Jenkinson Bec, Kruske Sue, Stapleton Helen, Beckmann Michael, Reynolds Maree, Kildea Sue
School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia; Mater Research Institute, The University of Queensland, Brisbane, Australia.
School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia.
Women Birth. 2016 Dec;29(6):531-541. doi: 10.1016/j.wombi.2016.05.005. Epub 2016 Jun 8.
PROBLEM/BACKGROUND: Ethical and professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy; the right to refuse care is well established. However, the existing literature is largely silent on the appropriate clinical responses when pregnant women refuse recommended care, and accounts of disrespectful interactions and conflict are numerous. Policies and processes to support women and maternity care providers are rare and unstudied.
To document the perspectives of women, midwives and obstetricians following the introduction of a structured process (Maternity Care Plan; MCP) to document refusal of recommended maternity care in a large tertiary maternity unit.
A qualitative, interpretive study involved thematic analysis of in-depth semi-structured interviews with women (n=9), midwives (n=12) and obstetricians (n=9).
Four major themes were identified including: 'Reassuring and supporting clinicians'; 'Keeping the door open'; 'Varied awareness, criteria and use of the MCP process' and 'No guarantees'.
Clinicians felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care. This, in turn, protected women's access to maternity care. However, the process could not guarantee favourable responses from other clinicians subsequently involved in the woman's care. Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident. These limitations may have been attributable to the absence of agreed criteria for initiating the MCP process and fragmented care. Varying awareness and use of the process also diminished women's access to it.
问题/背景：针对助产士和产科医生的伦理与专业指南强调知情同意以及对患者自主权的尊重；拒绝治疗的权利已得到充分确立。然而，现有文献在孕妇拒绝推荐治疗时的恰当临床应对方面大多未作阐述，而关于不尊重互动和冲突的报道却屡见不鲜。支持女性和产科护理提供者的政策及流程稀少且未经研究。
记录在一家大型三级产科单位引入结构化流程（产科护理计划；MCP）以记录对推荐产科护理的拒绝后，女性、助产士和产科医生的观点。
一项定性的解释性研究，对女性（n = 9）、助产士（n = 12）和产科医生（n = 9）进行深入半结构化访谈，并进行主题分析。
确定了四个主要主题，包括：“使临床医生安心并给予支持”；“保持沟通渠道畅通”；“对MCP流程的认识、标准及使用存在差异”以及“无法保证”。
临床医生通过结构化的文件记录和沟通流程感到受到保护且安心，并重视让女性参与医院护理。这反过来又保障了女性获得产科护理的机会。然而，该流程无法保证后续参与该女性护理的其他临床医生会做出积极回应。女性和一些助产士认为存在风险方面的持续讨论，即存在同意接受推荐治疗的压力，仍然很明显。这些限制可能归因于启动MCP流程缺乏商定的标准以及护理的碎片化。对该流程的认识和使用存在差异也减少了女性对其的利用。
