Thursday, July 17, 2008

Blogging about birth

As my regular readers know, I am committed to blogging as a learning tool for midwives and students. And I have been very concerned about moves by educational institutions to prevent students from blogging. I feel this is a mistake because it prevents students from using a very effective forum for learning from experienced midwives and networking with fellow students.

However, I have read a few students' blogs in the past couple of days and I have become concerned about what is being written in open forums. I have seen students write very detailed accounts of their clinical experiences, especially births. Whilst they have not used names, there is always a possibility for women to be identified.

Using stories to learn
Health professionals rely heavily on telling stories as a means of teaching and reflection. Our blogs are not dissimilar to the staff tea room at the end of the hospital corridor where health professionals do so much story-telling. The difference is that the door to the tea room is closed, whereas our blogs are open to all passers-by.

Who owns birth stories?
It isn't just an issue of confidentiality, but also a question about ownership. Whose story is it? A birth story is the woman's story. Do we the right to plaster a woman's birth story all over the Internet without her permission? What do you think?

Reflecting on clinical experiences
I am thinking that the best way to blog about clinical experiences is to write in a general way as opposed to a specific description of events. Make the story about you and your learning, not about the woman.

I also think it is important to consider the aim behind blogging about clinical events and practice. I think it is to help the processing of learning. But it also can be a resource for fellow students and midwives. So I would recommend that you should keep this aim in mind when you blog about your clinical experiences - that will help to focus your writing. If you are a student or midwife, what would be your aim for reflecting on a blog?

The scenario
Here is a suggestion for how you could blog about a clinical experience. First, read the scenario.
  • A student midwife is working on the labour ward (or delivery suite) alongside a midwife who is caring for a woman in labour.
  • The woman is expecting her first baby and has had her labour induced because she is seven days overdue. The woman goes into painful labour and ends up with an epidural. After two hours of pushing, the woman has her baby. The baby is a little slow to start breathing when he is born and requires some attention from the second midwife attending the birth. Once the baby is fine, he has his first breastfeed.
  • The student has a busy time, getting a chance to do a number of clinical skills like urinary catheterisation and intravenous cannulation (putting up a drip). She carries out a vaginal examination, supports the woman and her husband, catches the baby, does some documentation and even has a go at suturing. She helps the woman with the first breastfeed and watches the midwife carry out the first check of the baby.
The learning
There are any number of issues that the student may wish to think and write about, and share with fellow students and colleagues.
  • Induction of labour - indication, evidence, midwifery care and responsibilities, outcomes of birth.
  • How to care for women in labour so they do not require pain medication.
  • How to facilitate normal birth when a labour is no longer physiologically 'normal' ie when there has been some sort of medical intervention.
  • How to develop skills of accurate, detailed and contemporaneous documentation.
  • Caring for a woman who has an epidural including the 'management' of second stage.
  • Feelings of own inadequacies when dealing with the unexpected, such as when a baby who needs resuscitation.
  • Acquisition of clinical skills - competency and confidence.
How to blog
Here are a couple of ideas on how you could blog about this scenario.
  • Explore feelings about competency and confidence. Describe what you are going to do to become more skilled and suggest helpful resources that you have found useful eg YouTube video on cannulation.
  • Explore the evidence about induction of labour and critically evaluate it. Publish a list of useful references.
  • Same applies to evidence about epidural. Formulate a set of guidelines for midwives about caring for women who have an epidural based on the appraisal of the evidence.
  • Start a discussion about alternative ways of pain relief for women in labour.
What the...
"BORING!" "That's not what blogging is about". "Those suggestions sound like writing mini essays and I do enough of that already"

You may well be right - I'd love to hear what you think.

But writing posts like this as opposed to detailed and personal recounting of events will help develop critical thinking skills, develop resources that can be passed on to other students and hopefully inspire useful discussion.

Message to students
So my particular message to students is to think carefully about what you write in a blog. If you have any doubt, consult with your lecturers before you hit that 'publish' button. And do not forget the stringent institutional and professional rules about confidentiality.

Opening up discussion
I am not saying that this is how you should blog and you may completely disagree with what I have said. The last thing I want to do is be prescriptive about the contents of a blog. However, I would love to hear from you if you are a health professional - how do you think we should blog about our clinical practice? Do you think we should be developing guidelines for blogging? If so, what should they contain? Do you think there should be different guidelines for students compared to registered practitioners? What do you think about all this as students - what would you suggest?

If you are not a health professional, I would also value your opinion. What would you feel about having your health care related in a student/practitioner's blog? What would you like included in guidelines or do you think the content of a health professional's blog should be left to individual discretion?

Reference: Learning through storytelling. Maxine Alterio and Janice McDury. 2002. Dunmore Press, Palmerston North, New Zealand.

Image: Mark's trip 2008 Mark Stewart


Carolyn said...

Thanks for this Sarah. We desperately need to have this discussion and develop some clear guidelines to support bloggers to share information without compromising confidentiality. It is sad that people feel that the only option is to close their blog to public view. My question then is who are the people that are being invited to view this information? It is not the audience that is the problem but the type of information that is being shared. This is where we need to get smarter.
I have a brief posting on this topic on my own blog.

Carolyn said...

I said 'it is not the audience that it is the problem'. I would like to change that. certainly I think with blogging the fact is that once the post is published it is there in black and white for eternity. Even if it is deleted, others my have copied and saved it. This does add another dimension to the issue.
However we should be aware of confidentiality at all times and with whatever audience we are sharing. I believe that it is not OK to be sharing information related to a client, with anyone, family, friends or the WWW. Information can only be shared as necessary with other health professionals, or within the structures established to support this for midwives or midwifery students.

Sarah Stewart said...

I absolutely agree. At the same time, I hope that we don't let these concerns drive us into being too conservative or restrictive with our guidelines for blogging etc.

Bill Perry said...

I would have no problem having my healthcare info in a student blog IF it were properly protected. Personal health information in a publicly viewable blog is against the HIPAA laws in the US and can get you sued, fined or even jail time. It's a tricky balance to make information secure yet readily available to clinicians.

Sarah Stewart said...

Thank you for that perspective from the USA, Bill. I would love to hear about privacy laws & regulations from other countries, especially as blogs cross over international boundaries & laws.

Lisa Barrett said...

As a blogger it is very worrying to me that you would think about creating guidelines that you would expect students ( or even other health professionals) to follow. Freedom of speech is everything and if information in the public domain is a problem to an individual then it is up to them to complain in person. I don't think you should try and shut your students up which is basically what you want. Just get them to blog in a way that's acceptable to you. I can see the birth socialisation happening to them already!!

Carolyn said...

I really do not know what the answer to this is. I would absolutely not want to 'shut students up', nor would I want to 'shut midwives up'. But the issue remains about talking about clinical experience in a public domain and the legislation around privacy and confidentiality.
If I was writing a journal article there are very strict rules around how you can write about these things to protect the confidentiality of the people about whom you are writing. Journals have quite a limited audience, blogs have a much wider audience.
Wherever we are, in the hospital corridors or staff cafeteria, in the local supermarket, in the doctors waiting room, we need to take care with what we say and how we share.
I do not think we need specific guidelines for blogging but I do think that the use of this medium heightens awareness of how we share our experiences and talk about what we do. If we are merely talking with one another, once the words are said they are gone, there is no record. In a blog the words remain for ever.
Many of us would be quite anxious if we were to speak with reporters from the TV or news media. We might want to seek advice on what we should share with them before such an event, yet on a blog we are potentially speaking to the media every time make a posting or post a comment such as this.
What is the answer to responsible blogging? As lecturers should we be providing guidance to students around this? As lecturers should we be monitoring how our students are blogging and giving feedback on this? If we are giving feedback to students on blogging do we need some guidelines for us to do this?
I truly value to opportunity to share clinical experiences, I love reading about birth stories and seeing birth videos. I would love to make a post about a particular birth and how it all occurred. However without the woman explicit consent I would not do this. Ideally I would ask her to write her story of the birth and then I would add my account and OK this with her before posting. We do also need to think about writing about the practice of other health professionals involved in this scenario. Can we do this without their consent?
I look forward to this continuing discussion.

Lisa Barrett said...

I think you have hit the nail on the head with the last sentence. It's really about the students having an open opinion on the course, the midwives, the hospital and most importantly the womens experience.

I think that adults are able to make their own decisions surrounding their blogs. If they fall foul of laws then it isn't up to you to police it.

I understand that slanderous stories with no substance could be a problem. However the experiences of student midwives can really bring to the fore the really problems in maternity services.

It certainly appears that as uni lecturers you are taking on yourselves responsibility of lives of others that isn't really in your domain.
As a well known maternity anarchist it feels like control to me. ;)

Sarah Stewart said...

Hi Carolyn & LIsa, Thank you for your thoughts and comments. I am really enjoying the discussion.

Carolyn: I don't have the answers; I am asking the questions and hoping that we have some constructive discussion about the issues. I think this is a really valuable conversation because I want our students to benefit from blogging in the same way I do.

Lisa: I think we're singing from the same song book because I absolutely agree with you. I don't want to gag students & I'm not even sure that 'guidelines' are necessary or desirable - as I said, I'm asking the questions and seeking feedback. You see in my next post 'Knickers in a twist' that I have turned the issue on its head and have looked at the discussion from another angle all together.

But we do have responsibilities as health professionals and it's our jobs as experienced midwives and lecturers to educate students and role model good practice.

Sarah Stewart said...

I totally get what you're saying, Lisa & yes, students are adults and should have responsibility for their own actions and be able to make their own mistakes. And yes, I have enough trouble controlling my own actions let alone those of students. But the trouble is, there's the big picture stuff to worry about, certainly here in New Zealand. In other words, what one midwife/student does tends to reflect on the whole profession.

Yes, I know that's ridiculous but it's a sad fact of life here. So when one blogger appears to behave in an unprofessional manner we all get tarred with the same brush which can end up in generalized clamping down on online activity.

All I am asking for is student & midwives to be careful what they write about - to follow professional standards & legislative requirements. And to think about where the woman sits in all this.

Lisa Barrett said...

I totally agree that the most important thing is to consider the woman if the story and experience is directly related to her. Often though it isn't the woman and her story that is the problem, it's the treatment and the general outcome.
Unprofessional behaviour may mean something different to you than to me and I'm wondering how exactly there can be a crack down of online activity. Bombers have blogs!!!!

The big picture stuff is also a debate. I have no problem with whistle blowers or people standing up for what they feel to be right.

I do however see exactly what you mean and am not totally unsympathetic to some of your difficulties. I rarely discuss cases explicitly on my blog and leave the actual stories to the women themselves to write. Knowing from the issue with Virgina Howes how easily things can be pulled apart if you aren't careful. I don't even say how often I'm at a birth.

Lisa @ Boondock Ramblings said...

Thanks for stopping by my blog. Just wanted to let you know that I do not really think my midwife is a witch. In fact I could tell you many a story of how she changed my outlook on life and therefore my life.

As far as this post goes...I do agree with at least one statement you made..that the birth story is the woman's....for the rest you students can hammer it out. :-

Sarah Stewart said...

Leigh Blackall has another perspective - have a look at his reply to my comment:

What do you think?

Anonymous said...

for Lisa
writing about somebody elses life - their birth - in your chosen forum - not theirs - feels like control to me. I think many women have had enough of health professionals - even student health professionals - taking ownership of them - and I urge you to seriously consider your need or perceived right to do this.

Lisa Barrett said...

I did say the woman should be the centre of this. In my own forum nothing is written without permission and the women write their own birth stories. That doesn't mean that bloggers should not be able to write their own opinion pieces on their experiences.

Nicole Grant said...

This post is relevant to many different disciplines. I am an OT and blog about cases as a way of explaining the different roles of an OT. I believe that I maintain confidentiality, but I still have concerns as there is no specific literature on this. I look forward to reading further discussion on this topic.

Sarah Stewart said...

Hi Nicole, maybe this is a chance for you to get something published about the subject? :)

Lisa Barrett said...

Why do you have concerns that there is no literature on this. What difference would literature make. We all have the ability to make good choices around confidentiality. Just try asking permission from the people you want to mention.

Nicole Grant said...

Sarah - Interesting idea. I will give that some consideration.

Lisa - We have a very basic Code of Ethics with some reference to maintaining confidentiality. We need to adhere to the Privacy Act, which covers the use of Case Studies for educational purposes, but not necessarily for general interest. I am sure that as long as information is de-identified, there shouldn't be a problem. It's just that we live in a very litigious society, so I find this an interesting subject area.