Obstetrical Nurses' Intentions Toward Collaborating With Midwives

Nancy Kristine Schottle

A thesis submitted in confonnity with the requirements for the degree of Master of Science Graduate Department of Nuning

University of Toronto

<O Copyright by Nancy Kristine Schottle 1999

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Obstetrical Nurses' Intentions Toward

Collaborating With Midwivea

For the degree of MSc , 1999

by Nancy Kristine Schottle

Facuity of Nursing, University of Toronto

Abstract

Little is known about the collaborative

relationships between obstetrical nurses and midwives

in Ontario. The Theory of Planned Behaviour (Ajzen,

1985; 1988; 1991) was used to explore obstetrical

nurses' intentions toward collaborating with midwives.

Data were collected by mailed questionnaires in

three Labour and Delivery Units which provided low-risk

care. Responding nurses (N=45; response rate = 45%)

were typically 30-39 years old (35.5%), diploma

educated (62.2%), and had 6-10 years of obstetrical

nursing experience (28.8%) . Intention scores were mostîy positive (M = 61.5;

s.d. = 30.3). Behavioural attitude and perceived

behavioural control, were related to intention scores

(r = . 6 7 , pc.001; r = .65, pc.001). However subjective

nom scores were unrelated to intention (r = -42, ns).

Behavioural attitude scores accounted for a significant

amount of the variance in intention scores (F (l,25) =

23.91, pc.001) ; however, subjective n o m scores did not

contribute (p=. 22, ns) . Perceived behavioural control

scores were not included in regression analysis due to

high correlation with behavioural attitude scores.

The results indicate that these nurses had

positive intentions to collaborate with midwives.

These intentions are largely mediated by behavioural

attitude. This, in turn, implies that intention to

behave collaboratively could be supported by: 1)

demonstrating the positive outcornes of collaboration;

2) fostering the change process; and 3 ) increasing

interprofessional interaction. Implications for theory

and further research are also described.

iii

1 want to thank Dr. Hilary Llewellyn-Thomas for

al1 her time, effort, and guidance throughout this past

year. She has encouraged me to critically think and

read like a scientist. She has been a wonderful r o l e

mode1 . I would like to acknowledge Dr. Karyn Kaufman for

her support in the initial stages of this thesis.

1 also want to thank my thesis cornmittee members,

Dr. Ellen Hodnett and Ms. Roseanne Hickey, for their

efforts, expertise, and cornmitment to this thes i s .

Their long-standing assistance has been appreciated.

My husband, Scott, deserves my gratitude for so

many things. His loving support and understanding will

never be forgotten.

1 would also like t o thank the nurses who

participated in this research. 1 appreciated their

time and effort.

Table of Contents

Abstract

Acknowledgments

Table of Contents

L i s t of Tables

L i s t of Figures

L i s t of Appendices

iii

iv

X

xii

xiii

Chapter 1 1

Background 1

Problem Statement 7

Review of Related Research 8

Collaboration Between Health Care Professions 9

Components of Interprofessional

Collaborat ion

Factors Which Inhibit Collaboration

Relationships Between Health Care

Professions

Overail Sumrnary of Literature Review

Study Rationale

Study Purpose

Expected Contribution

Chapter II 24

Conceptual Framework 24

Overview of the Theory of Piamed Behaviour 24

Application of the Theory of

Present Study

Hypotheses and Questions

Research Hypotheses

Research Questions

Planned Behaviour to

Definitions of

Chapter III

Terms

Methods

Study Design

Setting

Sample

Data Collection Strategy

Instrument Development

Preliminary Steps

Outcome Evaluations, Motivation to Comply,

Perceived Control

Transformation of Indirectly-Measured

Independent Variables

Draf t Revision

Data Collection Questionnaire

30

34

34

35

35

41

41

41

41

41

42

43

46

and

Section 1: Measuring Previous Collaborative

Practice

Section II: The Indirect Measurement of

Behavioural Attitude

Section II: The Direct Measurement of

Behavioural Attitude

Section IV: The Indirect Measurement of

Subjective Nom 54

Section V: The Direct Measurement of Subjective

Nom 55

Section VI: The Indirect Measure of Perceived

Behavioural Control 55

Section VII: The Direct Measurement of

Perceived Behavioural Control

Section VIII: Measurement of Intention to

Collaborate

Section IX: Personal Data Form

Assessing Content Validity

Assumptions

Protection of Participantsf Rights

Informed Consent

Confidentiality

Risks and Benefits

Data Analysis

vii

Descriptive Statistics 61

Research Hypotheses and Questions 61

Limitations of the Study 64

Chapter IV 66

Resuits 66

Characteristics of the Participants 66

Research Hypotheses 68

Measurement of Behavioural Attitude 69

Measurement of Subjective Nom 73

Measurement of Perceived Behavioural Control 76

Correlat ions 78

Secondary Hypothesis 80

Primary Research Question 82

Direct-Measurement of Independent Variables 83

Indirectly-Measured Independent Variables 84

Additional Analyses 85

Notable Items 89

Chapter IV 92

Discussion 92

The Çample 92

Behavioural Attitude 93

Directly-Measured Scores for Behavioural

Attitude 93

viii

Indirectly-Derived Scores for Behavioural

Attitude 95

Summary of Behavioural Attitude 96

Subjective N o m 97

Directly-Measured Scores for Subjective Nom 97

Indirectly-Derived Scores for Subjective Nom97

Summary of Subjective Norm 99

Perceived Behavioural Control 100

Directly-Measured Scores for Perceived

Behavioural Control

Indirectly-Derived Scores for Perceived

Behavioural Control

Summary of Perceived Behavioural Control

Intent ion

Chapter V

Summary, Implications, and Conclusions

Summary

Support For the Theory of Planned Behaviour

Implications for Practice, Theory, and

Research

Practice

Practice Implications Derived From

Indirectly-Measured Independent Variables 114

Research 119

Conclusion

References

Appendices

LIST OF TABLES

1: Characteristics of Participants (N=25)

2: Intention to Collaborate: Distribution of LAS

Scores

3: Direct Measurement of Behavioural Attitude:

Distribution of LAS Scores 71

Indirect Measurement of Behavioural Attitude 72

Direct Measurement of Subjective Norm: Distribution

LAS Scores 73

Indirect Measurement of Subjective N o m 75

Direct Measurement of Perceived Behavioural Control:

Distribution of LAS Scores 76

8: Indirect Measurement of Perceived Behavioural

Control

9: Correlation Coefficients of Scores for Directly-

Measured Independent Variables and Intention 79

10: Correlation Coefficients of Scores for Indirectly-

Measured Independent Variables and Intention 80

11: Correlational Matrix of Directly- and Indirectly-

Measured Scores for Behavioural Attitude, Subjective

Norm, and Perceived Behavioural Control

12: Multiple Regression Equations: Contributions of

Directly-Measured Scores for Behavioural Attitude and

Subjective N o r m to Variance in Intention Scores 84

13: Multiple Regression Equations: Contributions of

Indirectly-Measured Scores for Behavioural Attitude and

Subjective Nom to Variance in Intention Scores 85

14: Scores for the Retrospective Measure of Previous

Collaborative Effort Linear Analogue Çcale 87

15: Reliability Coefficients for the Likert Scales 87

xii

LIST OF FIGURES

1: The Theory of Planned Behaviour. Adapted form

Ajzen, 1985; 1988; 1991) 25

2: Application of Theory of Planned Behaviour to Study

of Obstetrical Nursesr In tent ion to Collaborate with

Midwives . 3 3

xiii

Measurement of Intention to Collaborate

The Direct Measurement of Behavioural Attitude

a) Semantic Differential Scales

b) Global Linear Analogue Scale

The Indirect Measurement of Behavioural Attitude

The Direct Measurement of Subjective N o m

The Indirect Measurement of Subjective N o m

The Direct Measurement of Perceived Behavioural

Control

G: The Indirect Measurement of Perceived Behavioural

Control

H: Persona1 Data Form

1: Letter of Explanation to Potentiai Participants

J: Instructions Given to Participants

K: Measuring Previous Collaborative Practice

L: The Direct Measurement of Behavioural Attitude:

Means and Standard Deviations on the Semantic

Differential Scales

M: The Indirect Measurement of Behavioural Attitude:

Means and Standard Deviations

xiv

N: The Indirect Measurement of Subjective Nom:

Mean Scores and Standard Deviations 164

O: The Indirect Measurement of Perceived Behavioural

Control: Means and Standard Deviations 165

P: Comments Written on the Questionnaire 167

CBAPTER 1

Background

The profession of midwifery attained full legal status

in Ontario when the Regulated Health Professions Act was

proclaimed law on Decernber 31, 1993. Midwifery care is now

available in Ontario and covered by the Ontario Health

Insurance Plan (OHIP). Midwifery services include primary

care during the antenatal period, labour, birth, postpartum

period, as well as prirnary care for the newborn infant

(Bowles, 1993; Schlatter, 1991) . Midwifery services have

and will continue to change the health care system, offering

women an alternative to the dominant medical model.

As a new profession entering the health care system,

midwifery has been subject to a mix of reactions from other

professions, and It will be useful to examine the new

developing relationships between professions (Chalmers,

Enkin, & Keixse, 1989; Fagin, 1992; Vanwyck, 1992) . The

focus of this study is on the relationship between nurses

and midwives.

Until very recently, obstetrical nurses in Ontario

provided al1 the professional labour support and monitoring

of low risk labouring women and their families in the

hospital setting. Now midwives' role includes that of

primary caregiver to child-bearing women and their infants,

professional labour support, and birth attendant to their

clients within the home or hospital. Midwives now have

appointrnents as hospital staff, admitting privileges, and

the ability to write orders. Midwives are performing roles

in the hospital setting that were previously done only by

obstetrical nurses. These changes may be perceived as very

threatening to obstetrical nurses (Blais, Maheux, & Lambert,

1992; Vanwyck, 1992) . The xoles for midwives and nurses are based on the

legal scope of practice set out in the Regulated Health

Professions Act (RHPA). The midwives' scope of practice is

further elaborated upon by discussions between the College

of Nurses and the College of Midwives (Bowles, 1993) and

policies outlined in individual hospitals. Obstetrical

nurses will be required to work with midwives in specified

situations (e.g. caesarean sections, epidural analgesia

care, low risk midwifery clients that become high risk, and

emergency situations). This new role for obstetrical nurses

has been met with a mix of reactions (Kaufman & Renfrew

Houston, 1988; Vanwyck, 1992) . Hazle (1985) noted that midwives may create

hierarchical relationships with nurses since their role is

much like that of physicians, placing the nurse in a

subordinate position. Such role changes have been a source

of conflict (Hazle, 1985) and have been a barrier to

collaboration (Sheer, 1996). Conflict between professions

may lead to duplication of effort, hostility, and energy-

depleting discord, and thus poses potential risks to

patients (Fagin, 1992) . Health care professions are urged to take a

collaborative approach in working with this new regulated

health profession as the boundaries of responsibility are

redrawn (Lieba, 1993; Rafuse, 1993), instead of protecting

their own "turfw and viewing midwifery as a potential threat

(Michelson, 1988). Collaboration is a very large concept

which implies a process of working together toward shared

goals. Individuals in a collaborative relationship have

similar philosophies and have an understanding of their own

and their partner1s professional and individual skills,

knowledge, and characteristics (Aradine & Pridham, 1973).

Characteristics of interprofessional collaboration

include shared goals, trust, mutual respect, good

communication, understanding, joint decision making, joint

investment in the clinical process, and joint cornmitment to

high-quality patient outcomes, shared responsibility, and

accountability (Aradine & Pridham, 1973; Bushnell & Dean,

1993; Gregson, Cartlidge h Bond, 1991; Hennernan, Lee 6

Cohen, 1995; Makaram, 1995; Michelson, 1988; Pike et al.,

1993; Sheer, 1996). Collaboration is based upon non-

cornpetitive cooperative behaviour and non-hierarchical

organizational structures (Gregson, Cartlidge & Bond, 1991;

Hennenxnan, Lee & Cohen, 1995). Promotion of

interprofessional collaboration is futile without different

health care professionals having equal status, prestige, and

power (Gregson, Cartlidge & Bond, 1991).

The value of interprofessional collaboration is that it

can have a positive effect on: patient care, efficiency,

productivity, communication, and job satisfaction for health

professionals (Aradine & Pridham, 1973; Baldwin, Hutchinson,

& Rosenblatt, 1992; Bream & Schapiro, 1989; Bushnell & Dean,

1993; Fagin, 1992; Gregson, Cartlidge & Bond, 1991; Haas &

Rooks, 1986; Lappe, 1993; Makadon & Gibbons, 1985; Makaram,

1995; Michelson, 1993; Pike, McHugh, Canney, Miller, Reiley,

& Seibert, 1993; Prescott & Bowen, 1985). Therefore, it is

important to integrate the practice of nurses, midwives, and

the rest of the health care team, in order to provide high

quality health care to childbearing women.

Obstetrical nurses' intentions toward collaboration

with other health professionals have been described in the

anecdotal literature. Nurses have stated that they want to

work cooperatively as equal partners with other health care

professionals to bring about the best health care possible

(Callahan, 1992; Fagin, 1992; Kimbro, 1978 ; Secretary' s

Committee to Study Extended Roles for Nurses, 1972; Stein,

Watts, & Howell, 1990). Maternity nurses in particular have

stated that they want to contribute toward the improvement

of obstetrical care and they want to be essential,

functioning team members in health care (Hsia, 1984).

Collaboration between obstetrical nurses and midwives

has been described in the literature. Midwives with nursing

preparation practising in Ontario have reported good

collaborative (not hierarchical) relationships with nursing

staff at a hospital which has offered midwifery services for

a number of years (Kaufman & Renfrew Houston, 1988; Report

of the Task Force on the Implementation of Midwifery in

Ontario, 1988) . On the other hand, midwifery is being introduced to a

health care system where interprofessional conflict already

exists as a result of a lack of collaborative relationships

among professions. Conflict has been widely documented

between physicians and nurses (Davidson, 1991; Eubanks,

1991; Fagin, 1992; Goldberg, 1991; Heenen & Robinson, 1991;

LaCombe, 1988; Makaram, 1995; Pike et al., 1993; Stein,

Watts, & Howell, 1990; Vanwyck, 1992). Conflict has been

reported among physicians and midwives (Burgin, 1992;

Cushner, 1986; Rooks, 1983) and among nurses and midwives

(Kaufman & Renfrew Houston, 1988; Kimbro, 1978) in other

countries such as the United States of America and Britain.

Ambiguity and conflict among health professionals can

potentially lead to compromises in patient care (Fagin,

1992; Graham, 1991).

Some nurses may have negative feelings toward midwifery

since the midwifery education system in Ontario does not

require nursing as a foundation for the program (Muzio,

1991; Vanwyck, 1992) . The College of Nurses of Ontario, the

Registered Nurses Association of Ontario (RNAO), and the

Ontario Nurses' Association (ONA) would have supported

midwifery education if it required nursing preparation as a

prerequisite (Vanwyck, 1992) . However, the Task Force on

the Implementation of Midwifery in Ontario (1987)

recommended that midwifery education be an entirely separate

baccalaureate program. As a resclt, the professional

nurses' associations opposed such an education program

(Kaufman, 1991; Vanwyck, 1992). Therefore, nurses may

already have negative feelings toward midwives.

Introduction of a new profession into an established

patient care setting will disrupt and modify existing roles

and relationships (Murphy & Schmitt, 1979), especially for

obstetrical nurses. The anecdotal literature has

demonstrated some positive (Callahan, 1992, Fagin, 1992,

Kaufman & Renfrew Houston, 1988; Report of the Task Force on

the Implementation of Midwifery in Ontario, 1988; Stein,

Watts, & Howell, 1990) and some negative attitudes (Burgin

1992, Cushner, 1986; Davidson, 1991; Eubanks, 1991; Fagin,

1992, Goldberg, 1991, Heenen & Robinson, 1991, Kaufman &

Renfrew Houston, 1988; Kimbro, 1978; LaCombe, 1988; Rooks,

1983; Stein, Watts, & Howell, 1990; Vanwyck, 1992) amongst

health care professions.

In summary, anecdotal literature has shown some

obstetrical nurses to have positive intentions toward

collaborating with other health professions. However, no

systematic survey of obstetrical nurses has been undertaken

to determine the likelihood of positive collaborative

relationships occurring.

Insight into the relationships between nurses and

midwives may be obtained by exploring the determinants of

obstetrical nurses' attitudes and their intentions toward

working with rnidwives. The attitudinal data could identify

potential areas of strength or conflict within nursing/

midwifery relationships. Implementation cornmittees could

use this information to foster a smooth integration of

midwifery practice by fostering collaborative practices.

For patients to receive the best possible health care,

collaboration amongst al1 health professionals should be the

objective (Fawcett-Henesy, 1991) . Problem Statement

Midwives have a role in maternity care within hospitals

for their clients who have hospital births. Nurses and

midwives need to establish positive working relationships.

Collaboration is strongly associated with excellent patient

outcomes (Aradine 6t Pridham, 1973; Baggs ,Ryan, Phelps,

Richeson, & Johnson, 1992; Bushnell & Dean, 1993; Gregson et

al., 1991; Knaus, Draper, Wagner, 6 Zimmerman, 1986;

Michelson, 1988; Pike et al., 1993) . Therefore, it is

important to examine present relationships and the potential

for collaboration between obstetrical nurses and midwives.

Determining obstetrical nurses' intentions to collaborate

with midwives in the care of midwifery clients, as well as

examining obstetrical nurses' bel ie fs , which are the

foundation of their intentions, may provide useful

information to those wishing to perpetuate a successful

integration process of the profession of midwifery into

Ontario's hospitals.

Review of Related Research

The literature review is organised according to

relevant areas of research. A summary of methodological

considerations of the reviewed literature is included at the

end of the literature review. Sections include:

Collaboration Between Health Care Professions; Components of

Interprofessional Collaboration; Factors Which Inhibit

Collaboration, and Relationships Between Health Care

Professions.

Lirnited research existed on interprofessional

relationships between obstetrical nurses and midwives. Most

of the research reviewed has been done in other countries,

since legalised midwifery is so new to Ontario. Although

the models of midwifery practice differ from country to

country, the basic philosophy remains similar; thus,

research studies using samples from other countries have

been included in this review and are considered relevant to

this investigation.

Research on relationships between rnidwives and other

health care professionals also has been reviewed. The

investigator understands that the results of the reviewed

research are not generalizable beyond the samples used;

however, information obtained from groups of other health

care professions may give insight into relationships and

potential collaborative practice bettreen obstetrical nurses

and midwives.

Collaboration Between Health Care Professions

Collaboration Between Nurses and Physicians

Gregson et a1.(1991) examined collaboration between

district nurses (n=167), general practitioners (n=230), and

health visitors (home care personnel) (n=178) in Britain.

Five methods were used to measure the extent of

interprofessional collaboration between the three health

professions: a structured interview; a prospective record of

consultations, referrals, and meetings; a self-completed

questionnaire; a practice questionnaire completed by general

practitioners; and structured interviews with a senior

community nurse in each district. Health care workers rated

their self-perceived levels of collaboration significantly

higher than the interviewers (p<0.001). Collaboration

between each of the health care professions was actually

found to exist, but at low levels.

Collaboration Between Midwlves and Physicians

Samples of Certified Nurse-Midwives (n=280) and

physicians (n=46) in the U.S.A. were surveyed using

questionnaires and interviews to identify and quantify

specific factors that influence the success (defined as

adequate client population, financial stability, and

continuation of practice) of nurse-midwifery practice (Haas

& Rooks, 1986). A collaborative relationship between the

nurse-midwife and physician was found to be the most

important factor for nurse-midwifery success; at the same

time, one of the most important problems for midwifery

practice was identified as opposition from physicians (Haas

& Rooks, 1986) . Outcornes of Inter~rofessional Collaboration

Authors appear to be in unanimous agreement that

collaborative relationships lead to positive and progressive

outcomes (Baggs & Schmitt, 1997; Baggs et al., 1992; Knaus

et al., 1986; Koerner, Cohen & Armstrong, 1986; Williams,

Williams, Zinuner, Hall & Podgorski, 1982) . These four

studies assessed the positive or lack of negative outcomes

related to interprofessional collaboration.

Compelling support for the positive outcornes of

collaboration cornes from a time series study, in which the

investigators collected data before and after the-

implementation of a collaborative practice mode1 by

analyzing attitudinal data from physicians (n=112) and

nurses (n=26) (Koerner et al., 1986) . After engaging in

collaborative practices, a) there was greater physician-

nurse interaction, b) more professional relationships were

promoted, and c) physicians greatly improved their

perception of nurses' behaviour. The researchers found that

physicians perceived a broader role for nurses which

involved more âutoriomy, increased decision making, and more

input into the plan of care within the collaborative

practice system. Nurses felt that they had more freedom to

apply their knowledge and skills, and the nurses were more

frequently asked for their input by physicians in developing

plans of care within this environment. Both nurses and

physicians believed that collaborative practice facilitated

communication, efficiency of staff, and quality of patient

care. Al1 nurses and a majority of physicians perceived

increased satisfaction in their professional practice when

working collaboratively, and al1 nurses also noticed

increased collaboration with other disciplines. Koerner et

al. (1986) also reported that nurses clearly experienced

greater autonomy, independence, and clinical decision making

resulting in job satisfaction and greater retention on the

unit after the implementation of the collaborative practice

model. There was also significantly increased communication

between nurses and their patients, families, and physicians.

Similarly, the results of Knaus et al.9 (1986) and

Baggs et aL's (1992) studies demonstrated positive outcomes

related to interprofessional collaboration. Knaus et al

(1986) reported that communication, coordination, and

interaction between doctors and nurses in critical care

units correlate with positive patient outcomes (Le.

positive differences between predicted and observed death

rates) . Baggs et al. (1992) , in a prospective study,

reported that negative patient outcomes (i.e. readmission to

the Medical Intensive Care Unit or death) decreased from 16%

to 5% when full collaboration existed between nurses and

residents in a Medical Intensive Care Unit.

Baggs and Schmitt (1997) used grounded theory to

explore the collaborative relationship between intensive

care unit nurses and physicians. The major outcomes of

collaboration were described as improving patient care,

feeling better in the job, and controlling costs.

Collaboration amongst nurses and physicians has also been

associated with decreased lengths of hospital stays in a

geriatric setting (Williams et al., 1987) .

Summary of Collaboration Between Health Care Professions

Collaboration exists between health professions such

as general practitioners and district nurses in Britain, and

professional collaboration has been associated with the

success of midwifery practices. Thus, interprofessional

collaboration has been shown to be important in the success

of midwifery practice. However, no research has been done

which explores collaborative practices between obstetrical

nurses and midwives in Ontario.

Interprofessional collaboration has been associated

with many positive results. Investigators found that

interprofessional collaboration in samples of nurses and

physicians resulted in increased work satisfaction, a

climate of confidence and trust among physicians and nurses,

and enthusiastic responses from patients to the care they

received (Baggs & Schmitt, 1997). Positive outcornes for

patients' medical status (death rates being significantly

lower) (Knaus, et al., 1986), and decreased lengths of

hospital stays in a geriatric setting (Williams et al.,

1987) have been demonstrated when collaboration exists

between nurses and physicians.

However, some negative statements towards collaboration

with nurses were expressed by physicians. Some physicians

in the Koerner et al. study (1986) stated that they found

collaboration to be time consuming and this decreased their

efficiency. Some other physicians in this sample objected

to the close interpersonal contact with nurses that

collaborative practice required.

Components of Interprofessional Collaboration

Nurses and Physicians

Weiss and Davis (1985) tested an instrument designed to

measure collaborative practice behaviours between physicians

(n=94) and nurses (n=95). Certain factors were found to be

important to collaboration. These were: a) nurses asserting

professional expertise and opinions with physicians about

patient care; b) horizontal rather than vertical

communication between nurses and physicians; and c) making

active and assertive contributions to interprofessional

interaction. Behaviours such as: a) open discussion by

nurses and physicians about patient care; b) the

identification of disparate and cornmon perceptions; and c)

the delineation of mutually agreeable goals and

responsibilities were also found to be important factors in

the process of collaboration. There were positive and

significant relationships with level of collaboration when

each professional group recognised that the other has

distinct areas of expertise, and when each profession

actively sought opinions of the other health profession

regarding patient care.

Factors associated with collaboration were also

investigated by Gregson, Cartlidge, and Bond (1991) in their

study involving district nurses (n=167), general

practitioners (n=230) and health visitors (n=178) in

Britain. Higher levels of collaboration were associated

with: a) the members of the collaborative pair meeting

frequently at arranged meetings as well as by chance; b)

consulting one another frequently; c) referring to one

another; and d) consulting one another's records.

Precursors to collaboration include a friendly, informal

interprofessional relationship, reciprocal use of first

names, commenting on one another's work, and understanding

one another's responsibilities.

Summary of Components of Interprofessional Collaboration -. . - - - -. .- -- - .

Taken together, these studies demonstrate that certain

factors are apparently associated with higher rating of

collaboration. Frequent meetings, consultations, and

referrals were associated with higher ratings of

collaboration (Gregson et al., 1991; Weiss & Davis, 1985) , and a friendly informa1 relationship between professions

also seems to be associated with higher ratings of

collaboration (Weiss & Davis, 1988). Research was not found

investigating the variables associated with collaborative

practice between midwives and obstetrical nurses. Although

the reviewed research investigated the relationships between

physicians and nurses, these studies described the emotional

environment that has existed in health care systems. Trends

and patterns in interprofessional relationships in health

care systems may influence the development of relationships

between nurses and midwives. Therefore, these research

results are considered relevant to the current study.

Factors Which Inhibit Collaboration

Nurses, Midwives and Phvsicians -- -

Beaver et aL(1986) investigated midwife/nurse/

physician conflict and "burnout" in a randomly selected

stratified sample of U.S.-educated and employed certified

nurse-midwives ( n = 9 8 ) Burnout was measured with a 22 item

questionnaire which included questions on three components

of burnout: a) emotional exhaustion; b) depersonalization;

and c) persona1 accomplishments. Burnout was more likely to

occur in nurse-midwives who were newly employed in large

services and who lacked physician and nurse support.

Nurses and Physicians

Two studies identified factors which appear to be

negatively associated with collaborative practices between

physicians and nurses (Gregson et al., 1991; Robinson et

al., 1993). Gregson et al. (1991) observed that poor mutual

understanding was found to be associated with lower ratings

of collaboration. For example, twenty-two percent of

district nurses and 42% of health visitors (home care

personnel) felt that their general practitioner partner did

not understand the responsibilities of their profession, and

this perception was associated with lower ratings of

collaboration.

Robinson et al. (1993) surveyed general practitioners'

(n=2013) attitudes toward practising British nurses.

Factors perceived as barriers to the extension of the

practice nurse's role included: a) nurses having no desire

or need to extend their role; b) confusion about the roles

of the nurse and the doctor; c) nurses' lack of time, and d)

nurses' lack of self confidence.

Surnmary of Factors Inhibiting Collaboration

Poor interprofessional relationships have been

associated with lower ratings of collaboration and have led

to interprofessional conflict (Gregson et al., 1991).

Burnout in rnidwives was associated with non-supportive

relationships (Beaver et al., 1986). Factors such as role

confusion between the professions of nursing and midwifery,

obstetrical nurses' lack of desire to create new

relationships, obstetrical nursest lack of confidence, and

the busy job of an obstetrical nurse may be related to poor

interprofessional relationships between obstetrical nurses

and midwives. As no research was found specifically

exploring the interprofessional relationship between

obstetrical nurses and midwives, investigation is warranted

to explore factors which may influence obstetrical nurses'

collaboration with midwives.

Relationships Between Bealth Care Professions

Relationships Between Midwives and Obstetrical Nurses

The Groupe de Recherche Interdisciplinaire en Sante

(GRIS) (Blais, Lambert, Maheux, Loiselle, Gauthier, &

Framarin, 1991) conducted a survey to explore attitudes

toward midwifery implementation in Quebec. A theoretical

framework was not specified. Results were obtained by

Likert scales from a sample of doctors who provide primary

obstetric case (n=597), obstetrical nurses, perinatal nurses

(n=723), and midwives (n=70). The physicians' results are

not xeviewed since the nurse-midwife data are more relevant

to this literature review.

Thirty-eight percent of hospital nurses and 80 percent

of community nurses believed there was a need for midwives

in Quebec because medicine has an overly pathologic view of

childbirth. Forty-five percent of hospital nurses and 12

percent of community nurses believed that the arriva1 of

midwives would represent a threat to the role of the nurse.

Forty nine percent of nurses in obstetrics and twenty

percent of community nurses believed that birth of an infant

without the help of a doctor is dangerous for the health of

the mother and child. Most hospital and community nurses

believed that midwives should have formal training which

would requise a master's degree, with a bachelor's degree in

nursing.

While most nurses endorsed the idea that midwifery

could improve maternity care, community based perinatal

nurses were clearly more favourable about rnidwives than the

hospital based nurses. Al1 nurses saw midwives as more of a

threat to the physicians than to themselves. There was a

consensus among al1 groups that midwives should work in

close collaboration with current maternity care personnel.

Reiationshi~s Between Nurse-Midwives and Nurses pp - -- --

Hazle (1985) obtained a randomly selected ~ample of

nurse-midwives (n=100) and obstetric nurses (n=100) in the

U.S.A., and used Likert scales to investigate role

relationships and conflict between the two professions.

Both nurses and nurse-midwives had basically positive views

of one another; however, some degree of interrole conflict

was found to be present between these two professions.

Relationshi~s Between Nurses and Phvsicians

Robinson, Beaton, and White (1993) surveyed the

attitudes of a randomly selected sample of general

practitioners (n=2013) toward the extended role of practice

nurses (i.e. nurses with extended soles in general practice)

in Britain. The concepts under consideration in this study

were the expansion of the clinical role for nurses in

general practice and the adoption of the role of an

independent nurse practitioner (a new health care

profession). This research is considered relevant to this

study because the introduction of hospital midwifery

practice was an extension of the midwifery role as well as a

new regulated health care profession. These investigators,

as well as Beaton et al. (1991), reported that the important

factors which might prevent the extension of the role of

practice nurses were the attitudes of other health

professions (such as physicians) towards this new role.

Robinson et al. (1993) reported that general practitioners'

attitudes toward practice nurses, nurses' attitudes to

practice nurses, and nursing managers' attitudes toward

practice nurses were perceived barriers to the extension of

the practice nurse's role.

Summary of Relationships Between Health Care Professions - -

In summary, it appears that obstetrical nurses have

reported both positive and negative attitudes toward

midwives. However, hospital-based obstetrical nurses had a

less positive attitude toward midwifery than cornmunity

nurses (Blais et al, 1991). Negative attitudes have been

documented as a perceived barrier to a new role in a health

care system (Robinson et al., 1993). Positive attitudes

have been important to new roles entering a health care

system. No studies were found that explored attitudes of

obstetrical nurses in Ontario toward collaborating with

midwives . Overall Summary of Literature Review

There were very few empirical studies done on

interprofessional collaboration in the health care setting,

and even fewer studies have examined the relationship

between obstetrical nurses and midwives. Regulated

midwifery was a new profession in the Ontario health care

system, and this provided new opportunities for exploring

the development of interprofessional relationships.

Interprofessional collaboration has been shown to have

many positive results; it therefore is a desirable goal for

obstetrical nurses and midwives to obtain. The reviewed

research demonstrates that collaboration between obstetrical

nurses and midwives has been important in the success of

rnidwifery practices. No studies were available that

investigate the collaborative relationship between

obstetrical nurses and midwives in Ontario.

While examining the methodology of the reviewed

research, it became evident that many studies did not have a

specified theoretical framework. Two frameworks that were

used were grounded theory (Baggs & Schmitt, 1997) and role

theory (Hazle, 1985). Three other studies developed a

framework from the results of the studies. A framework of

burnout was described by Beaver et al. (1986) ; a framework

of collaboration was described by Ben-Sira and Szyf (1992);

and a framework of critical care nursing was described by

Mitchell, Armstrong, Simpson and Lentz (1989) . The

diversity of the many theoretical frameworks has led to many

different study methods as well as inconsistent definitions

of terms.

In the four studies investigating attitudes (Blais et

al., 1991; Hazle, 1995; Koerner et al., 1986; and Robinson

et al., 1993), role theory was the only specified theory

used (Hazle, 1995). Thus, in each study the definition of

"attitude' and the process of collecting attitudinal data

were different. The definition of attitude was not defined

at al1 in the study by Blais et al. (1991).

Study Rationale

Studv Pur~ose

The immediate purpose of this study was to gain insight

into some of the factors that may underlie obstetrical

nurses' collaborative relationships with midwives. This

study was also done to fil1 the gap in the literature on

collaborative relationships between obstetrical nurses and

midwives in Ontario.

Expected Contribution

The legalisation of the profession of Midwifery in

Ontario has raised much debate among professional

associations, but very little was known about nurses'

present relationships with midwives and their intentions to

collaborate with rnidwives in the care of midwifery clients.

Since midwives have now taken a new role in maternity care

within hospitals, the opinions of nurses toward working with

midwives should be documented. The exploration of

obstetrical nurses' intentions in terms of their attitude,

subjective norm, and perceived behavioural control could

help identify areas of potential support or conflict. Then,

in the long run, collaborative practices could be enhanced

by strengthening positive beliefs and/or intentions and

trying to alter negative beliefs and/or intentions. Thus ,

the ultimate motivation for this work was to seek

information that may be useful to midwifery task forces,

professional nursing associations, and hospital

administrations to best enable a successful integration of

the profession of midwifery within Ontario's health care

system.

C M R IX

Conceptual Framewoxk

Overview of the Theoxy of Planned Behaviour

The Theory of Planned Behaviour (TPB) (Aj zen, 1985;

1988) was used as the conceptual framework for this

investigation.

The Theory of Planned Behaviour is an extension of

Ajzen and Fishbein's (1975) Theory of Reasoned Action (TM) . The TRA assumes that human beings rationally combine

information about expected outcornes and about expected

social pressure, to arrive at a decision about whether or

not they will perform a given behaviour. The TPB goes

beyond this formulation, by adding the element of

behavioural control. This is done in terms of perceived

rather than actual control, since sometimes the behaviour of

interest is not completely under volitional control. The

elements of the TPB are outlined following the mode1 of the

Theory of Planned Behaviour (see Figure 1).

Behavioural Intention

A central element in the TPB is the postulation that

the attempt to perform a certain behaviour is a function of

an individual's intention to perform that behaviour. These

intentions remain dispositions until, at the appropriate

time and opportunity, an attempt is made to translate the

intention into action (Ajzen, 1985; 1988; 1991; Fishbein &

Ajzen, 1980). A t this point, the behavioural intention is

the imrnediate determinant of a person's attempt to perform a

behaviour (Ajzen, 1985; 1988; 1991) . Intention, in turn, is determined by: a) the

individual's "behavioural attitude1'; b) his/her "subjective

norm"; and c) his/her "perceived behavioural control" (see

figure 1) . Furthermore, "behavioural attitude", "subjective

norm", and "perceived behavioural control" are each in turn

determined by a set of underlying beliefs and their

associated modifiers.

Behavioural attitude is the individual's positive or

negative evaluation of the act of performing the behaviour

(Ajzen, 1985; 1988; 1991; Fishbein & Ajzen, 1980) . According to the TPB, behavioural attitude is a function of

two components. These are: a) the individual's expectation

that the behaviour will lead to particulas salient outcornes

(i . e. "behavioural beliefs") ; and b) the individual ' s evaluation of the desirability or undesirability of each of

these outcomes ( "outcome evaluations") ( A j zen, 1985; 1988;

1991; Fishbein & Ajzen, 1980). According to the theory, if

a person believes that performing the behaviour leads to

positive outcomes, his/her attitude is more favourable.

Fishbein and Ajzen (1980) argued that an important

preliminary s t e p in conceptualising the behavioural attitude

component of the TPB, for a particular clinical context, is

first t o identify the salient outcomes. This preliminary

step was not undertaken by t h i s investigator, b u t was

derived from data previously collected by colleagues in an

earlier investigation ( see below in the Methods chapter).

Subjective norm refers to the individual ' s perception

of the social pressures put on hidher to perform or abstain

from the behaviour under consideration. According to the

TPB, subjective norm is a function of two components. These

are: a) the person's estimation of the likelihood that

important referent others think they should perform the

behaviour (i . e. "normative belief s") ; and b) the person's motivation to comply with the referents i n question

("motivation to comply") (Ajzen, 1985; 1988; 1991; Fishbein

& Ajzen, 1980) . According t o the theory, if a person

believes that important others think the individual should

perform the behaviour and the individual is willing to

comply with these social expectations, their subjective norm

is more favourable, Fishbein and Ajzen (1980) a l s o argued

that an important preliminary step in conceptualising the

subjective norm component of the TPB, for a particular

clinical context, is first to identify the salient

referents . Perceived behavioural control refers to a person's

perception of the ease or difficulty of performing the

behaviour of interest. According to the TPB, perceived

behavioural control is a function of two components, These

axe: a) the individual's estimation of the likelihood that

he/she can control important factors that could promote or

undermine the performance of the behaviour ( L e . "control

beliefs"; and b) the individual's perception of the

promoting or undermining capabilities of these factors

("perceived power") (Ajzen, 1985; 1988; 1991). According to

the theory, if a person believes that there are numerous

promoting factors and he/she can control any undermining

factors, the level of perceived behavioural control is more

favourable.

Perceived behavioural control is assumed to reflect

past experience as well as anticipated impediments and

obstacles (Ajzen, 1988; 1991). Ajzen (1991) stated that

"these control beliefs may be based in part on past

experience with the behaviour, but they will usually also be

influenced by second-hand information about the behaviour,

by the experiences of acquaintances and friends, and by

o t h e r f a c t o r s t h a t i n c r e a s e o r r e d u c e t h e p e r c e i v e d

d i f f i c u l t y o f pe r fo rming t h e behav iour i n q u e s t i o n w (p .

1 9 6 ) .

I n many s i t u a t i o n s , p e r c e i v e d c o n t r o l may n o t be

r e a l i s t i c . T h i s i s l i k e l y t o occur when the i n d i v i d u a l h a s

l i t t l e i n f o r m a t i o n a b o u t t h e behav iour , when requi rernents o r

a v a i l a b l e r e s o u r c e s have changed, o r when new o r u n f a m i l i a r

e l e m e n t s have e n t e r e d t h e s i t u a t i o n (Beck & Ajzen, 1 9 9 1 ) . A

d i r e c t p a t h from p e r c e i v e d b e h a v i o u r a l c o n t r o l t o the

behav iour i s t h e r e f o r e e x p e c t e d t o emerge o n l y when t h e r e i s

some agreement between p e r c e p t i o n s o f c o n t r o l and t h e

p e r s o n ' s a c t u a l c o n t r o l o v e r t h e b e h a v i o u r . An i m p o r t a n t

p r e l i m i n a r y s t e p i n c o n c e p t u a l i s i n g the p e r c e i v e d

b e h a v i o u r a l c o n t r o l components o f t h e TPB, f o r a p a r t i c u l a r

c l i n i c a l c o n t e x t , i s t o f i r s t i d e n t i f y t h e s a l i e n t c o n t r o l

f a c t o r s .

Some A d d i t i o n a l C o n s i d e r a t i o n s

C l e a r l y , i n t e n t i o n s c a n change o v e r t i m e ; the l o n g e r

t h e t i m e i n t e r v a l , t h e g r e a t e r t h e l i k e l i h o o d t h a t

u n f o r e s e e n e v e n t s w i l l p roduce changes i n i n t e n t i o n s

( F i s h b e i n & Ajzen, 1980 ; Ajzen, 1985; 1988; 1991 ) . However,

b a r r i n g u n f o r e s e e n e v e n t s , a p e r s o n w i l l u s u a l l y a c t i n

accordance w i t h h i s o r h e r i n t e n t i o n ( A j zen, 1988) . The TPB a l s o r e c o g n i s e s t h a t t h e d e g r e e o f s u c c e s s i n

pe r fo rming t h e b e h a v i o u r depends n o t o n l y on o n e ' s i n t e n t i o n

but also on non-motivational factors such as the

availability of requisite opportunities and resources (e.g.

time, money, skills, cooperation of others) (Ajzen, 1985).

The resources and opportunities available to a person must

to sorne extent dictate the likelihood of performing the

behaviour (called actual control) . The Theory of Planned Behaviour does not include:

traditional attitudes such as attitudes toward objects,

people, and institutions; or variables such as personality

traits, or demographic variables. These are referred to as

"external variables" by the authors (Ajzen & Fishbein,

1980). According to the theory, external variables may

indeed influence behaviour, but only to the extent of

influencing an individual's salient beliefs and/or their

modifiers.

Application of the Theory of Planned Behaviour to the

Present Study

Figure 2 displays how the Theory of Planned Behaviour

was used to guide the formulation of the research hypotheses

and question, the development of the data-collecting

instruments, and the derivation of the data analysis plan.

Thus, according to Figure 2, obstetrical nurses' intentions

to collaborate with midwives in the care of midwifery

clients are postulated as determined by their behavioural

a t t i t u d e , s u b j e c t i v e n o m , and pe rce ived behav iou ra l c o n t r o l

regarding c o l l a b o r a t i o n w i th midwives.

These t h r e e independent v a r i a b l e s cou ld be measured

d i r e c t l y . They cou ld a l s o be d e r i v e d i n d i r e c t l y , u s i n g

measures developed in accordance wi th t h e unde r ly ing

structure of t h e TPB, which p o s t u l a t e s t h a t : a ) o b s t e t r i c a l

n u r s e s ' behav iou ra l a t t i t u d e i s determined by the sum o f t h e

p roduc t s of t h e i r behav iou ra l b e l i e f s and t h e i r e v a l u a t i o n s

of t h e outcornes o f c o l l a b o r a t i o n ; b ) t h e i r s u b j e c t i v e norm

i s deterni ined by t h e surn of t h e p roduc t s of t h e i r normat ive

b e l i e f s and t h e i r mo t iva t i on t o comply wi th t h e i r normat ive

r e f e r e n t s ; and c ) t h e i r pe r ce ived behav iou ra l c o n t r o l i s

determined by t h e surn o f t h e p roduc t s of t h e c o n t r o l b e l i e f s

and t h e i r judgements of t h e power of the c o n t r o l f a c t o r s

under c o n s i d e r a t i o n .

I n a d d i t i o n , s e l e c t e d v a r i a b l e s t h a t a r e " e x t e r n a l " t o

t h e TPB m e r i t e x p l o r a t i o n -- i n p a r t i c u l a r , p e r s o n a l

v a r i a b l e s like age, educa t i on , exper ience , and p a r t i c i p a t i o n

i n t h e p lann ing p roces s . Ex t e rna l v a r i a b l e s such a s these

have been a s s o c i a t e d wi th t h e a b i l i t i e s of some groups o f

h e a l t h p r o f e s s i o n a l s t o c o l l a b o r a t e wi th o t h e r s .

F i n a l l y , a l t hough it would be most d e s i r a b l e t o

under take a study d e s i g n i n which a c t u a l c o l l a b o r a t i v e

behaviour cou ld be examined i n t h e c l i n i c a l s e t t i n g , t h i s

i n v e s t i g a t i o n d i d apply t h e TPB t o t h i s f u l l e s t e x t e n t

possible. When this study was launched, midwifery was just

beginning to be integrated into the hospitals. Thus, many

nurses did not have ample opportunities to develop

collaborative relationships with midwives at the time of

data collection.

Hypotheses and Questions

Research Hypotheses

P r i m a r y Hypo theses

The two primary hypotheses are concerned with testing

the relationships between intention and its determinants, as

postulated by the TPB:

1. Obstetrical nurses employed in selected hospital

settings where midwives have active staff appointments will

report positive intentions to collaborate with rnidwives in

the care of midwifery clients; and

2. Their scores for reported intention will be positively

associated with directly-measured and with indirectly-

derived scores for their behavioural attitude, subjective

norm, and perceived behavioural control.

Secondary Hypothesis

The secondary hypothesis is concerned with the

concurrent validity of the direct and indirect approaches to

measuring the major determinants of intention:

1. Their directly-measured scores for behavioural attitude,

subjective norm, and perceived behavioural control will be

positively correlated with their indirectly-derived scores

for each of these variables.

Research Questions

P r i m a r y Q u e s t i o n .

To what extent do obstetrical nurses' directly- and

indirectly-measured scores for: a) behavioural attitude

toward collaborating with rnidwives; b) subjective norm; and

c) perceived behavioural control account for the variance in

strength of their intention to collaborate with midwives in

the care of midwifery clients?

Secondary Question.

To what extent have obstetrical nurses collaborated

with midwives in the care of rnidwifery clients since the

implementation of midwifery in the hospital setting?

Definitions of Terms

Midwives. Persons who are registered with the Ontario

College of Midwives.

Obatetxicrl Nuzae. A registered nurse, working full-time or

part-time in one of the designated hospital's Birthing Unit

in the province of Ontario, who has completed the three

month probationary period prior to permanent employment.

Dependent Variable

Intantion t o collabotata with nzi&ivar in th* casa of

midwifmzy cliaatr refers to the degree of effort obstetrical

nurses will put forth in a interprofessional relationship

with midwives when a Ndwifery client is hospitalised for a

birth.

In this study, strength of intention was assessed using

a single linear analogue scale to elicit a single global

score (Appendix A ) .

Predictor Variables

Bahavioural A t t i t u d e refers to an obstetrical nurse's

positive or negative evaluation or appraisal of

collaborating with midwives.

In this study, attitude score was assessed by using

direct and indirect measurement strategies.

Direct Measurement of Behavioural Attitude

Two different direct measures were used: a ) responses

were obtained on semantic differential scales and t h e n

summed (Appendix B, part a ) ; and b) a global score was

obtained on a single linear analogue scale (Appendix B, part

b)

Indirect Measurement of Behavioural Attitude

This strategy was based on the TPB's postulated

determinants of behavioural attitude--that is, behavioural

beliefs and outcome evaluations.

A behavioural belief refers to an individual's reported

likelihood or expectation that a given behaviour will lead

to a particular salient outcome. In this study, these

behavioural beliefs were assessed using Likert scales

(Appendix C) . An outcome evaluation refers to the subjective

importance or value that an individual places on a

particular salient outcome. In this study, these

evaluations were assessed using Likert scales (Appendix C).

Then, for each respondent, an attitudinal score was

derived by summing the products obtained when each reported

behavioural belief is multiplied by its associated outcome

evaluation.

(Note that the particular salient outcomes were derived

in a separate research project; see Methods. )

Subjactive N o m refers to an obstetrical nurse's perception

of the social pressures put on him/her to perform or not to

perform the behaviour under consideration (Ajzen, 1988;

In this study, subjective norms were assessed using

direct and indirect measurement strategies.

Direct Measurement of Subjective Norm

One direct measure was used; a response was obtained on

a single linear analogue scale (Appendix D).

Indirect Measurement of Subjective Norm

This strategy was based on the TPB's postulated

determinants of subjective norms--that is, normative beliefs

and motivation to comply.

A normat ive b e l i e f r e f e r s t o an i n d i v i d u a l ' s r e p o r t e d

l i k e l i h o o d o r e x p e c t a t i o n t h a t a s a l i e n t r e f e r e n t ( a n

i n d i v i d u a l o r g roup) t h i n k s t h e person s h o u l d o r s h o u l d n o t

pe r fo rm t h e behav iour ( A j z e n 1985; 1988; 1 9 9 1 ) . I n t h i s

s t u d y , t h e s e normat ive b e l i e f s were assessed u s i n g L i k e r t

s c a l e s (Appendix E ) .

Mot iva t ion t o comply r e f e r s t o t h e s u b j e c t i v e

impor tance o r v a l u e t h a t an i n d i v i d u a l places on behaving i n

a manner t h a t is c o n s i s t e n t w i t h t h e i n d i v i d u a l ' s assumpt ion

a b o u t a s a l i e n t r e f e r e n t . I n t h i s s tudy , these m o t i v a t i o n s

were a s s e s s e d u s i n g L i k e r t s c a l e s (Appendix E ) .

Then, f o r each responden t , a s u b j e c t i v e norm score was

d e r i v e d by surnming t h e p r o d u c t s o b t a i n e d when e a c h r e p o r t e d

normat ive belief i s m u l t i p l i e d by the n u r s e ' s r e p o r t e d

m o t i v a t i o n t o comply w i t h t h a t r e f e r e n t .

Pmrceivmd Bahrviowaf Coatrof r e f e r s t o an o b s t e t r i c a l

n u r s e ' s p e r c e p t i o n o f t h e ease o r d i f f i c u l t y o f pe r fo rming

t h e behav iour of i n t e r e s t .

I n t h i s s t u d y , p e r c e i v e d b e h a v i o u r a l c o n t r o l was

assessed using direct and indirect measurement s t r a t e g i e s .

D i r e c t Measuremen t of Perceived Behavioural Control

One d i r e c t measure was used; a r e sponse w a s o b t a i n e d on

a s i n g l e l i n e a r ana logue scale (Appendix F) .

I n d i r e c t Measurement of Perceived Behavioural Contro l

This strategy was based on the TPB1s postulated

determinants of perceived behavioural control--that is,

control beliefs and perceived power.

A control belief refers to an individual's reported

likelihood or expectation that he or she can control the

presence or absence of a salient factor (resource or

opportunity) that can support or block the behaviour (Ajzen ,

1985; 1988; 1991). These beliefs "may be based on past

experience with the behaviour, and will usually be

influenced by second-hand information about the behaviour,

by experiences of acquaintances and friends, and by other

factors that increase or reduce the p e r c e i v e d difficulty of

performing the behaviour in question" (Ajzen, 1991, p. 196).

In this study, control beliefs were assessed using Likert

scales (Appendix G) . Perceived power refers to the respondent's subjective

judgement of the strength of the factor's ability to support

or block the behaviour (Ajzen, 1991). In this study, these

p e r c e p t i o n s were assessed using Likert scales (Appendix G) . Then, for each respondent, a perceived behavioural

control score was derived by summing the products obtained

when each reported control belief is multiplied by the

nurse's reported perceived power score for that factor.

Exkrnal Variablas. For the purpose of this study,

obstetrical nurses' age, sex, education, obstetrical nursing

experience, experience with midwives during hospital births,

and participation during the process of midwifery

implementation were assessed (Appendix H).

M e t hods

Study Design

A d e s c r i p t i v e c r o s s - s e c t i o n a l des ign was used t o

exp lo re de te rmînants of o b s t e t r i c a l nu r se s ' i n t e n t i o n s t o

c o l l a b o r a t e wi th midwives i n t h e c a r e of midwifery clients.

Data were c o l l e c t e d us ing a s e l f - r e p o r t q u e s t i o n n a i r e .

S e t t i n q

The s tudy was conducted i n t h e labour and d e l i v e r y

u n i t s of t h r e e h o s p i t a l s i n Met ropol i t an Toronto which

provide o b s t e t r i c a l s e r v i c e s mainly f o r low risk p a t i e n t s .

These h o s p i t a l s were chosen because they had gran ted

midwives h o s p i t a l p r i v i l e g e s and had a c t i v e midwifery

p r a c t i c e s . Therefore , o b s t e t r i c a l nurses would have had

some o p p o r t u n i t i e s t o i n t e r a c t wi th midwives i n t h e c a r e of

midwifery c l i e n t s .

Sample

The popu la t ion i n t e r e s t f o r t h e study was

o b s t e t r i c a l nurses i n Ontar io who were working wi th midwives

i n t h e c a r e of midwifery c l i e n t s . The s tudy popu la t ion was

o b s t e t r i c a l nurses i n Ontar io who worked i n one of t h e t h r e e

des igna t ed h o s p i t a l s . A convenience sampie l i m i t s t h e

g e n e r a l i z a b i l i t y of r e s u l t s beyond t h e sample be ing s t u d i e d ,

but it has t h e advantages of f e a s i b i l i t y and lower c o s t

(Polit & Hungler, 1991). One hundred obstetrical nurses

were accessible in the hospitals chosen for this study.

Sampling Criteria

Registered Nurses who worked in one of the three

hospitals chosen for this investigation were eligible to

participate in the study if they were employed as a staff

nurse or charge nursekeam leader, worked full-time or part-

time in one of the labour and delivery units, and had

completed the hospital's three-month probationary period

prior to data collection.

Data Collection Strategy

Following approval of the study by the University of

Toronto's Office of Research Services, a letter requesting

permission to conduct the study was sent to the Ethics

Review Cornmittees at each hospital, to the Nursing Unit

Administrators (NUAvs or Head Nurses) of each labour and

delivery unit at the three hospitals involved, and to other

key persons identified by the hospital. After permission

was granted, individually addressed questionnaires were

delivered by the investigator through each unit's mail

delivery systen at each hospital. Persona1 presentation of

questionnaires to individual respondents has been found to

have a positive effect on the rate of return (Polit &

Hungler, 1991); however, each of the three Nursing Unit

Administrators preferred that the investigator deliver the

questionnaires via each unit's mail distribution system.

The nurses who were not reached by the investigator were

able to receive their package £rom the NUA. A large poster

was hung above the questionnaire return box to remind the

staff to complete their questionnaires. The poster a l s o

instructed staff, who had lost or not received a copy of the

questionnaire, to obtain a copy from the Nursing Unit

Administrator. The standard procedure for distribution of a

questionnaire is to include a cover letter (Appendix 1), an

addressed return envelope (Polit & Hungler, 1991), and an

instruction form (Appendix J), each of which were included.

No names or codes were placed on the questionnaires.

Completion of the questionnaire implied consent.

Respondents refusing to participate in the study were asked

to place a check mark in the appropriate box on the

information sheet. Participants placed their completed

questionnaires in the enclosed addressed envelope and

deposited this in a large sealed labelled box in each labour

and delivery unit, to be retrieved by the investigator.

Instrument Development

Data were collected using a self-administered

questionnaire. To the investiqator's knowledge, there had

not been any instruments developed that could have been used

specifically for this study, therefore, the questionnaire

was developed by the investigator.

At various points in the data-collection questionnaire,

Likert, linear analogue, and semantic differential scales

were used. Each type of scale is briefly described below.

Likert Scales

The Likert scale is an example of a direct estimation

method scale (Streiner & Norman, 1989) and is named after

its developer Renis Likert (1932) . The Likert scale can be

used to elicit a negative or positive viewpoint regarding

the construct under investigation by asking respondents to

indicate the degree to which they agree or disagree with the

opinion expressed in the item statement (Streiner & Norman,

1989). Degrees of agreement/disagreement are indicated with

descriptive terms and rated numerically; the respondent's

score for that item is determined accordingly.

This technique has been applied to many different

constructs in nursing research, especially behavioural

beliefs and attitudes (Ajzen, 1988; Fishbein & Ajzen, 1980;

Streiner & Norman, 1989; Woods & Catanzaro, 1988), and is

advocated as the evaluative scale of choice by Ajzen (1991)

for measuring salient beliefs. Likert scales are easily

understood by subjects and are easy to administer (Streiner

& Norman, 1989) .

L i n e a r Analogue S c a l e s

The linear analogues scale consists of a line, usually

l O O m in length, which is anchored on each end by a positive

and a negative statement. The participant is asked to make

a mark, usually a stroke, through the line at the point

which represents his/her response to the question (Streiner

& Norman, 1989).

Linear analogue scales have been used in to measure

subjective experiences in many settings and have the merit

of simplicity (Polit & Hungler, 1991; Streiner & Norman,

1989). These scales have demonstrated feasibility,

reliability, and validity (Selby, Chapman, Etazadi-Arnoli,

Dalley & Boyd, 1984; Sutherland, Walker, and Till, 1988) for

the assessment of values and symptom severity.

Semantic Differential Scales

Semantic differential scales ask respondents to g ive a

judgement of something along an ordered dimension (Polit and

Hungler, 1991). The respondent is asked to place a check in

the appropriate area that extends from one extreme of the

characteristic or dimension in question to the other extreme

(Streiner & Norman, 1989). Semantic differential scales

consist of bipolar adjectives that specify two opposite ends

of a continuum.

Semantic differential scales are usually assigned

scores from one to seven, and the positively worded

a d j e c t i v e is a s s o c i a t e d w i t h t h e h i g h e r s c o r e . P o l i t a n d

Hungler (1991) n o t e t h a t t h e s e m a n t i c d i f f e r e n t i a l i s

v e r s a t i l e ; however, r e s p o n d e n t s can become c o n f u s e d or b o r e d

w i t h t h e s e q u e s t i o n s and may r e spond by p l a c i n g a l 1 t h e i r

check marks i n t h e m i d d l e - s c a l e p o s i t i o n .

The s e m a n t i c d i f f e r e n t i a l is a t e c h n i q u e t h a t i s o f t e n

u s e d t o measure a t t i t u d e s ( P o l i t & Hungler , 1 9 9 1 ) . T h i s

t y p e o f scale h a s t h e a d v a n t a g e o f b e i n g e a s y t o c o n s t r u c t

and h i g h l y f l e x i b l e ( P o l i t & Hungler , 1991) . P r e l i m i n a r y S t e p s

" S a l i e n t l t b e l i e f s . The t h e o r y o f p lanned b e h a v i o u r

d e a l s w i t h t h e a n t e c e d e n t s o f a t t i t u d e , s u b j e c t i v e norm, and

p e r c e i v e d b e h a v i o u r a l c o n t r o l , which d e t e r m i n e i n t e n t i o n s

a n d a c t i o n s . The t h e o r y p o s t u l a t e s t h a t t h e s e a n t e c e d e n t s

c o n s i s t o f s a l i e n t b e l i e f s r e l e v a n t t o t h e b e h a v i o u r i n

q u e s t i o n . T h r e e k i n d s o f b e l i e f s are d i s t i n g u i s h e d :

b e h a v i o u x a l b e l i e f s which are assumed t o i n f l u e n c e a t t i t u d e ,

n o r m a t i v e b e l i e f s which a r e t h e u n d e r l y i n g d e t e r m i n a n t s of

s u b j e c t i v e norm, and c o n t r o l b e l i e f s which p r o v i d e t h e bas i s

f o r p e r c e i v e d b e h a v i o u r a l c o n t r o l . " S a l i e n t " b e l i e f s are

t h o s e b e l i e f s that are most i m p o r t a n t i n i n f l u e n c i n g t h e

i n d i v i d u a l ' s a t t i t u d e s , s u b j e c t i v e norm and p e r c e i v e d

b e h a v i o u r a l c o n t r o l . Thus, i d e n t i f y i n g t h e ' % a l i e n t W

beliefs f o r each u n d e r l y i n g d e t e r m i n a n t is a n important s t e p

towards drawing i n f e r e n c e s about

i n t e n t i o n .

A j zen ( 1 9 9 1 ) advocated t h a t

consequent behavioura l

s t a t e m e n t s about s a l i e n t

b e l i e f s f i r s t must be e l i c i t e d from t h e respondents

themselves, o r i n p i l o t work from a sample of respondents

t h a t i s r e p r e s e n t a t i v e o f t h e r e s e a r c h popu la t i on .

Boyle and Hickey (1993) c o l l e c t e d s t a t e m e n t s about the

s a l i e n t b e l i e f s r ega rd ing working wi th midwives from a

sample of o b s t e t r i c a l nu r se s from a rne t ropol i t an Toronto

t e r t i a r y c a r e c e n t r e ( n = l l ) . These d a t a were c o l l e c t e d by

Boyle and Hickey ( 1 9 9 3 ) u s ing open ended q u e s t i o n s .

The raw d a t a were ana lysed by t h i s i n v e s t i g a t o r and R .

Hickey accord ing t o t h e fo l l owing s t e p s . A c o n t e n t a n a l y s i s

of t h e behavioura l b e l i e f s t h a t had been e l i c i t e d about

working wi th midwives was performed. The responses were

o rgan i sed s o t h a t b e l i e f s t h a t r e f e r r e d t o s i r n i l a r outcomes

were grouped t o g e t h e r , t hen t h e frequency counts f o r each of

t h e behaviouxal b e l i e f s were determined. S ince t h i s

i n v e s t i g a t o r b e l i e v e d that t h e s e raw b e l i e f s t a t emen t s would

be r e p r e s e n t a t i v e o f t h e s a l i e n t b e l i e f s of o b s t e t r i c a l

nu r se s i n t h e s t u d y h o s p i t a l s , t h e s e were used t o develop

t h e d a t a - c o l l e c t i n g i t ems i n t h e behav iou ra l b e l i e f s s e c t i o n

( q u e s t i o n s 2a, sa, 6a, 10a, Ila and 12a) (Appendix C ) , c o n t r o l b e l i e f s s e c t i o n ( q u e s t i o n 8a)(Appendix G ) , and

attitude section (question 6)(Appendix B) of the

questionnaire used in the study reported here.

Note that, according to Ajzen and Fishbein (l98O), the

set of beliefs chosen to represent the behavioural beliefs

in a population must account for 75% of al1 beliefs

elicited. However, since Boyle and Hickey's sample size was

very small (n=ll), al1 beliefs (100%) related to

collaboration with midwives were taken into consideration by

this investigator and included in the questionnaire.

Blais et al. (1991) conducted a survey to explore the

attitudes of obstetrical nurses toward midwifery

implementation in Quebec, and this investigator considered

some of their survey topics to be relevant to the current

study. Blais et al. (1991) developed their questionnaire on

the basis of 30 study interviews with health care personnel

from the three designated study groups. This investigator

reviewed the question topics and concluded that 6 topics

were relevant to the current study. These formed the basis

for one salient behavioural belief item (question 5a)

(Appendix C) , and five salient control belief items (questions 3a, 5a, 6a, 8a and 9a) (Appendix G) in the

questionnaire used here.

Outcome Evaluations, Motivation to Comply, and

Perceived Control

As

belief

described in the TPB, the strength of each salient

is combined in a multiplicative fashion with its

modifier ( L e . behavioural belief x outcome evaluation;

subjective norm x motivation to comply; and control belief x

perceived control). Questions representing these modifiers

were developed by extrapolation from the belief questions as

described by Ajzen (1988; 1991).

Transformation of Indirectlv-Measured Independent Variables -- - -

The sum-of-products method of computation to determine

scores has been associated with methodological difficulties

(Lauver & Knapp, 1993). Lauver and Knapp (1993) noted that

such sum-of-products variables often have unusual ranges and

rather unusual distributions. The continuum of scores above

the theoretical neutral point to the maximum score is much

larger than the continuum of scores below the theoretical

neutral point. This oddity was apparent in this study's

data for the indirect-measurements of the hdependent

variables. Similarly, Evans (1991) argued against using

multiplicative composites (sum-of-products variables) in

simple regression or bivariate correlational analyses.

To correct for this inflation, the raw summed scores

were transformed. Each of the raw summed scores was divided

by the scale's total score minus the number of questions per

scale, then multiplied by 100.

Draft Revision

After the identification of salient beliefs from the

open ended questions by this investigator and R. Hickey, and

the consideration of the topics from the Blais et al. (1991)

study, the questionnaire for the study was drafted (see

Appendix A-H and K). After the questionnaire was drafted,

f i v e obstetrical nurses were given a copy of the draft to

identify any gaps in the content regarding salient beliefs,

and to check face validity.

Data Collection Questionnaire

There were ten sections to the questionnaire (see

Appendix A-H and K). Both direct and indirect assessments

were made of the independent variables in the Theory of

Planned Behaviour. This was done to test the entire Theory

of Planned Behaviour as well as to provide insight into the

salient beliefs of each of the theoretical constructs.

Section 1: Measurinq Previous Collaborative Practice

A linear analogue scale was used to measure

participants' previous collaborative efforts while c a r i n g

for midwifery clients since the implementation of midwifery

in the participants ' hospitals (Young, Lieman, Powell-Cope,

Kasprzyk, & Benoliel, 1991) (see Appendix K) . Each

participant was presented with a IOOmm line, The left end

of the scale (O), labelled "no collaborative effortw,

represented the least amount of collaborative effort

previously provided. The right end of the scale (100),

labelled "full collaborative effort", represented the most

amount of collaborative effort previously provided.

Subjects were asked to place a mark through or across the

scale at the point most closely representing the amount of

previous collaborative effort engaged in with midwives while

caring for a midwifery client.

Section II: The Indirect Measurement of Behavioural Attitude

An indirect measurement of behavioural attitude was

obtained based on the TPB's postulated determinants of

behavioural attitude -- that is, behavioural beliefs and outcome evaluations. Likert scales were used to measure

these behavioural beliefs and outcome evaluations, as

recommended by Ajzen (1985; 1988; 1991).

The questions assessing behavioural beliefs included

statements that related to obstetrical nurses' expectations

regarding the likelihood that collaboration with midwives

would produce a particular outcorne. The strength of each

salient belief (part "a" of each of these questions) is

linked to the outcome evaluation of the beliefls attribute

as recommended by A j zen (1991) (part 'b" of al1 questions) . Behavioural belief questions 2a, Sa, 6a, IOa, Ila, and 12a

were developed from beliefs staternents obtained by Boyle and

Hickey (1993). Behavioural belief questions la, 3a, 4a, 7a,

8a, and 9a were developed £rom topics seen as relevant £rom

the investigator's persona1 experience (Appendix C ) .

On positively phrased belief statements, answers of

"very strongly agree ' were scored a s 7, and answers of "very

strongly disagree" were scored as 1. However, on negatively

phrased questions, "very strongly disagree" was scored as 7,

and "very strongly agreel' was scored as 1.

The questions assessing outcome evaluations included

staternents that related to the nurses' judgement about the

relative d e s i r a b i l i t y h n d e s i r a b i l i t y of each possible

outcome. This evaluation of each outcorne was measured by a

seven point Likert scale labelled "not important to me" on

one side and "very important to me" on the other.

Positively phrased questions were scored 7 for "very

important to me" and 1 for "not important to me". Scoring

was reversed for negatively phrased statements.

Ajzen (1991) recomrnended that these two scores be

multiplied and that the products be summed to result in a

total score for behavioural attitude. However, the data

were then transfo~med as previously described. Thus the

transformed total score, representing the indirect measure

of behavioural attitude, could range from I to 100.

Section III: The Direct Measurement of Behavioural Attitude

Two direct measures of behavioural attitude were used:

a) responses were obtained on semantic differential scales

then surnmed; and b) a global score was obtained on a single

linear analogue scale.

a) Seman tic Differential Scales

Ajzen (1991) suggested that behavioural attitude be

measured by semantic differential scales (A jzen , 1991; Young

et a l . , 1991). This direct measure of behavioural attitude

was calculated by using a set of seven, seven-point semantic

differential scales that asked about a participant's

evaluation of collaboration with midwives (see Appendix B).

The sixth scale was developed from the Boyle and Hickey

(1993) data, and the others were developed by the

investigator according to Ajzen (1991) and Ajzen and Madden

(1986). In each of the seven scales, the most positive

response was scored 7, and the most negative response was

scored 1. The sum of these responses served as a direct

measure of behavioural attitude; the total score could range

from 7 to 49.

b) Global L i n e a r Analogue Scale

A single linear analogue scale was also used as a

direct measure of behavioural attitude toward collaborating

with midwives. Participants were presented with a lOOmm

linear analogue scale (see Appendix B). The left end of t h e

scale (O), labelled "absolutely unimportant", represented

the least favourable attitude toward collaborating with

midwives. The right end of the scale (100), labelled

"absolutely essential", represented the rnost favourable

attitude toward collaborating with midwives. Subjects were

asked to place a mark through or across the scale at the

point most closely representing the strength of their

attitude toward collaborating with midwives in the care of

midwifery clients. The participant's score was calculated

by measuring, in millimeters, from the zero-valued end.

Section IV: The Indirect Measurement of Subjective Norm

An indirect measurement of subjective norm was obtained

based on the TPBvs postulated deterrninants--that is,

normative beliefs and motivation to comply. As recommended

by A j z e n (1991), 1) normative beliefs were measured by seven

point Likert scales, 2) motivation to comply was rneasured Dy

seven point Likert scales, 3) the strength of each normative

belief was multiplied by the person's motivation to comply,

and 4) that the products were sumrned to obtain a total score

(Appendix E). The data were t h e n transformed as previously

described.

The seven-point Likert scales measuring normative

beliefs and motivation to comply were presented with "very

strongly disagree" on one end and "very strongly agree" on

the other. A response of "very strongly agree' was scored

as seven. The scores £rom belief items were multiplied by

the motivations to comply. The transformed score served as

an indirect measure of subjective nom; the total score

could range from 1 to 100.

Section V: The Direct Measurement of Subjective Nom

A j zen (1991) recommended obtaining a direct measure of

subjective norm by asking respondents to rate the extent to

which "important others" would approve or disapprove of

their performing the given behaviour. A single 1OOrnm linear

analogue scale was used for this direct measure of

subjective norm (Appendix D). The scale was presented with

"disapprove" on the left end, representing the least amount

(O) of approval; "approve" on the right end of the scale,

representing the most amount of perceived approval (100)

from important others to collaborate with midwives.

Participants were asked to place a mark on or through the

line which best represented the extent to which they

perceived that "important others" approved or disapproved of

their collaborating with midwives in the care of midwifery

clients.

Section VI: The Indirect Measure of Perceived Behavioural

Control

An indirect measure was obtained according to the TPB's

postulated determinants of perceived behavioural control-

that is, control beliefs and perceived power. As

recommended by Ajzen (19911, c o n t r o l b e l i e f s were measured

by seven p o i n t L i k e r t s c a l e s . Each c o n t r o l b e l i e f was

measured by a seven p o i n t L i k e r t scale l a b e l l e d "very

s t r o n g l y d i s a g r e e " on t h e l e f t s i d e and "very s t r o n g l y

agree ' on t h e r i g h t s i d e . P o s i t i v e l y worded q u e s t i o n s were

s co red as 7 f o r "very s t r o n g l y agree. Negat ive ly worded

q u e s t i o n s were s c o r e d as 7 f o r "very s t r o n g l y d i s a g r e e " .

Perce ived power was measured on seven p o i n t L i k e r t s c a l e s

l a b e l l e d ' ' l i k e l y " on t h e l e f t s i d e and l 'unlikelyl ' on t h e

r i g h t s i d e . P o s i t i v e l y worded q u e s t i o n s were s c o r e d a s 7

f o r " l i k e l y " . Nega t i ve ly worded q u e s t i o n s were s c o r e d a s 1

f o r " u n l i k e l y " . Each c o n t r o l be l i e f was m u l t i p l i e d by t h e

pe r ce ived power s c o r e , and t h e p roduc t s were summed. The

d a t a were t hen t rans formed a s p r e v i o u s l y d e s c r i b e d , y i e l d i n g

a n i n d i r e c t measure of pe r ce ived behav iou ra l c o n t r o l ; t h e

t r ans formed s c o r e cou ld range from 1 t o 1 0 0 (Appendix G).

Con t ro l b e l i e f q u e s t i o n 8a was developed from t h e d a t a

from Boyle and Hickey ( l 9 9 3 ) , a s w e l l a s from a t o p i c from

t h e B l a i s e t a l , (1992) q u e s t i o n n a i r e . Topics for c o n t r o l

b e l i e f q u e s t i o n s 3a, 5a, 6a, and 9a (Appendix G ) were

developed from t h e B l a i s e t al. (1992) q u e s t i o n n a i r e and

were modi f ied t o be r e l e v a n t f o r t h e c u r r e n t s t u d y . The

remaining questions Sa, 4a, 7a, and 10a were deve loped by

t h e i n v e s t i g a t o r (Appendix G) . Questions f o r p e r c e i v e d

power were developed by t h e i n v e s t i g a t o r as e x t e n s i o n s of

the control belief topics as described by Ajzen and Madden

Section V I : The Direct Measurement of Perceived Behavioural

Control

The direct measure of perceived behavioural control was

obtained, as recommended by Aj zen (1991) (see Appendix F) . A single lOOmm linear analogue scale, labelled wdifficult"

(O) at the left end and "easy" (100) at the right end, was

presented; respondents were asked to place a mark through

the line which best represented their perceived ease or

difficulty in collaborating with midwives.

Section VIII: Measurement of Intention to Collaborate

A single linear analogue scale was used to measure

participants' degree of intention to collaborate with

midwives in the care of midwifery clients (see Appendix A ) .

Participants were presented with a lOOm linear analogue

scale. The left end of the scale (O), labelled "not at

all", represented the least intent to collaborate with

midwives. The right end of the scale (LOO), labelled

"fully", represented the participant's greatest intent to

collaborate with midwives. Subjects were asked to place a

mark through or across the scale at the point most closely

representing the strength of their intention to collaborate

with midwives in the care of midwifery clients.

Section IX: Persona1 Data Form

Information was also collected on age, sex, education

levels, previous obstetrical nursing experience, previous

experience practising midwifery, experience working with

rnidwives in the care of midwifezy clients, participation in

integration of midwifery, and opportunity to practice with

midwives (see Appendix H).

Assessinq Content Validity

Content validity was established for the entire

questionnaire by three methods. 1) Salient beliefs of

obstetrical nurses were obtained from the Boyle and Hickey

(1993) data as described earlier (page 4 3 ) , and these were

used to prepare a draft form of the questionnaire. 2) Five

obstetrical nurses from another tertiary care obstetrical

unit were interviewed by the investigator and were asked

open ended questions to elicit salient beliefs. No

additional belief items were identified from these

interviews. These five nurses were then given the

questionnaire to review. These nurses were asked by the

investigator to verify the fact that the questionnaire

addressed their salient beliefs about collaborating with

midwives. These nurses al1 agreed that the questionnaire

did contain items which addressed their salient beliefs. 3)

Finally, four experts in the field of obstetrics (3 clinical

nurse specialists in labour and delivery, and 1 clinical

teacher in labour and delivery) were asked to review the

questions and their suggestions were also included in the

questionnaire.

Assumptions

The following assumptions are central to this study:

1. Obstetrical nurses employed in selected hospital labour

and delivery units have been working with midwives in the

care of midwifery clients.

2. Respondents have behavioural attitudes, subjective

norms, perceived behavioural control, and intentions to

collaborate with midwives in the care of midwifery clients

in the hospital setting.

3. Respondents will report these behavioural attitudes,

subjective norms, perceived behavioural control, and

intentions to the best of their ability.

4. Salient behavioural, normative, and control beliefs

(obtained from the questionnaire distributed by Boyle &

Hickey (1993) to obstetrical nurses in a tertiary care

centre in Metropolitan Toronto) are representative of the

salient behavioural, normative, and control beliefs of

obstetrical nurses in the study hospitals.

5. The behavioural belief and control belief topics

identified by this investigator (using the responses

collected by Blais et al. (1994)) are representative of the

behavioural beliefs and control beliefs held by the

obstetrical nurses in the study hospitals.

6. The transformation done on al1 the indirectly-measured

independent variables produced a data set which accurately

reflected the opinions of the respondents.

Protection of Participants' Riqhts

Informed Consent

The subjects were given an information sheet with the

questionnaire (see Appendix 1) which described the details

about participating in the study. This cover letter

reassured the participants that there would be no

consequences from their decision to participate or to not

participate in the study. Subjects were informed in this

letter that they were able to refuse to participate at any

tirne. Informed consent was defined in the letter as

completing and returning the questionnaire.

Confidentiality

The subjects were assured of confidentiality in their

responses to the questionnaire. Participants were informed

in the cover letter (see Appendix 1) that there were no

identifying marks on the questionnaire to link any

questionnaire to any individual. Subjects were instructed

not to add any identifying marks to the questionnaire.

Participants were asked to complete the questionnaire in a

location which was private and at a time which was

convenient to them. Each participant was asked to seal her

completed questionnaire in the envelope which was provided

and to deposit the questionnaire in the sealed box placed in

each labour and delivery unit. Completed questionnaires

were kept in the investigator's home, in a locked filing

cabinet.

Risks and Benefits

Subjects participating in the study were not exposed to

any direct risks or benefits. However, they were informed

that the information obtained from the study may assist

hospital administration with integration strategies for the

rnidwifery profession (see Appendix Il, as well as providing

a basis for further research in this area.

Data Analysis

Data for this study were organised and analysed using

the Statistical Product and Service Solutions (SPSS) for

Windows (1995) statistical software package.

Descriptive Statistics

Research Hypotheses and Questions

Pr imary Research Hypotheses

1. The dependent variable, intention, was measured with a

single linear analogue scale and was treated as interval

level data ( A j z e n & Fishbein, 1980; Nunnally, 1978; and

Streiner & Norman, 1989). This variable was described in

terms of frequency, mean, and standard deviation.

2. The main variables of the mode1 [a) behavioural attitude

(direct and indirect measures) , b) subjective norm (direct

and indirect measures), and c) perceived behavioural control

(direct and indirect measures)] were treated as interval

level data (Ajzen & Fishbein, 1980; Nunnally, 1978; and

Streiner & Norman, 1989) . These variables were described

terms of frequencies, means, and standard deviations. A

Kolomogorov-Smirnov Goodness of Fit Test was performed on

each of the variable distributions to determine if it was

normal data distribution.

The data distributions for the indirect measures of

behavioural attitude, subjective norm, and perceived

behavioural control (transformed data only) were described

using frequencies, means, and standard deviations. These

variables were also described after being transformed to

normalise score distributions. Only the transformed data

are reported in the results section and are used for al1

statistical analyses.

The Pearson product-moment correlation coefficient was

used to assess the relationship between scores for intention

and (both directly-measured and indirectly-derived) scores

for behavioural attitude, subjective norm, and perceived

behavioural control.

Secondary Hypothesis

The Pearson product-moment correlation coefficient was

used to assess the relationship between the directly-

measuxed scores and indirectly-derived scores for each of

the following: behavioural attitude, subjective nom, and

perceived behavioural control.

Research Questions

Primary Question

To assess the contribution of the scores for directly-

measured behavioural attitude and subjective norm to

intention to collaborate, a forced entry linear regression

was performed as per Ajzen (1988). Directly-measured scores

for behavioural attitude were entered as the first step, and

the directly-measured scores for subjective norm as the

second step.

To assess the contribution of the indirectly-measured

independent variables to intention to collaborate, a forced

entry linear regression was performed using the transformed

scores. The transformed indirectly-measured scores for

behavioural attitude were entered as the first step, and the

transformed indirectly-measured scores for subjective norm

as the second step.

Secondary Question

Descriptive statistics (mean, mode, and standard

deviation) were used to describe obstetrical nurses1

retrospective collaborative efforts with midwives while

caring for midwifery clients.

Demoqraphic Data

Demographic data were also described in terrns of

frequencies, means, and standard deviationç.

Limitations of the Study

Limitations of this study include:

1. Lack of random selection of the sample precludes

generalizations beyond the sample used for this

investigation.

2. The sample was self-selected, which may have introduced

potential sample bias. It is possible that many and/or only

the nurses with very strong attitudes completed and returned

their questionnaires.

3. A convenience sample of Toronto hospitals was

used. Thus, the sample may not be representative of the

larger population which includes tertiary care centres.

This limits generalizability of results beyond the sample.

4. The sample size was very small (N=45).

5. The questionnaire was not tested for reliability and

construct validity.

6. Actual collaborative behaviour was not investigated in

the current study because, at the time of data collection,

some nurses may not have had adequate opportunity to form

collaborative relationships with midwives.

7. Collaborative behaviour is a concept that requires the

p a r t i c i p a t i o n of both obstetrical nurses and midwives. This

study only explored the intentions of obstetrical nurses.

CEAPTER I V

R e s u l t s

C h a r a c t e r i s t i c s of t h e P a r t i c i p a n t s

Nine ty -s ix q u e s t i o n n a i r e s were d e l i v e r e d by t h e method

chosen b y each Nurs ing Admin i s t r a t o r , a n d 4 9 q u e s t i o n n a i r e s

were r e t u r n e d . Fo r ty - f i ve female o b s t e t r i c a l n u r s e s

completed t h e q u e s t i o n n a i r e and f o u r n u r s e s s u b m i t t e d

r e f u s a l s t o p a r t i c i p a t e , t h e r e f o r e t h e r e sponse r a t e was

46 .9 p e r c e n t .

The c h a r a c t e r i s t i c s of t h e p a r t i c i p a n t s a r e summarised

i n Tab le 1. P a r t i c i p a n t s ranged from 22 t o 54 years of age ,

w i th a mean age of 3 7 . 9 years ( s . d . = 9 . 3 ) . The modal age o f

t h e sample (35.5%) was 30 - 39 yea r s .

The m a j o r i t y o f p a r t i c i p a n t s r e p o r t e d having diploma-

l e v e l educa t i on ( 6 2 . 2 % ) . The remainder o f t h e sample

r e p o r t e d a c h i e v i n g o r a c q u i r i n g a Bachelor o f Sc i ence Degree

i n Nursing ( 1 7 . 8 % ) , o r a n u r s i n g diploma a s w e l l a s a non-

n u r s i n g Bacca l au rea t e deg ree ( 4 . 4 % ) . P a r t i c i p a n t s r e p o r t e d y e a r s of o b s t e t r i c a l n u r s i n g

p r a c t i c e t h a t ranged from one t o 30 y e a r s ( M - = 11.5, s . d .=

8 . 0 ) . The modal r e sponse t o work expe r i ence (28 .8%) was s i x

t o t e n y e a r s of o b s t e t r i c a l nu r s ing expe r i ence , and t h e

m a j o r i t y o f n u r s e s were employed f u l l tirne (68 .8%) . The

m a j o r i t y of n u r s e s (32) r e p o r t e d n o t having p a r t i c i p a t e d i n

t h e p l a n n i n g process f o r the i n t r o d u c t i o n o f midwifery

w i t h i n t h e i r h o s p i t a l s .

Twelve o b s t e t r i c a l n u r s e s ( 2 9 . 3 % ) r e p o r t e d having

midwifery e x p e r i e n c e i n a n o t h e r c o u n t r y rang ing £rom one t o

9 yea r s ( M - = 1.2, s.d.= 2 . 5 ) .

Table 1. Chazactmristica o f Participants (N=45)

~ C h a r a c t e r i s t i c

AGE :

YEARS OBSTETRICAL NURSING EXPERIENCE:

YEARS MIDWIFERY EXPERIENCE

EDUCATION Diplorna

BScN

B a c c a l a u r e a t e

PARTICIPATION IN MIDWIFERY INTEGRATION PROCESS Yes

1 EMPLOYMENT STATUS Fu11 T i m e Employment

I P a r t T i rne Employment

C a s u a l Employment

Research Hypotheses

1. Obatetrical nuxaaa rmployed i n aelectad hoapital

aettinga wherm midwivaa hava active s ta f f appointanenta w i l l

xepott poaitive intention. to collabo~ata with midrivai i n

the caze o f midwifery clients.

This hypothesis was addressed by examining the

distribution, mean, and standard deviation of the scores

obtained on the linear analogue scale (LAS) assessing

intention (see Table 2) . The reported scores ranged from one to 100 (n=38). The

Kolmogorov-Smirnov Goodness of Fit Test indicated a normal

data distribution (K-S Z = - 6 5 3 , p = .787). The mean score

was 61.6 (s.d. = 30.3) and this implied that, as a group,

the nurses held overall positive intentions toward

collaborating with midwives. (It should be noted that over

one fifth of the sample (22.2%) reported scores which

indicated highly positive intentions (90-100) toward

collaborating with midwives in the care of midwifery

clients.) Thus, the positive mean on the LAS supported

Hypothesis 1.

Tabla 2. Intention t o Collaborate: Diattibution of LAS

Scotma ( F I S ; n=38; 7 misaing 8cora8)(M = 61 .5 , 8.d. = 30.3)

60-69 70-79 80-89

90-100

Unreported

1 Total

Pmrcrnt

2 . Scotes f o t rmported intention ri11 be poiitively

asaociated w i t h àirectly-moaaurod and w i t h indirmctly-

detived icorea for behavioural attitude, subjectiva nom,

and pmrceivrd behavioutal conttol.

This hypothesis was addressed by: a) exarnining the

frequency distributions, means, and standard deviations of

the scores from the direct and indirect measurernent of

behavioural attitude, subjective norm, and perceived

behavioural control; and b) computing correlations between

intention scores and the directly-measured and indirectly-

derived scores for behavioural attitude, subjective norm,

and perceived behavioural control, respectively.

Measurement of Behavioural Attitude

Direct Measurement of Behavioural Attitude . - . . . .

a ) S e m a n t i c Differential Scales

There were 7 bipolar semantic differential scales

related to attitude toward collaborating with midwives. The

forty summative total semantic differential scores ranged

from 7 to 49 (M = 27.3, s.d.= 9.7); there were 5 missing

scores. The mean represents a fairly neutral score for

behavioural attitude by this sample since the neutral-point

of the scale was 28. The Kolmogorov-Smirnov Goodness of Fit

Test dernonstrated a normal data distribution (K-S Z = .492,

p = .969). See Appendix L for the results of the individual

semantic differential questions.

b) Global Linear Analogue Sca1e

On the Global Attitude Linear Analogue Scale, the 40

scores ranged from O to 100 (M - = 43.4, s.d. = 33.1) (see

Table 3 ) . The mean of this scale represents a slightly

negative score for behavioural attitude. Note that 11

(27.5%) participants provided very negative scores for

overall attitude (scores < 9 ) .

Scores from participants with completed data on both

the linear analogue and semantic differential scales were

exarnined by computing correlations between these two scores.

The Behavioural Attitude Linear Analogue and the scores on

the Semantic Differential Scales were rnoderately correlated

Table 3. Direct Merauranont o f Bahaviourrl A t t i t u à e :

Diattibution o f Global W Score8 (N=45; n=40; 5 incomiplete

20 - 29

50 - 5 9 60 - 69

80 - 89 90 - 100

LAS Scores

Percent

Indirect Measurement of Behavioural Attitude

The transforrned scores for the indirect measurement of

behavioural attitude were computed as described in the

Methods chapter (see page 48). These indirectly-derived

scores could range from 1 to 100; the observed scores ranged

from 13.4 to 71.5 (see Table 4 ) The mean was 36.6 (s.d. =

15.95, n = 2 7 ) . The observed mean was below the theoretical

neutral point of the scale, which is 50. Thus, the

indirectly-measured mean score represents a somewhat

negat ive behavioural attitude in this sample. The

Kolmogorov-Smirnov Goodness of Fit Test demonstrated a

normal t e s t distribution (K-S Z = .900, p = - 3 9 3 ) . Separate

examir.ation of each of the 12 beliefs and outcome

evaluations is reported in Appendix M.

Table 4. Indirect BWrmarmmont of Behaviouzrl Attitude (N=4S;

n=27; 18 miasing scores)

Dia tribution

Scores F req I l

Measurement of Subjective Norm

Direct Measurement of Subjective Norm

Twenty-nine complete LAS scores were obtained (16

incomplete scales), and ranged from 4 to 94 (M - = 53.7, s.d.= / C L .

21.9) (see Table 5). T h i s mean represents a slightly

positive subjective n o m held by this sample. The

Kolmogorov-Smirnov Goodness of Fit Test demonstrated a

normal data distribution (K-S Z = -568 , p = .904).

Table 5. Direct Meamarement of Subjective Norm: Distribution

of WIS Scoras (N=45 ; n=29; 16 incomplete scalea) (M = 53.7,

I Score

Incomplete 1 1 Total

Indirect Measurement of Subjective Norm

The transformed data for the indirect measurement of

subjective norm were computed as described in the Methods

chapter. Theoretically, these indirectly-measured scores

could range from 1 to 100; the observed raw scores ranged

fromto 17.5 to 47.9, with a mean of 28.9 (s.d. = 6.0, n =

38) (see Table 6). The observed mean was below the

theoretical neutral point of the scale, which is 50. Thus,

the mean score implies that this sample of obstetrical

nurses rnay not have been very concerned that specific

individuals or groups think that they should collaborate

with midwives and/or may not have been likely to comply with

these significant others. Note that al1 scores f e l l below

the theoretical neutral point on the scale. The Kolmogorov-

Smirnov Goodness of Fit Test demonstrated a normal data

distribution (K-S Z = S 2 8 , p = .943). A separate

examination of normative belief scores and motivation to

comply scores is described in Appendix N.

T a b l e 6 . Inâkoct Mmrsurmmant of Subjective Norm (N=45;

Measurement of Perceived Behavioural Control

Direct Measurement of Perceived Behavioural Control

The 33 reported scores ranged from 1 to 94 (12

unreported scores) with an overall mean of 40.6 and a

standard deviation of 28.1 (see Table 7 ) . This mean score

implies a somewhat negative evaluation of perceived

behavioural control by this sample. The Kolmogorov-Smirnov

Goodness of Fit Test demonstrated a normal data distribution

(K-S Z = .858, p = . 4 5 4 ) .

Table 7 . Diract lhr8utumrnt o f Pm~cmivmd Bmhrviourrl

Control: Distribution of LAS Scorm8 (N=45; n=33; 12

inaoinplete scales) (Y = 40.6, a . . = 28.1)

Unreported

Total

Indirect Measurement of Perceived Behavioural Control

The txansformed data for the indirect measurement of

perceived behavioural control were computed as described in

the Methods chapter. Theoretically, these indirectly-

measured scores could range from 1 to 100; the observed r a w

scores ranged from 9 to 60 (n = 32, 13 unreported scores),

with a mean of 36.2 (soda = 12.3) (Table 8 ) The observed

mean was below the theoretical neutral point of the scale,

which is 50. Thus, the scores imply that this sample of

obstetrical nurses had slightly negative control beliefs

toward collaborating with midwives. The Kolmogorov-Smirnov

Goodness of Fit Test demonstrated a normal data distribution

(K-S Z = .481, p = 3 7 5 ) . A separate examination of control

beliefs scores and the perceived power scores is described

in Appendix O.

Table 8 . Indirect Measurement o f Perceived Behavioural

Tzansformad Data

Distzibution

Scores Freq Mean s . de

Correlations

Direc tly-Measured Independent V a r i a b l e s

Significant Pearson Product-Moment coefficients

indicated that the scores for behavioural attitude (as

directly measured on the sernantic differential scale) (r

=.67) and for the direct measurernent of perceived

b e h a v i o u r a l control (r = 6 were related to the scores for

intention to collaborate (p<.001). These correlation

coefficients support Hypothesis 2 (see Table 9). On the

other hand directly-measured scores for subjective norm were

not significantly correlated with the scores for intention

to collaborate (r = 0 . 4 2 , p=. 05, ns) , which doesn' t support

the Hypothesis 2.

T a b l e 9. Corxalrtion Coafficimnts of Scoraa for D i r m c t l y -

maaurad In&pan&nt Variablœs and Intention

Cozrelrtion With Intention

Direct Measurement of .67** Behavioural Attitude - Semantic Differentials n=3 5

Direct Measurernent of .72** Behavioural Attitude - Global LAS n=38

Direct Measurement of 1 .42 Subjective Nom

Direct Measurement of 1 . 65* * Perceived Behavioural Control

2-tailed significance: * p<.01 * * p<.001

Indirectly-Measured Independent V a r i a b l e s

Significant Pearson Product-Moment coefficients

indicated that the indirectly-derived scores for behavioural

attitude (r = - 6 4 , p<.01) and perceived behavioural control

(r = -79, p<.001) were related to the scores of intention

to collaborate (Table IO). These correlation coefficients

support Hypothesis 2. On the other hand, indirectly-derived

scores for subjective n o m were not significantly related to

intention scores (r = -19, ns), which does n o t support

Hypothesis 2.

80

Table 10. Corrolrtion Coefficients of Scoras for Indirectly-

Measutad Indopondent Variables and Intention

Indirect Measurement of Behavioural Attitudes

Indirect Measurement of Sub j ective Norm

Indirect Measurement of Perceived Behavioural Control

Corralrtion With Intention

2-tailed significance: * pC.01 ** p<.001

Secondarv Hv~othesis - -

1. This surpl0 of obstatrical nurama' diroctly-uaaurad

mores for bahaoioural attitude, subjective nom, and

patceived behavioural conttol will ba positivoly correlatod

with thait indiroctly-dorivad acores fot mach of thesr

vaciablea.

The relationships between directly and indirectly-

measured independent variables were explored using Pearson

Product-Moment correlation coefficients and are reported in

Table 11. The indirectly-measured scores for behavioural

attitude were significantly correlated with the directly-

measured semantic differential scores (r = -55, p<.01) and

the Global LAS scores (r = .87, p<.001)(Table 11). These

correlation coefficients support the secondary hypothesis.

Similarly, the indirectly-measured scores for perceived

behavioural control were significantly correlated with the

directly-measured scores (r = .76, p<.001). This

correlation coefficient also supports the secondary

hypothesis (see Table 11). On the other hand, the scores

for the indirect measurement of subjective norm were not

significantly correlated with the directly-measured

subjective norm scores (r = .29, ns) (Table Il), which does

not support the secondary hypothesis.

Tabla 11. Cor~olrtionrl Matrix of Diroctly- and Xndirectly-

Maaaurmd Scoraa for Bohaviourrl Attituh, Subjmctive No-,

and Pmrcmivad Behavioural Control

Direct Measure of B e h a v i o u r a l Attitude - Semantic Differentials

Direct Measure of S u b j e c t i v e Norm

Direct Measure of P e r c e i v e d Behav C o n t r o l

Direct Measure of Beh. Attitude LAS

2 - t a i l e d significance: * pC.01 * * pc.001

Primary Research Q u e s t i o n

1. To what axtont do obatotrical nursmal diroctly- and

indirectly-maraurmd acorea for: a) bohavioural attitude

toward collaboration with midwivea; b) subjactive nom; and

c) patceivmd brhattiourrl control rccount for the vuiance in

scoraa for thmir intmntion to collaborate with midwivea in

Direct-Measurement of Independent Variables

The directly-measured scores for behavioural attitude

contributed significantly (F (1,251 = 23 91, p <. 001)

towards explaining 49% of the variance in the intention

scores (Table 12). The directly-measured scores for

subjective norm contributed an additional 3% (p=.22, ns) of

the variance in intention scores, and the two variables

together accounted for 52% of the variance (F (2,241 =

13.06, p<.001). The directly-measured scores for perceived

behavioural control were not entered in the regression

analysis because they were highly correlated with the

directly-measured scores for behavioural attitude (r = - 7 3 ,

p<.001) and thus were considered collinear.

In summary, it appears that much of the variance in the

intention to collaborate with midwives was due to

behavioural attitude toward collaborating with midwives in

the care of rnidwifery clients. Subjective norm made a small

contribution to the variance of intention. This is not

surprising since subjective norm was not significantly

correlated with intention (see Table 12) .

Table 12. ~ l t i p l m Raqreasion Equations: Conttibutions of

Directly-Maraurmd Scorma for Bmhrvioutrl A t t i t u d e and

Subjective Nomm to Vatiance in Intention Scores (n=26)

Variable Regres. Coeff.

Sub j ect . 1 Norrn

Beta

Indirectly-Measured Independent Var i ab l e s

The s c o r e s f o r t h e indirectly-measured behav iou ra l

attitude c o n t r i b u t e d significantly (F (1'22) = 15.37,

p<.001) towards explaining 41% of the v a r i a n c e i n scores f o r

intention (see Tab le 13). Scores for ind i rec t ly -measured

subjective norm contributed an additional 1% (p= .54 , ns) of

t h e v a r i a n c e i n i n t e n t i o n scores; t h e two v a r i a b l e s together

accounted f o r a total of 42% of the variance i n intention (F

(2,21 1 = 7.67, pC.01) (see Table 13).

The scores for indirectly-measured perceived

b e h a v i o u r a l control were not entered i n t h e r e g r e s s i o n

ana lys i s because t h e y were highly correlated w i t h the scores

for the indirectly-measured behavioural attitude (r = .74,

p<.001) and were considered collinear. The results of this

a n a l y s i s should also be viewed with caution given the small

sample size.

Tabla 13. Multiple Reqre8sion Equations: Contributions of

Zndirsctly-Maraurad Scoras for Behavioural A t t i t u d a and

Subjœctivm NOrm to Vaxiance in Intention Scores (n=23)

2. To whrt axtent have obstmtricrl nurses collaboxatad with

aidwavea in the car8 of màdwifary clianta aince the

implanmntrtion of midwifery in th0 hoapital settang?

S i n c e it was not possible to measure obstetrical

nurses' actual collaborative behaviour with midwives, an

attempt was made to examine obstetrical nurses' past

collaborative efforts with midwives, for the purpose of

describing the sample.

The 37 s c o r e s ranged from a m i n i m u m of O t o 100 on t h e

Re t ro spec t ive Measure o f Previous C o l l a b o r a t i v e Practice

Linea r Analogue Scale (see Table 1 4 ) . The mean (M - = 7 4 . 4 ,

s . d . = 2 6 . 8 ) r e p r e s e n t s a very p o s i t i v e r e p o r t o f p a s t

c o l l a b o r a t i v e behaviour . I t s h o u l d be noted that f o u r t e e n

o b s t e t r i c a l nurses ( 3 7 . 8 % ) r e p o r t e d very h igh s c o r e s (90-

100) i n d i c a t i n g t h a t t h e y had p rev ious ly provided almost

f u l l c o l l a b o r a t i v e e f f o r t wi th midwives.

Ajzen (1991) noted t h a t p a s t behaviour may r e f l e c t t h e

impact o f f a c t o r s t h a t i n f l u e n c e l a t e r behaviour . Past

behaviour may have a sma l l , but p o s s i b l y s i g n i f i c a n t

r e s i d u a l e f f e c t , beyond t h e p r e d i c t o r v a r i a b l e s i n a

t h e o r e t i c a l model. However, Ajzen (1991) a l s o s t a t e d t h a t

p a s t behaviour cannot be cons idered a c a u s a l factor i n i t s

own r i g h t . There fore , no presurnptions can be made f rom t h i s

sample ' s mean s c o r e . However, t h e mean s c o r e i n d i c a t e s t h a t

t h i s sample r epo r t ed having provided a large amount of

p r ev ious c o l l a b o r a t i v e e f f o r t i n t h e p a s t , and t h i s p a s t

behaviour may p o s i t i v e l y i n f l u e n c e f u t u r e c o l l a b o r a t i v e

behaviour .

Table 14. Scores fo r the Ratroaprctive Meraura of Previous

Collaborrtiva Effort Linerr Anrloque Scala (N=45; n=37; 8

incampleta scalms) (Y = 74.4, s.d. = 26.8)

Additional Analvses

Reliabilitv Coefficients

Direct Measurement of Behaviouxal Attitude-Semantic

Differen t i a 2 s

The Cronbach's alpha coefficient for the semantic

differential scale was .80 (n=40).

Indirectly-Measured Independent V a r i a b l e s

Table 15 presents the Cronbach's alpha coefficients

indicating the internal consistency for the Likert scales in

the present study. The scores for the multiplicative

composite (belief item x its moderator) were used to explore

internal consistency. The internal consistency coefficient

was the highest for the indirect measurement of behavioural

attitude (alph== .83) (see Table 15). The internal

consistency coefficient was lowest for the indirect

measurement of perceived behavioural control (alpha = . 6 0 ) .

The negative Cronbach's alpha coefficient observed for

the indirect measurement of subjective norm implied that the

scale may not be measuring a unidimensional construct. This

is a notable issue since the existence of disparate

constructs within this set of scales makes the assessment of

internal reliability inappropriate.

Tabla 15. Rmliabilitv Comffaciants for the Likrgt Scrlea

Indirect Measurement of Behavioural Attitude

Indirect Measurement of Subjective Norm

Indirect Measurement of Perceived Beh. Control

Notable Items:

Cronbrchrs alpha

18 incomplete scales

15 incomplete scales

13 incomplete scales

For al1 indirectly-measured independent variables,

interesting results were obtained on the items assessing

beliefs and their modifiers. These results are described in

detail in Appendices N-P . The most notable items for each

indirectly-measured variable are described below.

Indirect Measurement of Behavioural Attitude

Note that the most highly rated belief item in this

section referred to obstetrical nursesr ability to teach

certain skills to/share knowledge with midwives (M - = 5.8,

s.d. = 1.0) (Appendix N). The lowest attitudinal mean was

observed for the question that referred to the legal

responsibility to the midwifery client (M - = 2.2, s.d. =

1.6). The highest mean among the outcome evaluation

q u e s t i o n s was o b t a i n e d on t h e i t e m which a s s e s s e d t h e

impor tance of job s a t i s f a c t i o n t o the o b s t e t r i c a l n u r s e (M - =

6.0, s . d . = 1 . 8 ) . The l owes t e v a l u a t i v e mean was o b t a i n e d

on t h e q u e s t i o n which r e f e r r e d t o t h e impor tance o f l e g a l

r e s p o n s i b i l i t y t o t h e midwifery c l i e n t (M - = 1 . 4 , s.d. =

0 . 9 ) .

Indirect Measurement of Subjective Norm

Note t h a t t h e Nursing Uni t A d m i n i s t r a t o r ( M - = 5.3, s.d.

= 1 . 0 ) was s c o r e d a s t h e most impor t an t normat ive r e f e r e n t

and that t h e p h y s i c i a n s (M - = 2 .9 , s . d . = 1 . 4 ) were s c o r e d a s

t h e l e a s t impor t an t normat ive r e f e r e n t s (Appendix O ) . On

t h e m o t i v a t i o n t o comply q u e s t i o n s , t h i s sarnple's h i g h e s t

mean s c o r e was o b t a i n e d f o r t h e Nursing U n i t Adrn in i s t ra to r

(M = 4.5, s . d . = 1.81, and t h e lowes t mean was o b t a i n e d f o r

n u r s i n g c o l l e a g u e s (M= - 2 . 4 , s.d. = 1.2).

Indirect Measurement of Perceived Behavioural Control

Note t h a t t h e h i g h e s t mean was o b t a i n e d on t h e b e l i e f

q u e s t i o n which r e f e r r e d t o o b s t e t r i c a l n u r s e s midwives

ho ld ing a s i m i l a r ph i losophy o f c a r e ( M - = 5.0, s.d. = 1.7),

and t h e l o w e s t mean was o b t a i n e d on t h e b e l i e f q u e s t i o n

which referred t o n u r s i n g as founda t i on f o r midwifery

e d u c a t i o n ( M - = 1.9, s .d. = 1.4) (Appendix P ) . The h i g h e s t

mean on t h e p e r c e i v e d power q u e s t i o n s was 5.3. T h i s

o b s e r v a t i o n appeared on t w o q u e s t i o n s ; t h e f irst r e f e r r e d t o

collaboration being mandatory f o r obstetrical n u r s e s ( M - =

5.3, s a d a = 1 . 7 ) , and the second s t a t e d "1 d o n o t

c o l l a b o r a t e w i t h midwives because nur se s may l o s e jobs

because o f midwives" (M = 5.3, s.d. = 1 . 8 ) . The lowest mean

was ob ta ined on the perceived power q u e s t i o n which r e f e r r e d

t o rnidwives' o r d e r s be ing carried o u t by o b s t e t r i c a l n u r s e s

(M = 3.3, s . d . = 2.1).

Chrptmr V

Discussion

The results of this investigation will be discussed in

relation to the Theory of Planned Behaviour (Ajzen, 1985;

1988; 1991) . This theory was chosen for its consideration

of factors of volitional control over an intended behaviour.

Caution must be used in icterpreting the results of this

study, since the small convenience sample limits their

generalizability. However, some notable observations were

made and several of the hypothesised relationships were

supported.

The Sample

The characteristics of the sample indicate that it was

drawn from an exclusively female population (100%) of

generally experienced obstetrical nurses (M - = 11.5 years),

most of whom were employed mainly full time (68.8%), and

were aged 30 - 39 years (M - = 37.9 years). This sample

included several nurses (12) who had midwifery training and

experience in countries other than Canada (29.3%) (Table 1) . The response rate was 4 5 % , which approximately met the

standard for mailed questionnaires (Polit & Hungler, 1991).

If a second mailing of the questionnaire had been done, the

response rate may have been improved (Wilson, 1987).

Sampling bias may be present in this study. It is

possible that the respondents who chose to participate in

this study may have held either strong positive or strong

negative feelings related to midwifery and thus chose to

complete the questionnaire. Therefore, it should be noted

that the opinions of the study sample may not be

representative of the opinions of the l a r g e r group

(Nunnally, 1970) of obstetrical nurses. Following this

logic, the results from this study are not generalizable

beyond the sample studied.

Behavioural Attitude --

Three measurements of respondents' behavioural attitude

toward collaborating with midwives were obtained in this

study. Two involved direct measurement-- 1) a global

attitude score using a LAS, and 2) a score derived by

semantic differentials. A third, indirect, measure

consisted of scores derived from behavioural beliefs and

evaluations of outcomes.

Directly-Measured Scores for Behavioural Attitude

Global Attitude Linear Analogue Scale

The mean score on the Global Attitude Linear Analogue

Scale was 43.4 (s.d. = 33.2) out of a possible score of 100,

which indicates that this sample held a slightly negative

evaluation of collaboration with midwives (Table 3 ) . A

biasing effect may have been induced by providing the rater

with the particular definition of collaboration used here

(see Appendix B, part b) .

S e m a n t i c Differentials

The mean score on the attitude semantic differentials

was 27.35 (s.d. = 9.66), out of a possible 49 (mid range of

scale = 28). This indicates that many obstetrical nurses in

this sample held neutral if n o t slightly negative attitudes

toward collaborating with midwives. The overall slightly

negative impression of the reports from this sample was

primarily created by the "good-bad" and "easy-difficult"

semantic differentials (for more detailed results of

semantic differentials see Appendix L) . It is

understandable that the sample of nurses would find it

"difficult' to undertake collaboration with a new group of

health professionals. However, the investigator was

surprised that many nurses selected the "collaboration with

midwives is bad" response. The other five semantic

differential scales were scored very neutrally by the

sample. These ambivalent or neutral feelings toward

midwifery were evident in many of the comments written on

the questionnaires. Many comments written on the

questionnaires (see Appendix P) described this sample's

negative attitudes about the ongoing changes.

Summary of Directly-Measured Scores for Behav ioura l Attitude

The two directly-measured scores were moderately

correlated (r= .75, p< .001); this indicates that they may

be rneasuring the same concept. The neutral to slightly

negative scores on the direct measures of behavioural

attitude did not result in a neutral or slightly negative

intention to collaborate with midwives,

Indirectly-Derived Scores for Behavioural Attitude - -

Since the sum-of-product rnethod of computation tends to

inflate the scores above the theoretical neutral point,

these raw scores were not reported (see discussion in

Methods chapter). However, the mean transformed score for

the indirectly-measured behavioural attitude (36.6)

indicates that the respondents held negative behavioural

beliefs and outcome evaluations towards collaborating with

midwives (see Table 4). This transformed mean appears to be

consistent with the somewhat negative scores of the two

directly measured means for behavioural attitude.

It should be noted that the validity of the indirect

measure of behavioural beliefs has not been esïablished,

However, it is xeassuring that the Cronbach's alpha

coefficient for this scale was .83, and that the indirect

and direct-measures for behavioural attitude were moderately

correlated (r = .55, p< .01) . There may have been an unknown order effect induced

here, in that the behavioural belief items were irnmediately

followed by the outcome evaluation items. However, the

means of the outcome evaluation items were not scored

consistently higher or lower than the means of the belief

items. Çirnilarly, the standard deviations of the outcome

evaluation questions were not consistently higher or lower

than the standard deviations of the belief items. At the

same time, it is still possible that some type of order

effect may have occurred even though it is not readily

apparent. For example, if an obstetrical nurse held a very

strong positive or negative belief about a particular item,

the imrnediately-following second opportunity to evaluate the

same topic rnay have resulted in a more extreme evaluative

answer. However, it is also possible that the nurse could

become bored with answering an outcome evaluation question

about the same topic as the belief question, and therefore

answer more neutrally. If this study were to be repeated,

to mitigate a possible order effect, the behavioural belief

items should appear together as a set, followed by the set

of outcome evaluation questions.

Summary of Behavioural Attitude

The indirectly-derived scores for behavioural attitude

were moderately to highly correlated with: 1) the directly-

measured scores of the behavioural attitude sernantic

dif ferentials; and 2) the directly-measured LAS scores for

behavioural attitude. These two directly-measured scores

for behavioural attitude were significantly correlated. The

indirectly-derived scores for behavioural attitude were

significantly correlated with scores for intention. Also,

both of the directly-measured scores for behavioural

attitude were significantly correlated with scores for

intention. These hypothesised relationships support the

Theory of Planned Behaviour ( A j zen, 1985) . S u b j e c t i v e N o r m

Two measures of respondents' subjective norm related to

collaboration with midwives were obtained in this study. A

directly-measured score was obtained using a LAS, and

indirectly-measured scores derived from normative beliefs

and motivations to comply were also obtained.

Directly-Measured Scores for Subjective Norm

The mean score on the direct measure of subjective norm

reflected a fairly neutral response by this sarnple (M - =

53.7). This neutral mean may indicate that either: 1) many

nurses in this sample believed that important others neither

approved or disapproved of them collaborating with midwives

in the care of midwifery clients; or 2) this sample felt

that some referents approved of them collaborating, and

other referents disapproved of them collaborating with

midwives.

Indirectly-Derived Scores for Subjective Norm

The mean score for the indirect measurement of

subjective norm was 28.9 (s.d. = 6.9). These results imply

a somewhat negative subjective norm score for this sample

since the theoretical neutral point was 50. According to

the TPB (1985), the respondents' scores indicate that they

did not perceive that impostant others believed that they

should collaborate with midwives; thus, by inference, they

did not perceive social pressure to do so.

The mean from this sample may be: a) reflective of the

independent thinking and autonomous practice behaviours of

many obstetrical nurses; and/or b) reflective of nurses who

do not wish to perform their nursing care in order to

please certain referents. See "Implications" (p. 115) for

more detailed account of the normative beliefs and

motivation to comply items.

Again, it should be noted that there may be an unknown

order effect related to the sequence of questions for the

indirect measure of subjective norm. The logic for this

potential scoring bias is comparable to that described

earlier regarding the indirect measurement of behavioural

attitude. The mean for each motivation to comply question

was lower than the mean for the normative bel ie f question;

it is unclear whether this is related to the order of the

questions. If this study were to be repeated, to offset

this possible bias, it is suggested that the set of

normative beliefs questions should appear in the

questionnaire before the set of motivation to comply

questions.

Summary of Subjective Norm

Indirectly- and directly-measured scores for subjective

norm were not correlated in this sample (r = -29, ns). The

lack of relationship may be due to the motivation to comply

aspect of the indirect measure of subjective norm, the items

of which were rated more negatively than the belief items

(see Appendix N). Hence, since the linear analogue for

subjective norm did not take motivation to comply into

account, it was not surprising that the direct measure was

not correlated with the indirect measure of subjective norm.

The direct measure of subjective norm has been

measured many different ways. A direct measure of

subjective norm was calculated with a single scale by Young

et al. (1991). Ajzen and Driver (1992) and Ajzen and Madden

(1986) used two scales to directly measure subjective nom;

however, Ajzen and Madden (1986) used one of the scales to

assess motivation to comply. Thus, since there has been no

consistency or 'gold standard" in the method for directly

measuring subjective nom, the method used here should not

be dismissed as invalid. However, the inclusion of an item

to assess motivation to comply within the direct measure of

subjective n o m is suggested for further research.

Perceived Behavioural Control

Two measures of perceived behavioural control were

obtained in this study: 1) a direct measure; and 2) and

indirect measure (based on control beliefs and perceived

power) . Directly-Measured Scores for Perceived Behavioural Control

The mean directly-measured score for perceived

behavioural control (M - = 40.6., s.d. = 21.9) demonstrates a

somewhat negative evaluation of control factors by this

sample of nurses (middle point of scale = 50). The

distribution of scores indicates that the sample may have

felt it had been difficult to collaborate with midwives.

When the data were collected, midwives had hospital

privileges for a few months only and the collaboration

process was still being established. Collaboration with

midwives is a behavioural goal over which obstetrical nurses

have only limited volitional control. Collaboration depends

on the participation of both members of an interprofessional

relationship, thus limiting volitional control. Change is a

difficult process, and incorporation of a new health

profession has been documented in the literature as a time

of conflict (Blais et al., 1991; Haas & Rooks, 1986; Hazle,

1985; Robinson et al., 1993).

Ajzen (1985) notes that some behaviours are more likely

to present problems of control than others. Collaboration

may be a behaviour that presents some problem of control in

that true collaboration also depends on the other member of

the interprofessional relationship. A j zen (1985) notes that

"an inability to carry out an intention because of

dependence on others may have little ef fec t on the

underlying motivation" (p. 29). Thus, if an intention to

perform a behaviour, like collaboration, fails because of

dependence on others, repeated efforts will be made or a

more compliant partner may be sought. The intention remains

unchanged unless repeated efforts to perform the behaviour

fail, at which point potentially more fundamental changes in

intentions can be expected (Ajzen, 1985).

Ajzen and Madden (1986) used three questions relating

to control issues about performing the behaviour. These

included: 1) "How much control do you have over (the

behaviour of interest)"; 2) "If 5 wanted to 1 could (perform

the behaviour of interest) "; and 3) an "ease/difficult"

question similar to the one included in this study. Ajzen

and Driver (1992) used two questions. These included: 1)"I

believe 1 have the resources needed to (perform the

behaviour in question)"; and 2) an "ease/difficultl' question

sirnilar to the one included in this study. Young et al.

(1991) used one question inquiring about the ease/difficulty

of perforrning the behaviour of interest, and stated that it

is an appropriate direct measure of PBC. Thus, there has

been no consistency or 'gold standard" in measurement

techniques for directly-measured perceived behavioural

control. Therefore, the method used in this study should

not be dismissed as invalid, however, in future research,

the inclusion of two additional questions (such as "How much

control do you have over whether you do or do not

collaborate with midwives" and "If 1 wanted to 1 could

easily collaborate with midwives") is suggested for the

direct-measurement of PBC.

Indirectlv-Derived Scores fox Perceived Behavioural Control

The mean indirectly-derived score for PBC irnplies a

somewhat negative response by this sample of obstetrical

nurses (M - = 36.2, s .dm = 12.3) (middle point of scale =50) . This rneans that the participants reported responses which

reflected negative control beliefs and/or negative perceived

power. This is not a surprising result, since some issues

of collaborating with midwives are beyond the obstetrical

nurses' control.

Al1 of the questions used for the indirect measure of

PBC were based on issues that make it "easy" or "difficult"

to collaborate with midwives (Appendix O). The ten

questions al1 have a very tenuous link to the concept of

"control'. Therefore, this part of the questionnaire should

be considered a potentially less valid method of assessing

perceived behavioural control. However, the indirect

measure of PBC used in this study was rnoderately and

significantly correlated with the scores of the direct

measure of PBC (r = .76, p<.001) and intention scores (r =

-79 , pC.001). The items included for the indirect measure of

PBC rnay not accurately represent perceived behavioural

control; however, they may be important in determining

intention scores. These items may actually be items that

could be included in the indirect measure of behavioural

attitude, since they are significantly correlated to the

scores of the indirect measure of behavioural attitude (r =

- 7 4 , p<.001).

There may be an unknown order ef fec t induced by the

sequence of questions for the indirect measure of perceived

behavioural control. The logic for this potential scoring

bias is comparable to that described e a r l i e r regarding the

indirectly-measured behavioural attitude. The rneans of the

perceived power questions were neither consistently higher

or lower than the scores for the control belief items.

However, the standard deviations were consistently wider

than the standard deviations for the belief questions. This

may indicate more extreme responses for the perceived power

questions. However, it is uncertain whether this widening

of the standard deviation is related to the order of the

questions in this questionnaire or related to the questions

themselves. If this study were to be repeated, it is

sugges ted t h a t t h e set of c o n t r o l b e l i e f q u e s t i o n s appear

b e f o r e t h e set of pe r ce ived power q u e s t i o n s .

Summary of Perceived Behavioural Cont ro l

Both t h e i n d i r e c t l y - and d i rec t ly -measured mean s c o r e s

r e f l e c t e d a somewhat n e g a t i v e e v a l u a t i o n of pe rce ived

behav iou ra l c o n t r o l . There was a s i g n i f i c a n t c o r r e l a t i o n

between the two measures ( r = .76, p<.001) , as hypothes i sed .

However, t h i s shou ld be viewed wi th c a u t i o n , s i n c e t h e items

inc luded for t h e i n d i r e c t measure of PBC may have a tenuous

l i n k t o t h e concept of " c o n t r o l " .

I t is sugges ted t h a t , f o r f u t u r e r e sea rch , o t h e r LAS

q u e s t i o n s shou ld be i nc luded t o complernent t h e "esse/

d i f f i c u l t y " LAS q u e s t i o n i n a d i rec t -measure of pe r ce ived

behav iou ra l c o n t r o l . Th i s i s suppor ted by Ajzen and Madden

(1985), who inc luded t h r e e LAS q u e s t i o n s f o r t h e direct

measurement of pe r ce ived behav iou ra l c o n t r o l , and Ajzen and

Dr iver (1992) , who inc luded two LAS q u e s t i o n s t o assess the

d i r e c t measurement of pe r ce ived behav iou ra l c o n t r o l .

I n suppo r t of t h e Theory o f Planned Behaviour (Ajzen,

1985) , both t h e d i r e c t l y - and ind i rec t ly -measured s c o r e s f o r

pe r ce ived behav iou ra l c o n t r o l were moderate ly and

s i g n i f i c a n t l y c o r r e l a t e d w i t h i n t e n t i o n t o c o l l a b o r a t e w i th

midwives (p<. 001) .

I n t e n t i o n

I n t e n t i o n was measured w i t h a s i n g l e l i n e a r a n a l o g u e

s c a l e . I n t e n t i o n s c o r e s i n t h i s sample were m o s t l y p o s i t i v e

(M = 61.5, s.d. = 30.3) (middle p o i n t of scale = 5 0 ) ( T a b l e

2 ) . Forced e n t r y r e g r e s s i o n a n a l y s i s r e v e a l e d t h a t t h e

d i r e c t measurement of b e h a v i o u r a l attitude and the d i r e c t

measurement of s u b j e c t i v e norm each c o n t r i b u t e d t o t h e

v a r i a n c e i n t h e i n t e n t i o n s c o r e s . The direct rneasurement o f

b e h a v i o u r a l a t t i t u d e c o n t r i b u t e d towards 4 9 % o f t h e v a r i a n c e

i n i n t e n t i o n (p<.001) ( s e e Tab le 12), s u b j e c t i v e norm

accoun ted f o r a n a d d i t i o n a l 3% of t h e v a r i a n c e i n i n t e n t i o n

s c o r e s , and t h e two independen t v a r i a b l e s accoun ted for a

t o t a l o f 52% o f t h e v a r i a n c e (p< .001) . The d i r e c t measurement of p e r c e i v e d b e h a v i o u r a l c o n t r o l

was n o t added t o t h e r e g r e s s i o n a n a l y s i s s i n c e it was h i g h l y

c o r r e l a t e d w i t h t h e d i r e c t measurement o f b e h a v i o u r a l

a t t i t u d e , and g i v e n t h e s m a l l sample s i z e ( n = 25), it was

n o t p o s s i b l e t o i n c l u d e a n o t h e r independent v a r i a b l e t o

r e g r e s s i o n a n a l y s i s . When p e r c e i v e d b e h a v i o u r a l c o n t r o l was

not i n c l u d e d i n t h e r e g r e s s i o n model, t h e t h e o r y a c t u a l l y

t e s t e d was t h e Theory o f Reasoned Ac t ion ( T M ) ( F i s h b e i n &

A j zen, 1 9 8 0 ) . The TRA was s u p p o r t e d w i t h t h e two

independen t v a r i a b l e s e x p l a i n i n g t h e a n o t a b l e percentage of

t h e v a r i a n c e i n intention s c o r e s .

In conclusion, the Theory of Planned Behaviour was

supported by the statistically significant correlation

coefficients for the relationships between intention and the

direct measurements of behavioural attitude and perceived

behavioural control, The Theory of Reasoned Action was

supported by the significant contribution of the direct

measurements of behavioural attitude and subjective norm to

the variance in intention. However, the TPB and the TRA

were not fully supported in that the direct and indirect

measurements of subjective norm were not significantly

correlated. Similarly, the two theories were not fully

supported in that neither the direct and indirect

measurements of subjective norm were significantly

correlated with intention.

C-TER VT

Summary, Implications, and Conclusions

Summary

A number of studies

outcomes associated with

have demonstrated the positive

collaborative practice among health

professionals (Baggs & Schmitt, 1997; Baggs et al., 1992;

Knaus et al., 1986; Koerner et al., 1986; Williams et al.,

1982). However, in Ontario there have been few empirical

studies of obstetrical nurses' attitudes towards

collaborating with midwives. This study explored this gap

in the literature, using the Theory of Planned Behaviour

(TPB) (Ajzen, 1986; 1988; 1991) as a means of investigating

collaboration between obstetrical nurses and midwives.

The TPB maintains that directly- and indirectly- measured

behavioural attitude, subjective nom, and perceived

behavioural control can account for reported intention,

which in turn can predict behaviour (Ajzen;

1991).

A descriptive correlational design was

convenience sample of 45 obstetrical nurses

used with a

f rom t hxee

hospital settings which had midwives with hospital adrnitting

privileges. Data were collected using self-administered

questionnaires which were returned anonymously to a

collection box. The questionnaire sought demographic

information as well as responses to direct and indirect

measures of behavioural attitude, subjective norm, and

perceived behavioural control, as well as intentions toward

collaborating with midwives in the care of midwifery

clients.

Data for the study were analysed using the SPSS

statistical software package. The sample included

obstetrical nurses who tended to be 30-39 years old ( 3 5 . 5 % ) ,

diploma educated ( 6 2 . 2 % ) , and with 6-10 years of obstetrical

nursing experience (28.8%). Twelve nurses in the sample

( 2 6 . 5 % ) had 1-10 years of midwifery practice in another

country.

A j zen has advocated the sum-of -products method of

computation for the indirectly-measured independent

variables. However, in this study a l 1 indirectly-rneasured

independent variables were transformed in order to

compensate for the inflation of the high scores that are

induced by the sums-of-products method of computation.

Then, the Pearson's Product Moment Correlation

coefficient (r) was used to assess the relationships among

the independent variables of the theoretical framework, in

order to advance our understanding of obstetrical nurses'

intentions toward collaborating with midwives in the care of

midwifery clients.

Overall, the mean score for intention reilected

slightly positive intentions to collaborate with rnidwives in

t h e care of midwifery c l i e n t s . However, t h e mean s c o r e s f o r

most o f t h e p r e d i c t o r v a r i a b l e s w e r e s l i g h t l y n e g a t i v e .

Th i s was obse rved f o r : a ) t h e mean s c o r e s f o r t h e i n d i r e c t

and direct measure (LAS) o f b e h a v i o u r a l a t t i t u d e ; b ) t h e

i n d i r e c t measure o f s u b j e c t i v e norm; and c) bo th t h e

i n d i r e c t and direct measure o f p e r c e i v e d behav iou ra l

c o n t r o l . Note t h a t c a u t i o n must be t aken when i n t e r p r e t i n g

s c o r e s from t h e i nd i r ec t -measu re of p e r c e i v e d behav iou ra l

c o n t r o l . The q u e s t i o n n a i r e items f o r t h i s measure may have

a t enuous l i n k t o t h e concep t o f " con t ro l " , and t h e r e f o r e

i ts ' s c o r e s may n o t be c l e a r l y v a l i d . The mean s c o r e s f o r

t h e direct measurement of b e h a v i o u r a l a t t i t u d e ( s eman t i c

d i f f e r e n t i a l s ) and s u b j e c t i v e norm were n e u t r a l .

I n t e r p r o f e s s i o n a l c o l l a b o r a t i o n i s dependent upon a l 1

mernbers o f t h e h e a l t h c a r e team. The n u r s e s i n t h i s sarnple

t ended t o have s c o r e s t h a t were e i t h e r s l i g h t l y above o r

below t h e n e u t r a l s c o r e f o r a l 1 v a r i a b l e s i n t h e framework.

The mean s c o r e s f o r t h e t h r e e d i r e c t measures of t h e

concep t s of t h e TPB hovered around t h e t h e o r e t i c a l n e u t r a l

p o i n t s o f t h e s c a l e s . Th i s rnay i n d i c a t e t h a t t h i s sample

was n e i t h e r t e r r i b l y e n t h u s i a s t i c n o r v e r y opposed t o

c o l l a b o r a t i n g w i t h midwives.

Suppor t For t h e Theory of Planned Behaviour

According t o t h e theory, t h e results o b t a i n e d on t h e

i n d i r e c t and direct measure of b e h a v i o u r a l a t t i t u d e ,

subjective nom, and perceived behavioural control should be

correlated (Ajzen & Madden, 1986). This prediction was

largely supported in this study. Indirect and direct

measures for behavioural attitude were moderately

correlated. Indirect and direct measures of perceived

behavioural control (PBC) were a l s o moderately correlated.

However, since the validity of the indirect measure of PBC

is questionable, this relationship should be viewed with

caution. Furthermore, the relationship between indirect and

direct measures of subjective norm was not significant.

Highly significant relationships were found between

attitude and intention, as well as between perceived

behavioural control and intention.

In support of the Theory of Planned Behaviour, the

direct measure of behavioural attitude made the most

significant contribution towards accounting for the variance

in the intention scoxes. The direct measurement of

subjective norm made a very srna11 non-significant

contribution in the intention scores.

Implications for Practice and Research

Implications for practice, theory, and research should

be considered with caution, due to the small sample size.

The results are not generalizable beyond the sample studied.

Practice

Midwives need supportive and collaborative

relationships with obstetrical nurses for rnidwifery

successful in the hospital setting. It is of concern that

the directly- and indirectly-measured behavioural attitude

scores were either neutral or negative in nature. These

somewhat negative attitudes were also reflected in the

comments that were written on the questionnaires (see

Appendix P). The intention scores were the most positive

out of al1 the measured concepts. For the purpose of

smoothly integrating the profession of midwifery into the

hospital setting, efforts should be made to support

collaborative relationships between obstetrical nurses and

midwives . Collaboration contributes to excellent patient care and

a rewarding work environment. To achieve these results,

nurses need to improve their behavioural attitudes about

collaborative practice. Attaining more positive attitudes

toward collaboration may translate into more positive

intentions to do so.

It should be noted that interprofessional collaboration

requires the participation of al1 parties to contribute

toward achieving the same goals. This study only explored

the collaborative intentions of obstetrical nurses. The

beliefs and intentions of midwives were not explored. Thus,

the implications derived from this study, are only directed

at obstetrical nurses.

Three practice implications are suggested to increase

positive collaborative intentions: 1) assist obstetrical

nurses and midwives to understand the concepts of 4

collaboration; 2) foster the change process; and 3) provide

opportunities for interprofessional interaction.

1) Understanding the Concepts of Collaboration

To increase understanding of the collaborative process

Koerner et al. (1986) advocate theoretical, conceptual and

clinical skill preparation to enhance the practical day-to-

day opportunities for collaborative practice. This could be

done through seminars and workshops in which the concepts of

collaborative practice are reviewed. Through group

participation, goals could be set, attitudes and behaviours

could be explored, and expectations about collaboration

could be addressed. Published research results could be

supplied and reviewed in these seminars to increase staff

awareness of the benefits of collaboration. These

interactions may lead to increased respect for each other's

roles and increased sensitivity to each other's perspectives

(Pike et al., 1993) . 2) Fos ter ing the change process

The change process could be fostered by involving

obstetrical nurses and midwives in the development of unit

policies. This would provide opportunities for the two

professions to interact outside the clinical setting and

provide an opportunity to develop mutual respect,

understanding and cooperation (Bushnell & Dean, 1993; Lieba,

1993). Opportunities to address the emotions associated

with the change process could be given to obstetrical nurses

(Perlman & Takacs, 1990) through staff meetings and

brainstorming sessions. Supporting positive

interprofessional relationships in such a manner may

increase the success of the integration of midwifery into

the hospital setting. Collaboration cannot exist if only

one discipline is comrnitted to it. Therefore, both nursing

and rnidwifery should be involved in the nurturing of their

interprofessional relationships.

3 ) Increasing in terprofessional in teractions

Increasing interprofessional interactions has been

associated with increased collaborative practice behaviours

(Gregson et al., 1991; Weiss & Davis, 1985). This could be

achieved by having open discussions between nurses and

midwives about patient care and clinical practice issues,

and about the delineation of goals and responsibilities.

Collaborative intentions and practice behaviours may be

increased by forming committees including both midwives and

obstetrical nurses and by providing opportunities for face-

to-face interactions (Gregson et al., 1991; Weiss & Davis,

1985). Social events including both professions may

increase communication and provide opportunities for

interaction.

Practice Implications Derived From Indirectly-Measured

Independent Variables

Practice implications are derived £rom the results

observed for each indirectly-measured independent variable.

These are described below.

Implications From the Indirect ly-Derived Behavioural

A t t i t ude Scores

Nursing Managers rnay find the scores from the

indirectly-derived behavioural attitude scales helpful for

understanding the behavioural beliefs and outcome

evaluations of the sample. These data may provide insight

into some areas of positive and negative feelings.

Some very positive feelings were identified in the

following areas. The behavioural belief item that was

scored most positively by this sample of obstetrical

nurses referred to obstetrical nurses' ability to teach

certain skills to/share knowledge with midwives (M - = 5.8,

s .d. = 1. O) (see question 8a in Appendix C) . The

respondents also positively scored the belief item and

outcome evaluation item that referred to the achievement

of better quality materna1 care resulting from

collaboration (M - = 4 . 8 , s.d. = 2.0 and - M = 5.1, s.d. =

1.8) (see questions la and b in Appendix C) . This sample

responded very positively to the outcorne evaluation item

that referred to enhanced job satisfaction from

collaboration with midwives (M - = 6. O, s .d. = 1.8) (see

question 4b in Appendix C).

T h e s e data support reports by Baggs & Schmitt (1987),

Corless, (1982), Koerner et al. 1986) and Stein et al.

(1990) which demonstrated increased job satisfaction from

interprofessional collaboration. Çirnilarly, the data

support t h e study by Blais et al. (1991) which found that

obstetrical nurses endorsed t h e idea that midwifery could

improve maternity care.

Nursing managers in the study hospitals could use these

very positively scored belief and outcome evaluation items

to provide positive feedback to their staff. Positive

reinforcement might perpetuate and strengthen collaborative

behaviour. Positively reinforcing these collaborative

behaviours could be done personally by the NUA in staff

meetings.

The most negative score was attributed to the belief

item and outcome evaluation that referred to the legal

responsibility for the midwifery client (M - = 2.2, s.d. = 1.6

and - M = 1.4, s.d. = 0.9) (see questions lla and b in

Appendix C). The question was scored negatively if the

participant documented a "very important to me" answer.

This was done because the legal responsibility for the

client is well defined in the scenario of transfer of care,

and thus should not be an issue to the obstetrical nurse.

However, obstetrical nurses rnay have concerns related to

their legal responsibility for al1 clients under their care.

The belief item and outcome evaluation may have been

misunderstood by the respondents and the two questions'

inclusion in the questionnaire should be evaluated.

The NUA could examine the negatively scored behavioural

belief and outcome evaluation items to assess learning

needs. The NUA could create a presentation related to the

legal issues surrounding midwifery care to meet this need.

Impl i c a t i o n s From the Indirectly-Derived Subjective N o r m

Scores

The mean subjective norm scores for this sample

indicated that many nurses felt their Nursing Unit

Administrators (M = 5.3, s.d. = 1.0) and Hospital

Administration (M - = 5.4, s.d. = 1.3) believed that

obstetrical nurses should collaborate with rnidwives (see

Appendix E) . However, few participants indicated that the

physicians that they work with (M - = 2.9, s.d. = 1.4), their

nursing colleagues (M - = 3.4, s.d. = 1.6), or their charge

nurse/team leader (M - = 3.6, sed. = 1.5) felt that

obstetrical nurses should collaborate with midwives (see

Appendix E) . Sirnilarly, this sample of obstetrical nurses felt

motivated to comply only with their Nursing Unit

Administrators (M - = 4.5, s .dm = 1.8) (see Appendix E) . The

mean for this sample's motivation to comply with their NUA

is just slightly over the neutral point. This indicates

that they did comply with their NUA's wishes for them to

collaborate with midwives; however, they were only motivated

to do so at a low level. This may be reflective of the

hierarchical structure of the nursing unit and the power

structure for nurses within the hospital.

Taken together, the normative belief and the motivation

to comply scores for the NUA indicate that, for obstetrical

nurses, she was the most influential individual for

fostering collaborative practices. Thus, the NUA could

potentially influence her staff to increase collaborative

practice with midwives. This could be done by encouraging

collaborative practices with midwives through seminars,

staff meetings, bulletins, and cornmittees.

Implications From the Indirectly-Derived Scores f o r

Perceived Behav ioura l Control

The mean scores for the questions in the indirectly-

measured perceived behavioural control section provide

insight into issues which make collaborating with midwives

easy or difficuit for obstetrical nurses.

The most positively scored perceived behavioural

control items indicate that this sample: a) did not feel

that the practice of midwifery was dangerous to mothers and

their infants (M - = 5, s.d. = 1.8); b) did not feel obligated

to collaborate with midwives and do try to obtain a positive

working relationship with them (M - = 5.3, s.d. = 7 and c)

did not feel that they will lose jobs because of midwives (M -

= 5.3, s.d. = 1.8) (see Appendix G).

The most negatively scored response in the indirect

measure was to the question relating to the current

midwifery education requirements. Many nurses in the sample

felt that midwives should have nursing as a foundation for

midwifery education (M - = 1.9, s.d. = 1.4). Many obstetrical

nurses in this sample (12) had midwifery education and

experience in a country other than Canada. Some of these

midwives felt very strongly about having nursing as a

foundation for midwifery (see comments in Appendix O) . The negatively answered items in the indirectly-measured

perceived behavioural control section may indicate areas of

learning needs or areas of misunderstanding. These needs

could be addressed by the NUA through staff meetings. The

negative scores for the question related to nursing

education as a foundation for midwifery may demonstrate a

need for nurses to vent their frustration with the

"grandmothering" process which occurred. Obstetrical nurses

may need an outlet for their frustration with the rnidwifery

integration process. This frustration was apparent in the

written comments which appeared on the questionnaires (see

Appendix O). This frustration could be addressed through

developing a interprofessional committee including al1

professions involved in materna1 care. This committee would

be a venue to provide feedback for al1 professions

look at practice issues within the professions.

Research ---

There are a number of implications for theory

research that stem from the results of this study:

and to

and

1) Qualitative research could be conducted on the topic of

obstetrical nurses' collaboration with midwives. It would

be important to see what the experience of obstetrical

nurses is in relation to the initiation of midwifery into

the c u r e n t health care system. This could give more

detailed insight into the collaborative practices between

these two professions. Qualitative research may bring

insight into the historically negative feelings obstetrical

nurses hold about previous midwifery practice in Ontario.

These negative beliefs may be items included in future

measures of perceived behaviour control and may have

influence on obstetrical nurses' intentions to collaborate.

2) Parts of the questionnaire should be modified. This

should be done in three ways.

A) The definition of collaboration should be clarified

by including a statement that states that collaboration

occurs after transfer of care.

B) The phrasing of some belief items and outcome

evaluation items for the indirect measure of behavioural

attitude (Appendix C) should be modified as described below.

i) Question 9a should read, "1 believe that nurses and

midwives are considered equals when collaborating together",

since the original wording of the question may have been

confusing. Question 9b should read, "Being considered an

equal to a midwife is..", to be consistent with the changes

in the belief question.

ii) Question 10a should be changed to, "Collaborating with

midwives leads to having a higher risk patient assignment."

The wording of this question may have been confusing. This

was evident by the observation that the reliability

coefficient would have been higher if this item had been

removed. Question lob should be changed to, "Having a

higher risk patient assignment is ...", in order to be

consistent with the belief question.

iii) Question lla should appear as "Collaboration with

midwives decreases territoriality between nurses and

midwives oves patient care." The original wording of this

question may have been confusing to the reader. This was

evident by the reliability coefficient which would have been

higher if this question had been deleted. Question llb

should be changed to "decreasing territoriality through

collaboration is ...", in order to be consistent with the belief question.

iv) Question 12 should be deleted entirely, since this

belief is addressed by question 10. The reliability

coefficient would have been higher if this question had been

deleted.

C) The order in which the belief and modifier questions

are asked within the questionnaire should be altered so that

the modifier question does not follow directly after the

related belief question. This would eliminate any possible

order effects. The order of the questions in this

questionnaire may have potentially induced responses that

were either more invariant or more extreme; however, whether

or not this actually occurred in the study i s unknown.

3) Further studies could explore other populations of

obstetrical nurses. Populations of obstetrical nurses

practising in hospitals without midwifery privileges could

be compared to hospitals with midwifery practices. The

positive effects of collaborative relationships have been

well docmented in the literature. It is possible that

sarnples of obstetrical nurses who are currently engaged in

collaborative practices with midwives would have more

positive attitudes and intentions toward collaboration than

samples of obstetrical nurses who do not have opportunities

to collaborate with midwives.

4) Further research including measurement of actual

existence of collaborative behaviour between obstetrical

nurses and midwives is warranted. In a study which measures

actual collaborative behaviour, the relationship between

perceived behavioural control and actual collaborative

behaviour could be explored.

5) Replication of this study is recommended. This would

allow for investigation of the possibility of stronger

intentions to collaborate. Since some time has passed and

obstetrical nurses have had increased opportunities for

collaborative behaviour, their intentions may have become

stronger . 6) A larger sample size is also recommended so that al1

direct-measurements of the independent variables could be

included in a regression analysis.

Conclusion

This descriptive correlational study has attempted to

explore obstetrical nurses' direct and indirect reports of

their behavioural attitude, subjective nom, and perceived

behavi-oural control, as well as their intentions toward

collaborating with midwives in the care of midwifery

clients. This study was performed to explore the

relationships between obstetrical nurses and midwives in

Ontario hospitals, and to fil1 a gap in the literature.

Results indicated that intentions were associated with

the direct measurement of behavioural attitude and that the

direct measurement of subjective norm made a very small

contribution to accounting for the variance in intention

scores. The mean intention score was rated relatively

positively. The direct rneasure of subjective n o m scores

were slightly positive. The direct measure of behavioural

attitude (semantic differentials) was neutral. The direct

measure of behavioural attitude (LAS) and direct measure of

perceived behavioural control and were scored relatively

negatively.

This study also highlights salient beliefs and their

moderators, which are the basis for the direct measures of

the independent variables.

It should be noted that it has been four years since

midwifery proclamation. Since the time of data collection,

obstetrical nurses' intentions toward collaborating with

midwives may have changed.

Collaboration is a conscious, learned behaviour that

must be constantly nurtured, reinforced, and supported,

since it holds great promise for patients, providers, and

professional personnel (Makadon, 1995). Interprofessional

collaboration should be the goal for a l 1 health care

providers since has been associated w i t h such positive

outcornes.

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APPENDICIES A-H

Questionnaire Distributed to al1 Potential Participants

Appendix A: Measurement of Intention to Collaborate

This line r e p r e s e n t s your p r e s e n t and future intention to

collaborate with midwives in the care of midwifery clients.

Please make a mark th rough o r across t h a t p a r t of t h e line t h a t

b e s t represents y o u r intention to continue to collaborate wi th

midwives .

1 intend to collaborate with midwives in the care of midwifery clients:

Not at al1

Appendix B: The Direct Measurement of Behavioural Attitude

a ) S e m a n t i c Differential S c a l e s

Please place a check mark t h r o u g h t h e line which reflects your a t t i t u d e toward collaborating w i t h rnidwives.

Collaborating in an interprofmaaional rmlationahip ia charactetirad by a sense of colleagueahip and an absence of oppoaing intataats and conflicta.

Obstetrical nurses collaborating with midwives in the care of midwifery clients will be:

k x m f u l --- to patient care

pleasant -------

threatening -------

important -------

beneficial to patient care

unpleasant

undesirable

eas y

non- t h r e a t e n i n g

unimportant

139

Appendix B: The Direct Measurement of Behavioural Attitude

b) Global L i n e a r Analogue S c a l e

This line represent your overall attitude toward

collaborating with midwives in the care of midwi fe ry clients.

Please place a mark through or across that part of the line which best represents your opinion of the impottuice of collaborating

with midwives.

Absolutely Unimportant

Collaborating with midwives is:

Absolutely Essential

140

Appendix C: The Indirect Measurement of Behavioural Attitude

Please indicate your agreement or disagreement with the following statements by circling the most appropriate response number. Please do not circle between numbers.

1 2 3 4 5 Va- strongly disagree neutral agree

strongly disagrea dieagree

6 strongly

agree

7

v==Y a -ongly agree

la) Midwifery clients will receive better quality care if nurses and midwives collaborate together while providing care.

lb) Quality materna1 care resulting from collaboration is:

not important ------- very important to me to me

2a) Midwifery clients will experience more satisfaction in their childbirth experience if obstetrical nurses and midwives collaborate in their care.

2b) Midwifery clients' satisfaction in childbirth is:

not important - _ _ e _

very important to me to me

3a) Obstetrical nurses and midwives will develop better interprofessional relationships if they collaborate together in providing care.

1 2 3 4 5 VerY rtrongly diragtoe neutral agree

strongly diaagzee diaagree

3b) Good interprofessional relationships with midwives are:

not important very important to me to me

4a) Obstetrical nurses will experience better job satisfaction if they collaborate with midwives.

4b) Job satisfaction is:

not important to me

------- very important to me

5a) Collaborating with midwives in the care of midwifery clients requires a lot of my t ime.

5b) The amount of my time spent collaborating with midwives in the care of rnidwifery clients is:

not important very important t o me to me

6a) The role of the obstetrical nurse will change when obstetrical nurses collaborate with midwives in the care of midwifery c l i e n t s .

6b) Change in t h e role of t h e obstetrical nurse is:

not important ------- very important to me to me

1 2 3 4 5 6 7 VeW rtzongly dirrgree neutxal agxee strongly V-Y

strongly àiaagree agree a trongly diaagree ag="i'

7a) Obstetrical nurses may l ea rn certain skills from working with midwives.

7b) Learning skills from midwives is:

not important ------- very important t o me t o m e

8a) Obstetrical nurses rnay be a b l e t o teach certain skills to midwives .

8b) Teaching skills to midwives is:

not important ------- very important to me to me

9a) I b e l i e v e t h a t o b s t e t r i c a l n u r s e s and midwives are considered colleagues.

9b) Being considered a colleague by a midwife is:

not important ------- very important to me t o me

10a) The obstetrical nurse w i l l not get t o provide care for as many uncomplicated births if they collaborate with midwives in the care of midwifery clients.

lob) Providing care for uncornplicated births is:

not important very important to me to me

Ila) I am concerned about who has legal responsibility for the patient if 1 am caring for a midwifery client.

llb) Knowing who has legal responsibility for the rnidwifery client is:

not important ------- very important to me to me

12a) The obstetrical nurse will have to care for midwifery patients admitted to the hospital after a home birth has developed complications.

12b) Helping midwives with clients who had intended a home birth but developed complications is:

not important ------- very important to me to me

Appendix D: The Direct Measurement of Subjective Norm

This line represents your rating of the extent to which

important others (e.g. nursing unit manager, team leader,

hospital administration, physicians, nursing colleagues) approve

or disapprove of you collaborating with midwives. Please make a

mark through or across that part of the line which best

represents the extent to which "important others" approve or

disapprove of you collaborating with midwives in the care of

midwifery clients.

1 feel that "important others"

Disapprove

100

Approve

of me collaborating with midwives in the care of midwifery

clients.

Appendix E: The Indirect Measurement of Subjective Nom

1 2 3 4 5 6 7 va= atrongly diaagrea neutral agme atrongly VerY

rtrongly diaagree agree etrongly àisagtee agreo

la) My nursing unit manager thinks that 1 should collaborate with midwives .

Ib) 1 collaborate with midwives because my nursing manager thinks 1 should.

2a) The hosp i t a l administration thinks that 1 should co l l abora te with midwives.

2b) 1 co l l abora te with midwives because the hospital administration thinks 1 should.

3a) The physicians 1 work with think that 1 should collaborate with midwives.

3b) 1 co l l abora te with midwives because the physicians 1 work with think 1 should.

1 2 3 4 5 6 7 Va- atrongly disrgree neutral agrw strongly V e r Y strongly diaagree agree strongly diaagree agree

4a) My n u r s i n g c o l l e a g u e s t h i n k t h a t 1 s h o u l d c o l l a b o r a t e w i t h midwives,

4b) I collaborate with midwives b e c a u s e my nursing c o l l e a g u e s t h i n k 1 s h o u l d .

5a) My charge n u r s e / t e a m leader thinks that 1 should collaborate with midwives.

5b) 1 c o l l a b o r a t e w i t h midwives because my charge n u r s e / t e a m leader thinks 1 s h o u l d .

Appendix F: The Direct Measurement of Perceived Behavioral Control

This line represents your evaluation of whether it is

eaay or âifficult to collaborata with midwives in the care of

midwifery clients. Please place a mark through or across that

p a r t of the l i n e t h a t best represents your perceived ease o r

difficulty in collaborating with midwives.

Collaborating with midwives is:

Dif ficult Eas y

Appendix G: The Indirect Measurement of Perceived Behavioural Control

Please indicate your agreement or disagreement with the following statements by circling the most appropriate response number. Please do not circle between nurnbers.

1. Obstetrical nurses and midwives hold a similar philosophy of care ( L e . continuity of care, low interventions, support during labour) .

lb) 1 collaborate with midwives because midwives hold a similar philosophy of care:

likely - - - - u n l i k e l y

2. 1 have had previous positive experiences with midwives.

1 2 3 4 5 6 7

2b) 1 collaborate with midwives because of rny previous experience with midwives.

likely ------- unlikely

3a) Obstetrical nurses believe that midwifery care is an exciting alternative to the rnedical model.

3b) 1 collaborate with midwives because I feel that midwifery care is an exciting alternative to the medical model.

1 2 3 4 5 v=Y atrongly âiaagree neu-al agree

strongly diaagree disagreo

7 Vary

atxongly agree

4a) O b s t e t r i c a l n u r s e s w i l l c o l l a b o r a t e wi th midwives a f t e r a t r a n s f e r o f c a r e because c o l l a b o r a t i o n r e s p e c t s t h e midwife as p r imary c a r e g i v e r , and t h i s a l l ows f o r c o n t i n u i t y o f c a r e .

4b) 1 c o l l a b o r a t e w i th rnidwives a f t e r a t r a n s f e r 1 r e s p e c t them a s prirnary c a r e g i v e r .

l i k e l y -------

5a) 1 f e e l t h a t the p r a c t i c e of midwifery h e a l t h o f mothers and t h e i r i n f a n t s .

6 7

of care because

u n l i k e l y

i s dangerous t o t h e

5b) 1 do n o t c o l l a b o r a t e w i th midwives because 1 f e e l t h a t t h e p r a c t i c e of midwifery i s dangerous t o t h e h e a l t h o f mothers and b a b i e s .

l i k e l y

6a ) 1 f e e l t h a t midwifery e d u c a t i o n shou ld r e q u i r e a n u r s i n g deg ree a s a p r e r e q u i s i t e .

6b) 1 do not c o l l a b o r a t e w i th rnidwives because 1 b e l i e v e t h a t midwifery educa t i on shou ld require a n u r s i n g degree as a p r e r e q u i s i t e .

l i k e l y ------- u n l i k e l y

7a) 1 feel t h a t n u r s i n g should be a foundation f o r midwifery e d u c a t i o n ,

7 VOIY

8 trongly agrw

7b) 1 do not collaborate with midwives because 1 be lieve that nursing should be a foundation for midwifery education.

8a) 1 am obligated to work with midwives in the care of midwifery clients.

8b) 1 may be obligated to work with midwives, but I do not try to attain a positive working relationship with them.

likely ----

9a) Obstetrical nurses may legalization of midwifery.

1 2 3

lose their jobs

unli kel y

because of t h e

9b) I do not collaborate with midwives because obstetrical nurses may lose their jobs because of midwives.

likely ------- unlikely

10a) Obstetrical n u r s e s have d i f f i c u l t y collaborating w i t h midwives because they f ee l that home births are unsafe.

lob) 1 do not collaborate with midwives because 1 be l ieve home births a r e unsafe.

likely ------- unli ke ly

1 2 3 4 5 va- strongly diaag~ee nouba1 rgree atrongly diaagree disagree

7 ''==Y atrongly agree

Ila) Obstetrical nurses feel cornfortable carrying out orders written by midwives.

llb) I carry o u t orders w r i t t e n by midwives.

li kely ------- u n l i k e l y

Appendix H: P e r s o n a 1 Data Form

P l e a s e answer the f o l l o w i n g q u e s t i o n s .

1. Age:

2. Sex: Male Female

3. Please i n d i c a t e a l 1 of your I e v e l s o f e d u c a t i o n : diploma program BScN B a c c a l a u r e a t e d e g r e e (non n u r s i n g ) Midwife

-

MScN o r MN Mas te r s (non n u r s i n g ) PhD ( n u r s i n g ) PhD (non n u r s i n g ) o t h e r p l e a s e specify

4 . Years of o b s t e t r i c a l n u r s i n g e x p e r i e n c e

5. Years o f o the r n u r s i n g e x p e r i e n c e

6. Years (if any) of p r e v i o u s e x p e r i e n c e in practising midwifery i n a Country other t h a n Canada

7 . Have you worked wi th a midwife i n t h e c a r e o f a midwi fe ry c l i e n t who had a h o s p i t a l b i r t h yes no

8 . Did you p a r t i c i p a t e i n the p lann ing process about t h e i n t e g r a t i o n of midwifery t o your h o s p i t a l ?

Appendix 1

Letter of Explanation for Potential Participants

Appendix 1: Letter of Explanation for Potential Participants

Dear Participant,

My name is Nancy Schottle and 1 am a registered nurse enrolled in the Master of Science in Nursing Program at the University of Toronto, under the supervision of Dr. Karyn Kaufman. As part of my program requirements, I am conducting a study for my thesis project.

The profession of midwifery attained full legal status in Ontario when the Regulated Health Professions Act was proclaimed law on Dec 31, 1994. Midwives have applied and received privileges at your hospital to practice midwifery. The purpose of this study is to examine nurses' attitudinal basis for collaborating with midwives. For the purpose of this study, collaboration betwmmn nura.8 and midwives will be d r f i n d a8 a ralrtionnhip chatactmzizd by a aanm of collmagueuhip and an abiancr o f oppoaing intatests and conflicta. T h i s study may assist hospital staff in the integration process of this new profession in Ontario.

Participation in this project will involve the completion of the Questionnaire (attached), which will take approximately 15 minutes of your time. Participation is completely voluntary and you may refuse to participate or answer any question. The questionnaire is anonymous and your responses will remain confidential. T h e r e is no way to link a questionnaire to a respondent. Please do not add any identifying marks to the questionnaire. Returning the questionnaire is considered your consent to participate. If you do not consent to take part in this study, it would be appreciated if you would place a check mark in the appropriate box (see ) .

Although you will not benefit directly from your participation in this study, it is anticipated that you will contribute significantly to the integration strategies for the profession of midwifery. Results from this project will be shared with al1 units upon cornpletion of this project.

If you have any questions about completing this questionnaire, you may c o n t a c t m e directly a t (519) 471-1578 o r D r . Karyn Kaufman at (416) 522-1155 ~ 5 2 2 4 . Please complete the questionnaire at a location which is private, at a time which is convenient to you, and d e p o s i t it in the sealed box l o c a t e d on y o u r unit. Thank you fcr helping me with t h i s project. Your time and effort are appreciated,

Sincerely,

Nancy schsttle, B.ScN., R.N.

Refusal to Participate

1 have read the information l e t t e x and 1 choose not to participate in this study

Place c h e c k mark in box

Appendix J

Instructions to Complete Questionnaire Given to P o t e n t i a l Participants

Appendix J: I n s t r u c t i o n s Given t o P a r t i c i p a n t s

fnstmactaona to Answar Items:

Answer items below by c i r c l i n g t h e number b e l i e f S. Example :

1 2 3 4 5 VerY atrongly disagree neutral agz-

itrongly diuagree diaagree

which r e p r e s e n t s your

6 7 8 trongly VeW agree s trongly

agroe

A. 1 l i k e c h o c o l a t e ice cream.

1 2 3 4 5 7 The c i rc le above would mean t h a t you s t r o n g l y a g r e e t h a t you like c h o c o l a t e ice cxeam.

Answer items below by making a check mark on o r through the answer U n e . Example:

B . Having a v a c a t i o n d u r i n g t h e summer is

very i m p o r t a n t n o t i m p o r t a n t t o m e to m e

The check mark above would mean t h a t hav ing a summer v a c a t i o n i s somewhat i m p o r t a n t t o you.

P l e a s e answer t h e items on t h e n e x t pages now. A l 1 i t e m s are t o be answered. I f you need any h e l p , p l e a s e ask the r e s e a r c h e r . I f you r e c e i v e d t h i s package from your charge nurse / t eam l e a d e r and you have any q u e s t i o n s about t h e i t e m s o r how t o answer them p l e a s e c a l 1 t h e r e s e a r c h e r a t (519) 471-1578 and reverse t h e c h a r g e s . She w i l l be happy t o assist you.

Thank you for youi: time and participation!

Appendix K

Measurernent of Prev ious Collaborative Practice- P a r t of P a r t i c i p a n t Questionnaire

Appendix K: Measuring Previous Collaborative Practice

This line represents your efforts ta &ta ta collaboratm w i t h

miduives in the care of midwifery clients. Please place a mark

through or across that part of the line which best represents the

amount of your past effort in collaborating with midwives in the

care of midwifery clients.

Since the introduction of l ega l i zed midwifery to my h o s p i t a l , 1 have provided:

O No

Collaborative Effort

100 Full

Collaborative Effort

When caring for a midwifery client.

Appendix L

R e s u l t s of Direct Measurement of Behav ioura l A t t i t u d e - Semant ic D i f f e r e n t i a l Scales

Appendix L: The Direct Measusement of Behavioural Attitude: Means and Standard Deviations on the Semantic Differential Scales

' Semantic Dif f erential good - bad harmf ul- benef icial pleasant - unpleasant desirable -

n 4 0

39

undesirable difficult -

4 1

easy threatening-

M 3.7

5. O

4 1

non- threatening important - unirn~ortant

s.d. 2.7

2 . 2

4.2

42

2. O

4.5

4 1

4 1

2 . O

2.9 2.0

4 . 1

4.0

2 .1

2 . 1

Appendices M-O

Results of Indirectly-Measured Independent Variables

Appendix M : The I n d i r e c t Measurement of Behavioural A t t i t u d e : Means and Standard Deviations

~ e h a v i o u r a l Belief n - M

Belief: Better Quality Materna1 Care 4 4 4 . 8 f rom Collaboration

Evaluation: Better Quality Materna1 Care 4 1 5 . 1 from Collab

Belief: Increased Client Satisfaction 4 2 4 . 2 2.0 from Collab

Evaluation: Increased Client 4 4 4.6 2.1 Satisfaction

Y Belief: fmproved Interprofessional Relations

Evaluation: fmproved Interpzofessional 4 5 4 - 8 1 .9 Relations

Belief : Enhanced Job Çatisf action 3 9 3,2 2.2

Evaluation: Enhanced Job Satisfaction 4 4 6,O 1.8

Belief: Collab is Time Consuminq 4 2 3.7 1.6

1 Evaluation: Collab is Time Consuminq 1 4 4 1 4 . 4 1 2 .O

Belief: Collab requires Role Change 4 1 4 . 3 2 . 1

Evaluation: Collab requires Role Change 4 3 2.6 2 . 1

1 Belief: Nurses can learn f rom miduives 1 4 2 1 3 . 2 1 2.1

Evaluation: Nurses can learn from 4 4 3 . 3 2 .3 midwives

1 Belief: Nurses can share knowledge to 4 2 5 . 8 1. O ' midwives Evaluation: Nurses sharing knowledge to 4 5 4 . 3 2 -1 midwives

Belief: Nurses and midwives are considered colleagues

Evaluation: Being considered colleagues 4 5 3 . 8 2.3

Belief: Caring for uncomplicated births 39 4.5 1.7

Evaluation: Uncomplicated births are important

Belief: Legal Responsibility of client 42 2 . 2 1.6

Evaluation: Legal responsibiiity is 4 4 1.4 O. 9 important

1 Belief: Midvifary leads f o home birth 1 42 1 2.7 1 2.0 complications

Evaluation: Home birth complications are 4 4 4 .9 2.0 imp t

i

Appendix N: The Indirect Measurement of Subjective Norm : Mean Scores and Standard Deviations

Normative Beliefs n M - s.d.

Nursing Unit Administrator 40 5.3 1.0

Motivation to Comply 1 43 1 4 . 5 1 1.8

Hospital Administration 43 5.4 1 . 3

Motivation to Comply 42 3 . 5 1.8

Physicians 1 43 1 2 . 9 1 1.4

Motivation to Comply 1 43 1 2.7 1 1 . 4

Nursing Colieagues 1 43 1 3.4 1 1 . 6

Motivation to Comply 1 43 1 2.4 1 1 . 2

Charge Nurse/Team Leader 1 42 1 3 .6 1 1.5 --

Motivation to Comply 1 43 1 2.5 1.2

Appendix O: The Indirect Measurement of Perceived Behavioural Control: Means and Standard Deviations

Control Belief n - M s.d.

Belief: Nurses have similar 43 5 . O 1.7 philosophy

Perceived Power: Nurses have 42 4.4 1.9 similar philosophy

Belief: Previous positive 41 4.3 1.8 experience with midwives

Perceived Power: Previous positive experience

Belief: Midwifery as alternative to Medicine

Perceived Power: Midwifery as 42 3.6 2.1 alternative to Meds

Belief: Collab allows for 4 1 3.8 1.9 continuity of care

Perceived Power: Continuity of care 41 3.3 2.0

Belief: Midwifery is dangerous practice

Perceived Power: Midwifery is 40 5. O dangerous

Belief: Nursing should be 1.9 foundation to midwifery

.. --

Perceived Power: Nursing as foundation to midwif ery

Belief: Nurses are obligated to collaborate

Perceived Power: Being obligated to 40 5.3 1.7 collaborate

Belief: Nurses will lose jobs 41 3.9 1.8 because of midwifery

Perceived Power: Nurses losing jobs 1 41 1 5.3 1 1.8

Belief: Home b i r t h s are unsafe 1 40 1 3.6 1 1.8

Perceived Power: Home births being unsafe

Belief: Nurses will have orders from midwives

Perceived Power: Taking orders from midwives

Appendix P

Tsanscribed Comments From Questionnaires

Appendix P: Comments Written on the Questionnaires

Comments about Plannina Process

* "We were not asked. Our opinion didnlt matter"

"Participation was not offered"

Comments About Collaboration

* "1 collaborate with midwives because 1 feel cornfortable with it. Collaborate because i t l s the Law"

* (collaborating) . . "this depends entirely on the attitude of the midwives"

* "1 consider the midwives to be part of the 'team' but many of their clients who plan a home birth, and for one of many reasons are admitted to hospital for hand over of care, itls the client, 1 find, the rnost difficult to build a relationship with. The client must see nursing as interventionalists, unfortunately we (nursing) are not treated kindly by the clients. The client is usually very upset that their birthing plans did not go as hoped."

* "Midwife and pt should form their interpersonal relationship from the beginning of pregnancy to the end. So nurses should not get involved as a 3rd party"

* "But we have NO choice. The patient is important to US l'

* "1 do not have a choice"

Comments About the Questionnaire

* "This survey will be inaccurate as al1 questions are written with a slantl'

* "This questionnaire is very bias and shows that the person for these questions is not well informed on the topic"

* "Questions don't work because only work with midwives when care handed over because of problems"

Comments About Midwifery Education

* "We would like the midwives to view background course of British trained midwives. Trained midwives should be able to cope in a l 1 aspect of care just as RN's do"

* "We may not share midwives' views!! A lot of us nurses are trained midwives. Why when midwifery was being implemented were we not asked to qualify as midwives? But now, we should share our expertise. That's not ethical. We are human beings! !"

* "We could teach midwives some s k i l l s . We have years of experiences as certified midwives"

* "Since the nurse is the super experienced person they should have been allowed to be grand mothered in as midwives. Midwives should take care of the total pt care. The pt will see who is the expert!!"

* .... nursing should be a foundation for nidwifery education. " YES, DEFINITELY ! ! "

Comments About Job Satisfaction

* "We are happy doing what we are doing. We do not need to learn anything from rnidwives. The babies I delivered are now teenagers"

Comments About Midwives

* "So called midwives have a chip on their shouldersw

* "1 may not agree on midwives' judgernent"

* "Patientls with good insight w i l l r ea l ize that after al1 nurses are the more experienced person to give total caret'

* "Primary caregiver should be capable to give TOTAL CARE "