Nurse Case Management for Pregnant Women Experiencing

¶ … Nurse Case Management for Pregnant Women Experiencing or at Risk for Abuse," by Curry et al.

The research article chosen to critique is titled, "Nurse Case Management for Pregnant Women Experiencing or at Risk for Abuse." This title accurately reflects the topic of the research study. The topic of the study is very specific and narrow. It would not be of broad interest to many nurses. However, the issue of having significant individual impacts on participants in a study that are not measured by the measures of outcomes utilized in the study would be of broad interest to researchers trying to design a study or nurses trying to apply the findings. It would be nice if this aspect of the study was also indicated in the title to broaden the number of readers who would find this article of interest. However, this article is of interest to me because I plan to work with at risk populations of pregnant women in the future.

The abstract of this article includes a list of the main categories of the research paper and a short summary of each of these categories. This type of abstract is useful for finding particular details of a study quickly and easily as opposed to a paragraph style abstract. However, an abstract should be succinct and compact so that readers can quickly decide whether the study is of enough interest for them to read and does not need to necessarily include so many details as this abstract does. The abstract does not include any information about the researchers or any potential conflicts of interest. The majority of information included in the paper about the researchers occurs at the end of the paper. It lists the researchers' names, credentials, degrees and current affiliations. The research team at each site is also briefly described in the design of the study section under the heading, "Sample and Setting," which consisted of an investigator, research nurse and a nurse case manager. The lack of information about potential conflicts of interest could indicate that there are none, but this should not be left for the reader to assume.

Although the objective of the study is included in the abstract, the purpose of the study is not. I think this would be important to include in the abstract, whereas the details of the participants recruited and intervention used are less critical to include in the abstract. Also, I think that the headings of setting, participants, and intervention could have been included in less detail within the heading of design since they are aspects of the design of the study. Additionally, the conclusion of the study listed in the abstract does not reflect the main conclusion listed within the discussion portion of the article, which was the fact the researchers felt they had a significant impact on individuals that was not measured to be statistically significant by the outcome measures. The results of the study are of interest to my planned future work with at risk pregnant women. The study indicates that nurse case management does reduce stress in women, but not significantly, and that these women want to focus that intervention on their pregnancy rather than the abuse, which I would not have expected prior to reading this study.

The problem being studied is whether nursing case management for individuals can reduce stress in pregnant women who are experiencing abuse currently or who are at risk for abuse. This is an important problem in nursing to study because high stress levels have been linked to poor pregnancy outcomes including low birth weight. Also, nurse case management has been shown in previous studies to reduce prenatal stress. The purpose and objective of the study, to reduce stress in women experiencing or at risk for abuse, is clearly stated within the introduction of the paper. The expected results of the study are mentioned within the hypothesis of the study. The hypothesis of the study is not mentioned until the design of the experiment section. The hypothesis of this study is that nurse case managers would impact the outcomes of pregnancy by reducing stress. Therefore, in this particular instance the problem, hypothesis and expected results of the study are not consistent with the purpose and objectives of the study since the aspect of influencing pregnancy outcomes is not mentioned as an objective or purpose of the study. The authors do mention that this paper will only include findings related to stress reduction. However, it seems confusing to even introduce this aspect of hypothesis when the outcomes of this portion of the study will not be included in the report. I think that if this aspect was going to be introduced at all it would have been clearer to also include it in the purpose and objective and then say that the results of this aspect would not be included in this particular paper. The research variables are not listed explicitly. These variables include whether or not the women enrolled in the study are considered at high risk for abuse and nurse case management. Both are operationally defined by the authors describing exactly what they mean by each term as well as how that differs from historical definitions of the terms.

The paper includes a short, but thorough, background summary on the topics of effects of abuse and stress on pregnant women and maternity case management. These are the critical topics within the study problem that need to be reviewed. Research has found a link between levels of stress and experience of abuse. Also, there is a link between stress and poor pregnancy outcomes. How abuse directly affects pregnancy outcomes, aside from violent trauma, is not known. Abuse is proposed to indirectly affect pregnancy outcomes by affecting prenatal care, poor maternal weight gain, increased alcohol, drug and tobacco use, and low self-esteem. Maternity case management has been used to improve pregnancy outcomes. Several outcomes that are affected by abuse have been shown to be improved with maternity case management such as lifestyle factors, prenatal care, referrals for support services and hospital costs. However, its impact on low birth weight and gestational age has been inconclusive. These theories suggest that by using nurse case management the researchers can affect women's experience of abuse and stress since the two are linked. It can also improve some factors related to poor pregnancy outcomes due to abuse. The research articles cited in this paper are current and relevant to the topic of the study. The majority of articles used occur within ten years of the study and one third of the articles occurring within five years of the research study. The authors do not offer any critique on the relevant research studies, they only state the previous findings. Almost entirely supportive articles are listed. Only one contradictory article is discussed in the review to do with the lack of impact of nurse case management on low birth weight and gestational age. Some gaps in knowledge are discussed such as the direct biological pathway by which abuse affects pregnancy outcomes. Also, the researchers cite a lack of knowledge about interventions that address individual needs of women in or at risk for abusive relationships.

The authors discuss the research methods used to answer the research question. The design is a multisite randomized controlled trial. Two sites were chosen, one in the Midwest and one in the Pacific Northwest, where pregnant women were recruited into the study at their prenatal check-up. The participants were screened for abuse indicators and stress indicators and then broken up into high and low risk groups at each site. The high risk women in the control group did not receive nurse case management intervention whereas the high risk group did. Stress was measured again at the end of the pregnancy to see if the intervention affected stress or not. The sample consisted of 1000 women, approximately 500 at each site, who spoke English and were between 13 and 23 weeks pregnant at the time of recruitment. One obvious bias in this study is that there is not a control group of low risk women who received nurse case management, which would also be important to look at when determining if there is any overall affect. Several limitations were listed by the researchers. One of the clinics used had a change in Medicaid funding, which caused a reduction of diversity of women seen at that site during the study. This was a major set-back because this site was specifically chosen for its high diversity of women served. Also, although the nurse case managers were kept separate from the clinic operations in order to make analyzing their unique contribution to intervention easier, it also limited their effectiveness. The researchers found that the outcome measurements were not sensitive enough to measure the differences that they saw on an individual level. The recruitment process was also a limitation since women seeking prenatal care after 23 weeks, who are shown to have higher risk factors, were not included in the study. Because the researchers found that the measured outcomes were not sensitive enough, it is likely not the best research design for this particular research problem. And, this is exactly one of the future recommendations given by the researchers at the end of the paper.

The demographics of the sample include mainly Caucasian women in their late twenties with 15 years of education. However, a range was seen amongst the participants. Some significant differences were seen between the participants at each site. One site contained women who were older and more educated than the other site. Also, women who were considered at high risk for abuse were significantly different than the low risk women in the study. The high risk women were younger, less educated and tended to be single. All women at both clinics who were between 13 and 23 weeks pregnant and spoke English were eligible to participate in the study. Women who were more than 23 weeks pregnant were excluded as were women who did not speak English. I have not worked with pregnant women in the clinical setting yet, but the demographics of pregnant women in my area are similar to those found in this study. Location of the clinics plays a role in the outcomes since age, income and education were significant factors that determined who was at high risk and these factors varied between the two chosen sites. Also, not including women more than 23 weeks pregnant, and more likely to be at high risk, would affect the outcome of this study. The researchers indicate that they thought greater differences due to nurse case management might have been measured if women more than 23 weeks pregnant had been included. Sample mortality was not a problem in this study. Procedures used to protect identifying information were not discussed in the paper. However, the participants do not seem to have been made vulnerable due to diminished autonomy. This intervention could have been harmful to the participants if the abusers were to become aware of their participation in the study. Therefore, patient safety was of top concern to the researchers and nothing identifiable about the intervention program was given to the women and safety for taking informational cards home was assessed thoroughly. Also, the nurse case managers asked each woman for a safe way to contact them in the future. Internal Revue Board approval for consent procedures was obtained.

The only measured data collected for the study was stress level at the time of recruitment and at the end of the pregnancy. Other information was collected and categorized, but it was not used as a measure of the results of the study. Since the reduction of stress was the key component of the research question collecting stress level data was appropriate data to collect during this study. Questions from two standard assessment tools were used to determine stress level. The assessment tools themselves are not directly related to stress. Since the questions used were not given it is hard to say how valid these questions were for measuring stress. It would not be possible to repeat this study without getting further information from the researchers. The data collection occurred in an oral interview with a nurse, which is similar to any health information gathering situation at a real-life doctor's appointment. Although the high risk women scored for abuse and stress, very few disclosed being in or previously being in abusive relationships. This could possibly be due to distrust of the healthcare system. This indicates that the results may show less of a change due to the women's fear of disclosing abuse. The results might have been more accurate if the questionnaires were taken anonymously rather than in an interview, or if the interviews were given by abuse support group personnel that the women already worked with and trusted. The instrument used was an interview with questions taken from two different assessment screening tools. Questions from one screening tool were to assess abuse, Abuse Assessment Screen, and the other to assess stress, Prenatal Psychosocial Profile. The reliability and validity of the instruments was not addressed, nor was the use of the particular questions from each screening tool to be able to answer the questions the researchers were studying.