Professional Documents
Culture Documents
a r t i c l e i n f o a b s t r a c t
Article history: A retrospective cohort study was conducted with 83 midwives working across the Western Australian
Accepted 11 June 2015 (WA) maternity sector who graduated from one WA University. We explored midwives' attitudes and
utilisation of research and assertive communication in addition to perceptions of their educational
Keywords: preparation to advocate for women. The greatest opportunity for research exposure was working on a
Research utilisation clinical audit (25.3%). No differences were found between graduate groups using the Edmonton Research
Patient advocacy
Orientation subscales, although findings suggest a positive view towards research. Midwives were more
Graduate midwives
likely to be assertive with their clinical colleagues than a midwifery manager or medical colleague when:
expressing their opinions (P ¼ <0.001); saying no (P ¼ <0.001); allowing others to express their opinions
(P ¼ <0.001); and making suggestions to others (P ¼ 0.025). A qualitative phase with 15 midwives
explored concepts around advocating for women. Four themes emerged: ‘having the confidence to
question’, ‘communication skills’, work environment’ and ‘knowing the woman and what she wants’.
Findings suggest strategies are needed in their entry to practice preparation and ongoing professional
development to facilitate research engagement. Using assertive behaviour to provide feedback to clinical
colleagues warrants attention to enhance reflective practice. Building communication skills through
observing positive role models and participating in role play was highlighted.
© 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2015.06.004
1471-5953/© 2015 Elsevier Ltd. All rights reserved.
306 Y. Hauck et al. / Nurse Education in Practice 16 (2016) 305e311
Although health professionals such as midwives, nurses and period they were students. Ethical approval was obtained from the
occupational therapists have reported positive attitudes toward university (SONM44-2012). Graduates were also given the option
research, confidence in their knowledge and research skills con- to express interest in participating in an individual telephone
tinues to be less than optimistic (Lyons et al., 2010; Smirnoff et al., interview with a non-university based midwife to ensure they felt
2007; Witzke et al., 2008) reflecting reduced involvement comfortable providing constructive feedback regarding their uni-
(Smirnoff et al., 2007). What we do know is that participation has versity preparation and workplace support.
been positively correlated with education levels, completion of a
research course, prior experience in research, engagement with Data collection and analysis
journal articles, administrative support, and knowledge and con-
fidence in using research (Smirnoff et al., 2007). Demographic data such as gender, age, and clinical experience
To achieve woman centred care in midwifery and foster were collected including time since completion of their midwifery
informed choice, it is imperative that midwives are able to provide course; current employment; clinical experience in midwifery;
full and unbiased disclosure of evidence. If midwives are not able to exposure to past research units of study; experience with research
interpret and disseminate research or withhold information due to related opportunities since graduation and a ranking of their cur-
paternalistic attitudes, ritualistic practice or negative attitudes to rent research knowledge. The Edmonton Research Orientation
research, evidence based practice is not being achieved (Poat et al., Scale (EROS), a two part self-report questionnaire was used
2003). Having a university education that provides knowledge on (McCleary and Brown, 2002) to collect data on research knowledge.
research designs or how to read and use research contributes to a One item seeking a ranking from a five point Likert scale (very poor
positive attitude and greater utilisation for nurses (McCleary and to very good) around perceived understanding of research topics
Brown, 2003). The challenge for midwifery education, therefore, was expanded from five to ten topics. Aside from this item, the
is to ensure midwives have adequate knowledge, skills and positive EROS was unchanged and included four subscales: Valuing
attitudes to interpret and translate research into evidence based Research (8 items) with a Cronbach alpha (internal consistency)
practice. Appropriate use of assertive behaviour is also essential to a ¼ 0.82; Research Involvement (7 items) a ¼ 0.79; Being at the
providing women centred care. Nurses and midwives acknowledge Leading Edge (6 items) a ¼ 0.68; and Evidence Based Practice (10
their responsibility to their clients as a key factor for being assertive items) a ¼ 0.87. The EROS Scale total reported Cronbach alpha was
(Timmins and McCabe, 2005). a ¼ 0.94 (McCleary and Brown, 2002). A 24 items assertive
Early career midwives face numerous challenges during their behaviour scale developed and tested in Ireland (Cronbach alpha of
transition to the profession such as developing personal attributes, 0.88) with nurses and midwives (Timmins and McCabe, 2005) was
understanding the influences of the workplace and consolidating used seeking frequency of eight assertive behaviours with three
their skills in client advocacy (Barry et al., 2013). Core competencies groups (clinical midwifery colleagues, midwifery managers and
for Australian midwives include the skills to assertively commu- medical colleagues).
nicate evidence whilst advocating for women's choice (NMBA, Data were analysed in SPSS for Windows (Version 21.0) with
2006). Incorporating research knowledge and communication significance being set at 5%. Medians and interquartile ranges were
skills such as assertiveness behaviours in the educational prepa- used to summarise continuous data. To compare the medians ob-
ration of midwives is one strategy to address this competency. tained from the three groups (those qualifying in 2010, 2011 and
However, early career support by their employer is also a key factor 2012) a non-parametric median test was utilised and for means
to facilitate client advocacy (Barry et al., 2014). To gain insight and ANOVA was used. Frequency distributions summarised categorical
contribute to our knowledge around client advocacy, the aim of this data. Chi-squares compared age and working characteristics be-
study was to explore early career midwives' attitudes and uti- tween the groups. Cochran's Q test was used to compare the three
lisation of research and perceptions of their educational prepara- correlated proportions for assertive behaviours between. Internal
tion in relation to research knowledge and assertive consistency of the four EROS sub scales (evidence based practice,
communication skills. valuing research, research involvement and leading edge) and eight
assertive behaviour items computed by Cronbach's alpha. The five
Design point Likert scale for rating of research knowledge and assertive
behaviour was converted to a binary variable, with ratings one
A retrospective cohort cross sectional study was conducted with (very poor or never), two (poor or seldom) and 3 three (sometimes)
early career midwives who had completed their education within classed as ‘poor’, and ratings four (good or usually) and five (very
the past three years. A qualitative phase was also undertaken to good or always) classed as ‘good’.
further explore in depth the concept of using evidence to advocate The qualitative component incorporated one-on-one telephone
for women's choice. Mixed methods have been recognised as useful interviews with interested midwives who completed the ‘expres-
due to recognised benefits from both research paradigms sion of interest’ invitation in the survey. All digitally recorded in-
(Nieswiadomy, 2012). Quantitative methods allow for objective terviews employed a semi-structured approach to allow for a
measurement of variables and their relationships and qualitative “flexible and fluid structure” suitable to generate in-depth data
methods provide data that offers a depth of understanding of a (Lewis-Beck et al., 2004, p.1020). Data analysis of transcripts
phenomenon (Langford and Young, 2013). involved a modified constant comparison method to capture and
describe the midwives' experiences (Schneider et al., 2007).
Sample and recruitment Themes and subthemes extracted from the transcripts were final-
ised through collaboration between research team members. Data
The study population included graduate midwives from one collection and analysis ceased once data saturation was reached.
Western Australian (WA) University who completed the post-
graduate midwifery course following a previous nursing qualifica- Results
tion. The midwives were working across the WA health sector in
private and public hospitals. Permission was granted to access The total cohort of potential graduates was 231. We posted
university records for eligible graduates (2010e2012) to obtain surveys or emailed an information letter and an online survey link
contact information such as an email or postal address during the to all graduates. Unfortunately, 50 were not able to be contacted
Y. Hauck et al. / Nurse Education in Practice 16 (2016) 305e311 307
through emails or postal surveys returned, leaving a potential medical colleague (97% versus 75% and 85%; P ¼ <0.001); make
cohort of 181. We received 87 surveys (55 postal and 32 online), a suggestions to others if they were a clinical colleague rather than a
response of 48.1%. However, due to substantial missing data, four manager or medical colleague (54% versus 38% and 48%; P ¼ 0.025);
were not useable leaving a total response rate of 46% (n ¼ 83). and compliment others if they were a clinical colleague rather than
A summary of demographic data, research education within a manager or medical colleague (95% versus 70% and 60%;
nursing and midwifery courses and a subscale scores from the EROS P ¼ <0.001).
are provided in Table 1. As anticipated there was a significant dif- Although 24 midwives expressed an interest in participating in
ference between the three graduate groups around months work- an in-depth interview only 15 could be contacted. We attempted to
ing as a midwife as the 2010 group had three years of employment contact all who had expressed interest but after three attempts we
whereas the 2012 group had less than 12 months. However, no did not pursue further contact. Data saturation was achieved with
differences were found for age, months working as a nurse, number 15 participants. Of these 15 participants, four graduated in 2010,
of research units completed and scores for valuing research, five in 2011 and six in 2012. Four themes and three subthemes were
research involvement, evidence based practice and being at the extracted from analysis (Table 4). Presentation of the themes and
leading edge of research. In relation to exposure to research op- subthemes will be presented and supported by direct participant
portunities, 21 (25.3%) had worked on a clinical audit; 14 (16.9%) quotes using a coding system (P1eP15).
had worked on a quality improvement project or attended a con- The first theme ‘Having the confidence to question’ captures the
ference; 12 (14.5%) had collected data or were a participant in graduate midwives' perception that confidence to advocate is built
research; 8 (9.6%) had contributed to writing a proposal; 7 (8.4%) on being informed and having the skills to support or defend an
contributed to a report or publication and 3 (3.6%) had given a idea or fact. I guess knowing what the evidence and the policies were
presentation at a conference. Descending mean values across the … gave me the knowledge to actually speak up and say something
graduate groups revealed valuing research ranked highest (31.3 out (P13). The midwives also suggested that being able to use academic
of 40); being at the leading edge of research (23.7 out of 30); evi- knowledge and information is the foundation of offering informed
dence based practice (38.3 out of 50) and research involvement choice to women and respecting her wishes: having the knowledge
(17.6 out of 35). behind you and knowing what you're talking about to confidently go
Table 2 provides a summary of the graduates' ranking of their “ok this is what I think's best for the woman, we're all here for the
research knowledge. No differences were found between groups woman” (P9).
with perceptions of knowledge to use strategies to apply research ‘Having recent knowledge’, a subtheme under ‘Having the
to practice and using evidence to change policy ranked highest confidence to question’ related to how the midwives felt it was
(46% and 45% respectively). Although 44% indicated they could important to ensure their knowledge reflected the latest evidence
interpret qualitative journal articles, only 27% felt they understood in order to inform women and back up their requests if they are
qualitative methodology. Having the knowledge to interpret challenged by the maternity care team. If you know what the recent
quantitative journal articles was noted by 40% corresponding research and things say and you've got that knowledge behind you
closely with the 43% who felt they understood quantitative then you can feel more confident in the information that you're giving
methodology. (P1). Offering women knowledge so they can make an informed
Midwives were asked if they used assertive behaviour with decision is a responsibility that wasn't taken lightly. If I didn't have
clinical midwifery colleagues, midwifery managers and medical the knowledge I wouldn't know to question or to challenge a decision
colleagues (Table 3). Midwives were more likely to: express their they made or some of the things that are asked of me … being current
opinions to clinical colleagues than midwifery managers or medical in my knowledge of the evidence that supports the practice then I feel
colleagues (61% versus 30% and 34%; P ¼ <0.001); say no to clinical in the right place to advocate for the woman (P4).
colleagues rather than midwifery managers or medical colleagues In relation to where the midwives sought knowledge, there was
(63% versus 37% and 35%; P ¼ <0.001); allow others to express their a substantial reliance on clinical guidelines for recent evidence: I
opinions if they were a clinical colleague rather than a manager or tend to refer to the [hospital] guidelines more than anything else (P5).
Table 1
Demographics, research education and Edmonton Research Orientation Subscale scores for three graduate groups.
Age (years)
20e30 15 (54) 11 (48) 20 (69) 0.192 46 (58)
31e40 8 (28) 10 (43) 4 (14) 22 (27)
41ee50 5 (18) 2 (9) 5 (17) 12 (15)
Variables may not add up to 100% due to missing values for some variables; IQR ¼ interquartile range. R ¼ range M ¼ mean.
*p Value one way ANOVA ± p value for non-parametric; Cronbach alpha for subscales - evidence based practice ¼ 0.81, Valuing research 0.77. Research involvement 0.80 and
Leading edge 0.71.
308 Y. Hauck et al. / Nurse Education in Practice 16 (2016) 305e311
Table 2
Ranking of research knowledge as good or very good according for three graduate groups.
Table 3
Midwives who usually or always use assertive behaviour with three groups of colleagues.
Assertive behaviour Clinical midwifery colleagues Midwifery managers Medical colleagues P value
n (%) n (%) n (%)
Having trust in the guidelines was paramount because the gradu- see a weight lifted off them and they become more empowered
ates acknowledged that they don't have time to conduct their own themselves (P8).
search of the literature. Having knowledge … how to access the Having education sessions on communication skills were
policies, procedures … you've got to trust that the policies and pro- considered necessary and valuable. In fact, midwives recom-
cedures when they get changed are being changed to the best practice mended more use of role play in their education: university role play
(P7). even, just practising … in groups of, speaking up in certain scenarios
The second theme, ‘communication skills, acknowledges the and situations that might have helped (P13). Role play in combina-
importance of being able to act upon the knowledge to be an tion with challenging realistic scenarios were suggested: you could
advocate. Midwives noted how being assertive was recognised as do like a scenario based thing where … this is the situation, this is
essential and how previous life experience such as past nursing what's been ordered by an obstetrician or a GP obstetrician and … just
roles may have contributed to this awareness. Having good a bit of a training, scenario thing on advocating for the woman, I feel
communication skills, respectful communication skills, the ability to that would be really beneficial (P14).
listen, mutual respect I think that goes a long way (P12). The mid- ‘Access to role models’ was a subtheme under ‘communication
wives suggested that to work effectively in a team … you need to be skills’. Some graduate midwives shared examples of witnessing
able communicate positively with the whole team and then you'll be questioning approaches by other members of staff and how this
able to make changes and advocate for the women. It's about having offered reassurance that these practices are not only acceptable but
good communication with the whole team … do it with a smile on your expected. I think it helps you in your confidence and I think it helps if
face (P9). Although these midwives were previous nurses, the new you know that other people have tried it and it's worked then you can
role and different hierarchical context did not always mean open feel more confident that what you're endorsing does work (P3).
communication was encouraged or appropriately role modelled: Another graduate stated: it's having mentors there who you can sort
my first experience of midwifery when I first graduated, I don't think of role model off. You see them doing it and the way they go about it
was a very good one and I think a lot of that was because you weren't (P9).
able to communicate effectively with medical staff and you didn't get Midwives noted how they then felt more comfortable to chal-
the support that you really needed from senior midwifery staff (P15). lenge through questioning after observing role models who suc-
Midwives also offered examples of using communication skills cessfully demonstrated this practice. So if you're on with a
to empower women to question and gather information to make an coordinator who is calm and is a good advocate themselves then it's
informed decision: use communication to help them and you almost definitely going to promote that in yourself (P15). Access to positive
role models encouraged the midwives to use assertive communi-
Table 4
Themes and subthemes.
cation in advocating for women: I felt quite prepared … it's just a
matter of … tapping into those resources and then using them in your
Theme and subthemes midwifery practice and I think the more you do that the better and
Theme e having the confidence to question more efficient and competent and confident you become (P5).
Subtheme e having recent knowledge ‘Work environment’ was another theme that influenced mid-
Theme e communication skills
wives' opportunities to advocate for women. If knowledge is
Subtheme e access to role models
Theme e work environment valued, the environment is open to change and evidence-based
Subtheme e knowing when to advocate and when to let go practise is standard, the midwife feels supported to present
Theme e knowing the woman and what she wants choice so the woman makes an informed decision. I think being in
Y. Hauck et al. / Nurse Education in Practice 16 (2016) 305e311 309
the public system is really good ‘cause it [care] is all based on guide- differences across the graduate groups. However, there were dis-
lines so as a midwife you can say to a doctor or an obstetrician that this crepancies between being able to interpret and understand quali-
is the guidelines and things so that's really good (P6). tative research, in particular. However, having a positive attitude
In cases where the work environment is based on authority and does not always correspond with knowledge or engagement in
hierarchy the midwife can feel undermined or ignored and unable research activities. For example, findings from an American study in
to have their voice heard. Challenges of being cut off, of not being a large medical centre found that although nurses had positive
listened to of being, being just a midwife. It's a subservient role and attitudes their actual involvement in research activities did not
continues to be viewed as a subservient role (P12). Again midwifery reflect corresponding engagement (Smirnoff et al., 2007). Positive
role models in work environments not supportive of questioning attitudes were not enough to increase involvement and additional
also influence whether the midwife feels comfortable to question: institutional infrastructure and educational support were recom-
There was a senior midwife and I think it was even the coordinator mended. Fear, apprehension and anxiety around research for
standing behind him and she said nothing. So it was like well what graduate nursing students in Jamaica were allayed during their
hope do I have if … [they don't speak up] (P15). postgraduate studies due to genuine expressions of interest, and
‘Knowing when to advocate and when to let go’ is a subtheme affirmation and respect of their learning needs by academic staff.
under ‘work environment’ highlighting how the situation and Improvements in attitudes were realised through expert guidance
timing can influence the success of an opportunity to advocate for a within a supportive learning environment (Lindo et al., 2013). A
woman. Midwives shared an awareness of potentially causing prospective follow up study with nursing students in Sweden re-
conflict when giving women options which opposed the expecta- ported a modest intention to use research evidence and how these
tion of the maternity care team: what's better for the patient is you intentions were an important predictor of subsequent research use
let it go and the way I justify it for myself is I say well they chose to go one year following graduation (Forsman et al., 2012). Focussing on
to this person [health professional] … that's why they're having this strengthening students' research knowledge through critical re-
done to them … but you wonder how much knowledge they have (P8). view of educational curriculum around methodologies is recom-
There are times when being assertive on the woman's behalf is mended with midwifery students to sustain and build upon current
more likely to cause confusion and angst. Pick your challenge positive attitudes around research.
depending which doctor and what else is going on within the envi- Midwives ranked their knowledge of strategies to apply
ronment … the whole point of advocacy … do you want any friction research into practice as highest at 46% which still reflected less
between yourself and the doctor to be evident to the families (P2). than half of the cohort. This interpretation of the ease in translating
The final theme ‘knowing the woman and what she wants’ re- evidence into practice is concerning given literature suggesting that
flected the midwives acknowledgement that in continuity of care although midwives often assume implementation will ‘just
models the woman's preferences would be known by the care happen’, there are recognised barriers influencing translation into
provider and discussed throughout pregnancy. I'd built this bond practice (Hunter, 2013). Barriers can include characteristics of the
with my patient and being in a Caesarean, saw her in the pre- evidence; the context into which the evidence is to be introduced;
admission clinic and so I guess that maybe my relationship with the the issue and its significance to holders of authoritative knowledge;
patient was quite important to me and that's what helped me … speak who will use the evidence and how the evidence fits with other
up for myself and for the patient as well (P11). In the situation when knowledge sources (Hunter, 2013). Consciously using dissemina-
the woman has not met the midwife who is looking after her, the tion strategies to facilitate translation of evidence into practice are
midwife must quickly build a rapport and make important choices ongoing challenges for midwifery researchers and clinicians.
and decisions at a point of potential vulnerability. I don't know how Graduates may have an unrealistic view around the ease of using
much discussion was around that and that's one of the very hard evidence to change policy and practice which could contribute to
things about it is you know taking over and not having the continuity. disappointment or frustration in the process.
Like I'm meeting her for the first time … very difficult (P14). The Our findings suggest that opportunities to develop research skills
participants suggested that the woman may be more susceptible to through quality improvement (QI) projects or research studies were
being accepting of what is put in front of her: limited with less than 20 percent ranking their knowledge to
develop a research proposal or QI application as good or very good.
mothers that have come in and said they definitely don't want an
Research education for graduate nurses and midwives in the United
epidural but you have an anaesthetist or a doctor that'll come and
Kingdom (UK) was found to be a main determinant of research
say ‘I want them to have an epidural’ and trying to be the advo-
engagement in practice (Snelgrove and James, 2011). In fact, UK
cate for the woman saying ‘no this is what she has asked’ (P7).
graduates wanted increased opportunities for conducting research
to maintain their research knowledge and skills and although they
Discussion held strong intentions to conduct research they were often
discouraged by lack of institutional and cultural support (Snelgrove
Findings suggest that although graduate midwives valued and and James, 2011). A positive attitude towards research by senior
generally held a positive view towards research, few had found the nurse managers has also been found to influence others to establish
opportunity to work in research apart from a clinical audit. Our a research culture and promote evidence-based practice (Bonner
findings also suggest that graduate midwives do not use assertive and Sando, 2008). This highlights the importance of the work
behaviour to offer constructive criticism to their clinical midwifery environment to provide early positive research experiences essen-
colleagues but are more forthcoming with their managers and med- tial to building research capacity and ensure care is evidence-based.
ical colleagues. Indeed building communication skills through role Cooke (2005) proposed a framework to build research capacity
models who could demonstrate appropriate assertiveness behaviour which includes developing skills, supporting partnerships,
within the clinical setting was highlighted within our themes. ensuring the research is ‘close to practice’, ensuing dissemination,
and building sustainability and continuity through individual, team
Are we doing enough to facilitate research engagement? and organisational networks. Midwives in this study confirmed
that knowledge was important to be able to advocate for women,
Findings from the research orientation subscales confirm that however, they relied strongly on clinical guidelines which they
midwives generally held a positive view towards research with no expected represented the best evidence. Health services must
310 Y. Hauck et al. / Nurse Education in Practice 16 (2016) 305e311
therefore ensure clinical guidelines are regularly reviewed and Australian university over a three year period with a restricted
updated so their employees and clients can be confident the sample size. Findings reflect the educational offerings of one
guidelines reflect recent evidence. postgraduate midwifery course; however, the curriculum of this
accredited course does meet NMBA (2006) national competency
Reflective practice: valuing the feedback cycle standards for the midwife.
Mann, K., Gordon, J., MacLeod, A., 2009. Reflection and reflective practice in health Rafferty, A.M., Traynor, M., Thompson, D.R., Ilott, I., White, E., 2003. Research in
professionals education: a systematic review. Adv. Health Sci. Educ. Theory nursing, midwifery, and the allied health professions: quantum leap required
Pract. 14 (4), 595e621. for quality research. BMJ Int. Ed. 326 (7394), 833e834.
McCleary, L., Brown, G., 2002. Use of the Edmonton research orientation scale with Reid, J., O'Reilly, R., Beale, B., Gillies, D., Connell, T., 2007. Research priorities of NSW
nurses. J. Nurs. Manag. 10 (3), 263e275. midwives. Women Birth 20 (2), 57e63.
McCleary, L., Brown, G., 2003. Association between nurses' education about Schneider, Z., Whitehead, D., Elliott, D., Lobiondo-Wood, G., Haber, J., 2007. Nursing
research and their research use. Nurs. Educ. Today 23, 556e565. & Midwifery Research: Methods and Appraisal for Evidence- Based Practice,
McNicholl, M.P., Coates, V., Dunne, K., 2008. Driving towards an improved research third ed. Mosby Elsevier, Sydney.
and development culture. J. Nurs. Manag. 16 (3), 344e351. Smirnoff, M., Ramirez, M., Kooplimae, L., Gibney, M., McEvoy, M.D., 2007. Nurses'
McVicar, A., Caan, W., 2005. Focus. Research capability in doctoral training: evi- attitudes toward nursing research at a metropolitan medical center. Appl. Nurs.
dence for increased diversity of skills in nursing research. J. Res. Nurs. 10 (6), Res. 20 (1), 24e31.
627e648. Snelgrove, S., James, M., 2011. Graduate nurses' and midwives' perceptions of
Murdoch-Eaton, D., Sandars, J., 2014. Reflection: moving from a mandatory ritual to research. J. Res. Nurs. 16 (1), 7e20.
meaningful professional development. Arch. Dis. Child. 99, 279e283. http:// Tashiro, J., Shimpuku, Y., Naruse, K., Maftuhah, Matsutani, M., 2013. Concept anal-
dx.doi.org/10.1136/archdischild-2013-303948. ysis of reflection in nursing professional development. Jpn. J. Nurs. Sci. 10 (2),
Muir, F., Scott, M., McConville, K., Watson, K., Behbehani, K., Sukkar, F., 2014. Taking 170e179. http://dx.doi.org/10.1111/j.1742-7924.2012.00222.x.
the learning beyond the individual: how reflection informs change in practice. Timmins, F., McCabe, C., 2005. Nurses' and midwives' assertive behaviour in the
Int. J. Med. Educ. 5, 24e30. http://dx.doi.org/10.5116/ijme.52ec.d21f. workplace. J. Adv. Nurs. 51 (1), 38e45.
Nieswiadomy, R., 2012. Foundations of Nursing Research, sixth ed. Pearson, Sydney. Warland, J., McKellar, L., Diaz, M., 2008. Assertiveness training for undergraudate
Nursing and Midwifery Board of Australia, 2006. National Competency Standards midwifery students. Nurs. Educ. Prac. 24 (1), 12e18.
for the Midwife. NMBA, Melbourne. http://www.nursingmidwiferyboard.gov. Witzke, A.K., Bucher, L., Collins, M., Essex, M., Prata, J., Thomas, T., ,
au/. et al.Wintersgill, W., 2008. Research needs assessment: nurses' knowledge,
Poat, A., McElligott, M., Fleming, V., 2003. How midwives' attitudes can affect the attitudes, and practices related to research. J. Nurs. Staff Dev. 24 (1), 12e20.
research process. Br. J. Midwifery 11 (6), 396e400. http://dx.doi.org/10.1097/01.NND.0000300846.89598.85.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.