were not able to use the film due to a lack of equipment. The group then put forward a solution to their inability to undertake home study – a 3-day face-to-face workshop to augment the study materials already provided. This was agreed and funded. The group asked Foss to facilitate the workshop and be available to answer midwifery-related questions.

This process supported both the action research design and the adult learning philosophy underpinning this work, demonstrating a participant-centred approach. Following this reassessment of the progress and achievements of the study thus far, it was recognised that the social situation of the participants was unique and that the proposed focussed face-to-face 3-day study period might result in a better outcome. The research then began its final, unexpected, cycle of action, implementation and evaluation.

The 3-day workshop

The workshop was designed to meet the participants’ needs – a focussed time for their study, access to the DVD and an expert to answer their questions related to the content of the educational materials. This workshop was organised in May 2011 in the centre of Shivpuri. The site was a hotel, which provided the participants with accommodation if required and was situated close to the district hospital. A large room was offered for the 3 days with electricity and chairs. The electricity supply varied but was usually available from 11.00 hours, and with the use of a laptop and projector the DVD recording could be projected on one wall of the room. Access was also possible to the internet through a ‘dongle’ attachment to the laptop, so animations which were previously removed from the film due to copyright were available for viewing as a separate medium.

All 14 completing participants (all ANMs) arrived (group 1) together with an additional 19 ANM participants sent by the Chief Medical Officer (group 2), totalling 33 participants with experience as an ANM ranging from one year to over 35 years. No reasons for non-attendance were given by members from group 1 who did not return. The arrival of the extra participants was a surprise, as is often the case with such events: the rationale for sending extra ANMs was that the workshop applied theory to practice, which had not previously been part of their training and was therefore an opportunity not to be missed. The new participants were accepted into the group because it would have been culturally unacceptable to turn them away and their inclusion provided an opportunity to add a convenient comparison group to the original participants (group 1). Group 2 was given the pre-test performance MCQ paper at the beginning of the first day. The second group had not received the workbook ahead of the workshop, although it was made available afterwards. Only 27 participants sat the closing MCQ as six participants from group 2 chose to omit this element of the programme. Although group 1’s scores did not improve markedly (Figure 6) before completion of the face-to-face workshop further improvements occurred after this, group 2’s scores did improve (Figure 7) (pre-test scores ranged from 15 to 25 (mean 18.8, SD 3.18), post-test scores ranged from 17 to 31 (mean 25, SD 4.06)), which suggests that coupling self-directed guided study material with an enabling, face-to-face environment can be successful, this was echoed in the evaluation data (see below).

Figure 6.

Results of all three multiple choice question test scores for group 1. Pre-intervention scores to the left: post-intervention score 1 in the middle and 2 on the right of each participant’s number.

Figure 7.

Group 2 pre- and post-intervention multiple choice question test scores at the end of 3-day workshop. Pre-intervention scores to the left-hand side of each participant’s number.

Participant evaluation

All 33 participants completed this evaluation. Generally, the whole group found the workbook material and the film helpful, with 31% saying they had learnt something new. More specifically, 27% of the participants had already applied some of their new knowledge to their practice, with only a small number not having had that opportunity. Being able to read and understand the materials was very important to the group. A question related to the language used confirmed that they all understood the text. An antenatal record book which was designed using the World Health Organization’s (2002b) antenatal care model was used and found to be helpful. Questions related to the film identified that all participants who had seen the film found it useful, but there had been difficulties viewing it for some participants. All wished to view the film again and it was played every day. Finally, the participants were asked if this type of education should be available to others, and 84.8% agreed that it should. This was supported by the comments within the suggestion section of the form. Three of these comments related to providing the material to all primary healthcare workers. Twenty participants (61%) identified the partogram and its uses as an area of new knowledge, this is particularly important because partograms can be used to identify when labour is becoming protracted and requires specialist management beyond the skillset of an ANM. The additional comments also revealed that participants appreciated being given the opportunity away from work and home commitments to complete their study. Two participants stated that meeting with ANMs from across the district meant they could discuss and share their practice experiences. Another participant liked the link between theory and practice and that the tutorial support aided their understanding.

Discussion and conclusions

‘Why would she do this for us?’ was a quotation taken from one of the participant’s evaluations. It serves as an introduction to this concluding section of our paper. As supervisors, le May and Gobbi noted Foss’s deep sense of justice for women and how she would always persevere to enable female empowerment within the bounds of cultural context. Foss sought to work with people rather than for them, to improve practice and create partnerships which would strengthen women’s status in either their work or home life and improve their health and that of their children. She concluded her thesis with a chapter on partnerships – something although at the core of action research, adult learning and practice development work, is hard to achieve successfully. We, le May and Gobbi, have inserted extracts from her thesis here to tease out the nature of the partnership(s) at the root of this research.

Partnerships… are an inevitable element of action research. Using action research within a complex cultural society needs to be very carefully considered; planning to incorporate all those who are to benefit from the outcomes will present challenges. Using a method which is underpinned by an individualist philosophy within a collective society or community will challenge the ability of the researchers to apply the process successfully. Working within one stratum of that society would give a greater scope for success as there would be a greater understanding of the social challenges, but working across the strata offered almost impossible challenges and constraints. The impossible was not achieved but where there appeared to be a possible compromise, the almost impossible was overcome. (Foss, 2014: 116)

Partnership is not always easy to achieve and sustain, even when it is with your key collaborator.

The partnership, whilst it did achieve a positive outcome, did not function in a totally collaborative manner as my partner did not discuss or want to reveal aspects of his personal limitations related to the study. This might well have been due to his role within his family and social circle. ‘Playing cards close to the chest’ is not just a cultural issue but one which maintains personal control and social standing. It did increase my frustration and lack of understanding related to some of the decisions made often without consultation. Undertaking a cross cultural study requires a greater personal understanding of the skills required to negotiate and work within all strata of Indian society, so that all participants can develop skills of enquiry which would enhance their professional development. (Foss, 2014: 119)

Partnerships are with people and technology.

Filming the skills DVD in India also presented challenges as roles and responsibilities were not always clear. This is demonstrated by the film director’s approach as his personal agenda often prevented partnership working and clarity of aim. Although the film did achieve some level of success, it could have been greatly improved by involving partners in discussion on the best way forward. There appeared to be a pride in the sole directorship of the film to the exclusion of everyone else. This individualistic focus impacted on the partnership working across the study, including the study partnership, women in the film and the crew. (Foss, 2014: 119).

Emancipation through cross-cultural action research and partnership development is complex.

Collaboration with women of higher caste status has delivered an educational package which was prescribed for the ANMs. The teachers of ANM students who evaluated the workbook content had their own agenda. They wanted the whole ANM training on pregnancy and childbirth to be included. Was this for the practicing ANMs or for them as they could use the materials in their own teaching? Some areas of the workbook had been criticised by the teachers as they were new ways of working (such as alternative positions for delivery), but the ANMs within that group were very interested. This reaction leads me to conclude that there was more control being applied to what the ANM should know rather than being open to change. Working across the social strata constantly gave mixed messages and those who were of higher social status dictated what did and did not occur. The ANMs were not totally consulted on what they needed, and this may be because they didn’t know what they didn’t know. This inability to understand what they needed to know could possibly be addressed by an interactive working partnership. This did not occur as the partners in the study didn’t see the need for including them; although I suggested their involvement could enhance the process. These social constraints inhibited the development of a meaningful partnership.

I would suggest however that those who worked through the educational material were clinically emancipated in that they had a greater understanding of the principles of care, which have been applied and are maintained (personal communication Dr R April, 2013). They were delighted with a midwifery text in their own language, which they appeared to ‘own’. This has been the trigger for some change within the practice of the ANMs, who were not applying theory to practice or using the recommended tools in the care of women, due to a lack of knowledge and understanding.

It had been suggested by the doctors involved in the study that the medical officers, working in obstetrics should also use the workbook to improve their knowledge but this was deemed unacceptable by some as they were of higher social and educational status than the ANMs. This cultural aspect of the study has contained the potential for wider application of the educational materials and has been central to some of the difficulties in the development of a broader content. Reducing the information offered for the extension of the ANMs’ knowledge base has been a constant challenge, as the decisions related to what the ANM needed to know were made by those who are not of the same caste or work as an ANM. (Foss, 2014: 114).

This study was conducted across a vast distance both in miles and within the cultural/ethical expectations of those involved. The main practical challenges of this study were associated with the distance between partners, resulting in many misunderstandings and requiring keen negotiation between all involved to ensure collaboration was maintained and enhanced. The choice of action research as a design enabled the time and flexibility for better understandings of cultural expectations, and the nuances of being an ANM in MP to develop. As a woman working in a relatively familiar culture, Mary Foss found that she often had to argue with male local healthcare providers for the enhancement of the knowledge and skills of ANMs. These inequal partnerships would have limited the technical/practical outcomes of the educational materials without the use of diplomacy, a research design that enabled critical dialogue and a high level of subject knowledge.

In terms of design-related limitations the sample size was small following the voluntary reduction in numbers from the original 28 participants. The total number of participants was not within the control of Mary Foss. However, the positive results following the workshop suggest that this method of educational delivery was not only acceptable but provided a medium for the ANMs to explore their practice. A larger study could verify the outcomes and further expand understandings of the ANMs’ knowledge base.

Using an MCQ paper to assess the ANMs’ increase in personal knowledge was limited to academic knowledge outcomes – it could not provide evidence of changed practice. Assessing the ANMs’ skills (either in the classroom or in practice) together with an MCQ paper would have provided a more robust assessment. The geographically dispersed nature of the participants in this study made practice visits impossible and the lack of midwives in MP meant that there were no midwives with the knowledge or skills available to assess competencies at that time.

In conclusion, the results of this action research study showed some success in improving the knowledge of the participating ANMs. The ANMs, like many others, struggled with managing their time to include study. Their solution to this challenge was to have some ‘ring-fenced’ time, in an environment conducive to study, where the self-directed element of the workbook could be combined with face-to-face facilitation to improve knowledge. When le May and Gobbi revisited Foss’s thesis it became evident that the then local factors also influenced the reliability and accuracy of information gleaned from local stakeholders. For example, the enthusiasm with which the DVD was recommended as a strategy for reaching the ANMs was subsequently shown to lack practical reality. Was it that the informants were not sufficiently grounded in the realities of the lives of the ANMs in this district? Or, was it that the idea was attractive and for unknown reasons the practical challenges were ignored or not disclosed? Action research is, as this paper shows, a complex and constantly evolving process, but one which can have considerable impact if its dynamism and flexibility are enabled.

Postscript

Since this study was completed the Indian central government has developed courses for nurses to train as midwives (e.g. https://www.spiegel.de/international/globalsocieties/india-turning-toward-midwives-to-reduce-maternal-mortality-a-1265427.html 2019).

Key points for policy, practice and/or research

Distance learning among nurses and midwives in rural communities may be enhanced when accompanied by face-to-face workshops.

Action research’s flexibility and emphasis on stakeholder inclusion and involvement as well as critical respectful dialogue enables cross-cultural, contextually dependent research.

Stakeholder engagement and partnerships may fail due to local barriers associated with the practical usability of new educational techniques – particularly those involving technology.

In cross cultural educational development, especially with language and gender differences, the mediating influence of stakeholders cannot be underestimated.

Practicalities, such as rurality, poor transportation, fluctuating power supplies, and the cultural expectations and norms of stakeholders should not be underestimated when designing learning programmes for healthcare workers in low or middle income countries.

Footnotes

Acknowledgements

The author(s) would like to thank: all the participants in the study, especially the ANMs, without whom this work would not have been possible; the director of the partnering NGO for making it all feasible; the film director; Dr Elizabeth Cluett for advice to le May and Gobbi – related to midwifery following Foss’s death.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Andrée le May is Co-editor-in chief of the Journal of Research in Nursing.

Ethics

Research governance and ethical approval for this study was granted by the then University of Southampton’s School of Nursing and Midwifery’s ethics committee.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the James Tudor Foundation (for funding the production of the educational material and the testing of these within India) and the Burdett Trust (for funding the multimedia resource).

ORCID iD

Mary Gobbi

Mary Foss was Senior Lecturer in Midwifery at the School of Nursing and Midwifery, University of Southampton, UK. Mary’s professional life spanned over 40 years; first as a nurse, then as a midwife and for her last 20 years a midwifery teacher. Her passion for the uniqueness of each person, and their entitlement to just, equitable and safe care and kindly consideration was contagious and reflected in the research and approaches to care and education that she became involved with.

Andrée le May is currently Professor Emerita of Nursing at the University of Southampton and Joint Implementation Lead at the East of England NIHR Applied Research Collaboration. She is Co-editor-in-Chief of the Journal of Research in Nursing. Her interests focus on research implementation, the use and evaluation of learning techniques and the care of older people.

Mary Gobbi is currently Professor Emerita of Nursing Education, School of Health Sciences, University of Southampton, UK and Visiting Professor, Tartu Health Care College, Estonia. Mary is currently engaged in a range of international projects associated with nurse regulation and educational developments in nursing and health care. Editor of the Tuning Journal of Higher Education.

References

Costello

(2003) Action Research, London, UK: Continuum.

Dick

Carey

(2001) The systematic design of instruction, New York, US: Longman.

Drummond

Themessi-Huber

(2007) The Cyclical process of action research: The contribution of Gilles Deleuze. Action Research 5(4): 430–448.

Elliot

(1991) Action Research for Educational Change, Buckingham: Open University Press.

Foss M (2014) Development and testing of a distance learning package used to improve the knowledge of trained Auxiliary Nurse/Midwives (ANM) in normal midwifery practice in Central India. PhD Thesis, Faculty of Nursing and Midwifery, University of Southampton, UK.

Government of India (2011a) Maternal Child and Total Fertility Rates, Delhi, India: Office of the Registrar General.

Government of India (2011b) Family Welfare Statistics in India, Delhi, India: Office of the Registrar General.

Hart

Bond

(1995) Action research for health and social care: A guide to practice, London, UK: Open University Press.

International Confederation of Midwives (2010) Essential Competencies for Basic Midwifery Practice. www.ICM.org.

10.

le May

Lathlean

(2001) Action research: A design with potential. Nursing Times Research 6(1): 502–509.

11.

Lewin

(1946) Action research and minority problems. Journal of Social Issues 2: 34–46.

12.

McNiff

Lomax

Whitehead

(2003) You and your action research project, London, UK: Routledge.

13.

Meyer

(2010) Action Research, Chapter 22. In: Gerrish

Lacey

(eds) The Research Process in Nursing, Oxford, UK: Wiley Blackwell Publishing.

14.

Pallikadavath

Foss

Stones

(2004) Antenatal care: Provision and inequality in rural north India. Social Science and Medicine 59(6): 1147–1158.

15.

Rowntree

(1994) Preparing materials for open, distance and flexible Learning: An action guide, London, UK: Kogan Page.

16.

Schon DA (1983) The Reflective Practitioner: How Professionals Think In Action. New York: Basic Books.

17.

United Nations Population Fund (2011) State of the World’s Midwifery. Delivering Health, Saving Lives. New York: UNFPA.

18.

Waterman H, Tillen D, Dickson R, et al. (2001) Action research: a systematic review and guidance for assessment. Health Technology Assessment 5(23): iii–15.

19.

World Health Organization (2002a) Millennium Development Goals, Geneva: WHO.

20.

World Health Organization (2002b) Antenatal Care Randomised Control Trial: Manual for the Implementation of the New Model, Geneva: WHO.