Effect of Respectful Maternity Care Educational Program on the Perception of Internship Nursing Students

Background: Providing women with respectful maternity care will raise the standard of treatment; reduce their psychological strain, and lower maternal and newborn mortality rate. Aim: evaluate the effect of the respectful maternity care educational program on the perception of internship nursing students. Method : Quasi-experimental research design (pretest/posttest) was adopted . A convenience sample of 96 internship nursing students was recruited. This study was conducted at Minia University Hospital for Maternity and child. Minia governorate, Egypt. Four tools were utilized: A structured Interviewing questionnaire Schedule, an Observed Disrespect, and Abuse Checklist, Students‟ Perceptions of Respectful Maternity Care Scale, and Perceptions of Changed Knowledge, Attitude, and Practice after Intervention Scale. Results: The majority (88.5%) of the sample reported observing disrespectful or abuse behavior towards women by healthcare providers during childbirth. There were highly statistically significant differences between the pre-and post-intervention mean perception scores regarding respectful maternity care among the internship nursing students (p<0.001). Post-intervention, the majority of the internship students had a good understanding, and positive views, intended to use the obtained knowledge about respectful maternity care, and were aware of disrespectful care by other healthcare providers in their practice 57.3%, 53.1%, 52.1% 57.3% respectively. Conclusion : The perspective of the knowledge, attitude, and practice of the internship nursing students was enhanced by the respectful maternity care educational program. Recommendation : Raise awareness among healthcare professionals about the value of respectful maternity care .


Introduction
All women have a right to respect, privacy, and secrecy, as well as to be safe from injury, cruel treatment, and coercion.They also have a right to respectful continuity of care during pregnancy, labor, and the postpartum period (1) .The rise in rude and abusive treatment of pregnant women has received a lot of attention in recent years around the globe (1)(2)(3) .Obstetric violence is the term for the disrespect and abuse of women throughout childbirth.This includes actions like not allowing women to move around, eat, or drink; violating their privacy; conducting routine episiotomies; conducting episiotomies and suturing tears without anaesthesia; and conducting an emergency cesarean section without their approval (4) .The significance of the responsibility of the midwife in promoting and upholding the needs of the woman is acknowledged in the International Confederation of Midwives' (ICM) (2019) (5) international competencies.International support is given to the White Ribbon Alliance Campaign for Respectful Care, which aims to enhance the care provided to women during delivery.The campaign emphasizes the importance of relationships and interpersonal connections in providing respectful care (6) .Vol. 31.No. 4 (Suppl 1) ,November 2023 According to the definition of respectful maternity care (RMC), it is "care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, assures freedom from prejudice and mistreatment, and enables informed choice and continuous support during childbirth" (1) .Additionally, RMC covers every childbearing woman's fundamental right to care that, if feasible, respects her dignity, autonomy, choices, feelings, and preferences, including her choice of companionship and cultural rites during childbirth (7,8) .Additionally, avoiding disrespect and maltreatment during pregnancy and delivery is intimately associated with RMC.It is acknowledged that the absence of RMC prevents women from using maternity care services (9) .The goal of institutionalizing maternal care as a standard of care is to increase knowledge of and desire for respectful care for women, make a national commitment to do so, and activate communities and service providers to fulfill this inherent right of women (10) .Global health and development circles are now reflecting the rise of RMC, and the detrimental effects of abuse on health-seeking behavior and, ultimately, results are being acknowledged (11,12) .Despite the fact that providing women with respectful maternity care is a global goal, this practice nevertheless occurs during childbirth in medical institutions.RMC is a low-cost option, but many healthcare settings do not prioritize it (1) .The provision of RMC improves the care that women receive and raises satisfaction among women and healthcare professionals.By achieving RMC, care will be of higher quality, negative psychological effects on women will be reduced, and more competent birth attendants will be used during childbirth, which will lower maternal and newborn mortality (8) .World Health Organization (2018) lately commended an intrapartum care guideline for a positive childbirth experience out of concern for the increasing evidence of disrespect and abuse, noting that "the guideline highlights the importance of woman-centered care to optimize the experience of childbirth for women and their children through a holistic, human rights-based approach".A rich, positive birth experience for women and their newborns has been suggested by the WHO, along with woman-centered care (WCC) as a maternity care strategy (1) .The growing awareness of disrespect and abuse during delivery in low-and middle-income countries has led to the need to promote RMC (13,14) .RMC-promoting interventions act on many levels (15) .At the personal level, the provision of respectful and dignified care requires relational care, which may be learned to transform spontaneous kindness into professional caring ways, which goes beyond the natural caring attitude (16,17) .Although treatment-based procedures may be preferred in clinical practice, these abilities are at the foundation of the nursing and midwifery professions (18,19) .Perception is defined as to see it, be aware of it, and comprehend it.Depending on their life experiences and capacity for empathy, several students may view the world differently.Clinical or personal experiences from the past or present are likely to have an impact on students' perspectives (20) .Students may be aware of RMC, but depending on their experiences with how women are handled during childbirth in a hospital or birthing centre or the role of women in their families and community, they may have various perspectives about RMC.Different interpretations of the same event are impacted by students' perceptions, which are affected by their beliefs, feelings, and thoughts, (21) .Respectful maternity care is a fundamental aspect of high-quality care (22) , and obtaining it requires knowledge.On the care provided to women during childbirth, obstetric nurses and midwives can have a significant and beneficial impact (23) .The knowledge, attitudes, and practices of healthcare Vol. 31.No. 4 (Suppl 1) ,November 2023 professionals may all be improved by training in RMC.To improve RMC, it has been suggested that healthcare professionals get education and training (24) .However, students haven't received much attention.Therefore, in order to improve RMC, undergraduate education must encourage students' comprehension and behavior (25,26) .The opinions and experiences of midwifery students regarding disrespect and abuse during delivery have only been the subject of one published qualitative study in low-and middle-income countries (27) .This reveals a gap in our knowledge of how nursing students perceive RMC in Egypt.

Significance of the study
Each woman has the right to compassionate care throughout childbirth.Each woman should get the best maternal health care, their individual, cultural, personal, and medical requirements must be met with dignity and respect (14) .Limited levels of satisfaction with care, a psychological barrier between patients and carers, and limited future acceptance of facility-based care are all indicative of disrespectful care, which may lead to elevate rates of maternal and neonatal death and morbidity (28) .In certain nations, more than one-third of women suffer from mistreatment, which is frequently physical and verbal.Younger women and those with less education vulnerable to suffer from abuse (29) .From our clinical experience, it was observed that there are disrespectful and abusive care behaviors toward women from health care providers during childbirth, this situation puts women under stress, feel unsatisfaction with care, affects contact with their child, and dislike the childbirth journey, and will have a bad experience in their life.So, if their application of RMC and their ongoing support of women has been linked to shorter labors, a reduced need for analgesia, a higher incidence of spontaneous vaginal delivery, fewer negative birth experiences, lower caesarean sections rates, and instrumental vaginal delivery, it may also encourage women's sense of self-worth and improve newborn Apgar scores (2) .Additionally, nursing students may see disrespectful and abusive care giving techniques during their clinical maternity training and may accept such behaviors as the norm.There is scattered nursing research carried out to examine the effect of respectful maternity care educational programs on the perception of internship nursing students.Moreover, this study will increase internship nursing students' knowledge about RMC, change staff attitudes and educate childbearing women about their rights to lessen the occurrence of disrespect and abuse during childbirth.Moreover, empowering nursing interns with information regarding RMC may alter their future clinical work (9) .Furthermore, RMC will raise the standard of care, lessen the psychological effects on women, and reduce maternal and neonatal mortality.In order to effect change, this planned programme of action concentrated on nursing students who are still developing their knowledge and practice.Therefore, one of the crucial elements in improving women's experiences of care understands students' opinions about RMC and teaching and empowering them about it.

Aim of the study
This study aimed to evaluate the effect of respectful maternity care educational program on the perception of internship nursing students.

Operational definition
In this study, the perception of internship nursing students includes perceptions of RMC in labor area, perception of changed knowledge, attitudes, and practices regarding RMC in labor area.These outcomes were measured using the Students" Perceptions of Respectful Maternity Care (SPRMC) Scale (pre-post-test) and Perceptions of Changed Knowledge, Attitude, and Practice after Intervention Scale.

Research hypothesis
Internship nursing students who complete the respectful maternity care educational program will have higher posttest perception scores than the pretest perception score.

Subjects and Method Study Design
A quasi-experimental design (pre-and post-test) was adopted in the current study.One form of quasi-experimental design is the one-group (pre/post-test) design, in which the baseline measurements of the dependent variables were carried out for all individuals.After that, participants were given the suggested program.To determine the extent of the dependent variable changes, all individuals underwent posttesting (30) .

Study Setting
The study was conducted at Minia University hospital for maternity and child.The hospital is thought to be one of the most essential medical and specialized hospitals in North Upper Egypt because it provides free health services for women and children in Minia City and its villages.The hospital includes antepartum, intrapartum, and postpartum care services for low-risk and high-risk pregnant women, and it also includes a gynecological area and a delivery unit.The delivery unit is on the second floor, and it includes 3 rooms.The first room is for normal delivery, the second room is for cesarean section, and the third room is for instruments and medications.It conducted approximately (5580) deliveries annually according to its local statistics for the year 2022 (Obstetrics and Gynecological Hospital, Minia University statistics, 2022).Physicians and professional and diploma nurses who are in charge of providing nursing care also give care.

Study Subjects Sample
A convenience sample of 96 internship nursing students training in labor and in the operating room of cesarean section and accepted to take part in the study.Sample Size Based on data from the literature (23) , considering the level of significance of 5%, and power of study of 80%, the sample size can be calculated using the following formula: n = Where, SD = standard deviation obtained from the previous study; Z α/2 , for 5% this is 1.96; Z β , for 80% this is 0.84 and d, for the expected difference.Therefore, n = =95.7 Based on the above formula, the sample size required is 96.

Data Collection Tools
Data was gathered by utilizing four tools: I.
A structured Interviewing questionnaire Schedule: This schedule was developed by the researchers after reviewing the related literature (4,17,23,28)   .It included two parts: the first part: General characteristics of the studied students: such as age, residence, and preuniversity education, second part: Clinical orientation details: such as duration of clinical orientation in the labor area, number of observed childbirths, and number of births assisted in labor.II.Observed Disrespect and Abuse Checklist: It was adopted from Afulani et al., 2017 (31) the midwifery clinical practicum students were asked if they had seen any disrespectful or abusive care behaviors.If students said yes, they answered to a checklist containing 15 yes/no incidents of disrespect and abuse such as shouting at a woman, slapping, pinching, and scolding a woman …etc.And an "other" option.

III.Students'
Perceptions of Respectful Maternity Care (SPRMC) Scale: It was adopted from Dhakal et al., 2022 (23) .Which is used to measure students" level of perceptions of the RMC.In addition to changes perceived after the educational program by students.It consisted of 18 items.The scale is divided into three subscales: The respectful care subscale (the 1 st 10 items), the safety and comfort subscale (the 2 nd 5 items), and the supportive care subscale (the last 3 items).The majority of the RMC domains (27) are represented by the ten-item "Respectful Care" subscale, including "Preserving women's dignity, free from harm, free from mistreatment, prospective information provision, seeking informed consent, maintain privacy, maintain confidentiality, improve physical environment quality, resource availability, and equitable maternity care."The 'Safety and Comfort' subscale includes the following five RMC items: "upholding privacy and confidentiality, anticipating information provision and requesting informed consent, remaining safe and unharmed, and engaging with women through effective communication"; The 'Supportive Care' subscale includes questions about women's support, encouragement, and active participation in their care (27) .Scoring system Each item is scored on a Likert scale ranging from 1 to 5 (1 = Strongly disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly agree), with higher scores indicating higher perceptions.IV.Perceptions of Changed Knowledge, Attitude, and Practice after Intervention Scale: This tool adopted from Dhakal et al., 2022 (23) .It was used after intervention to evaluate perceptions of changed knowledge, attitude, and practice.It Scoring system Each item is scored on a Likert scale ranging from 1 to 5 (1 = not at all, 2=to a small degree, 3not sure, 4=most of them, 5=all of them agree), with higher scores indicating higher perceptions of changed knowledge, attitude, and practice after intervention.

Tool validity and reliability Tool validity
Five academic nursing experts in the fields of women's health and midwifery nursing assessed and verified the structured interviewing questionnaire schedule's content validity.This tool was created by the researchers.The tools' contents were checked for completeness, relevancy, and clarity.The suggested adjustments were made as a result.

Ethical Consideration:
Ethical approval to conduct the study was attained from the Research Ethics Committee at the Faculty of Nursing, Minia University (REC 202351/ 2023).Official permission to carry out the study was attained from the director of Minia University hospital for maternity and child.The researchers explained to internship nursing students the aim and advantages of the study.The researchers told them that their participation was completely voluntary, and they had the right to withdraw at any time, for any reason.The students were also told that there were no health Vol. 31.No. 4 (Suppl 1) ,November 2023 risks or dangers from this study.Internship nursing students were given the assurance that the data would only be used for the purposes of the study, and precautions were taken to ensure anonymity in data coding.Each internship nursing student who agreed to take part in the study and met the eligibility requirements was asked for written consent.

Pilot study
The Pilot study was conducted preceding data collection on 10% of internship nursing students (10 students) to assess the clarity and applicability of these tools.Based on the findings of the pilot study, no modifications were made, and the pilot study sample was excluded from the study sample.Procedure Data was collected within six months from February 2023 to July 2023.The researchers attended the predetermined setting four days a week from 10:00 am to 4:00 pm.The researchers reviewed appropriate national and international literature linked to the study, prepared, and constructed the data collection tools.Then the researchers designed the content of the educational program about respectful maternity care, a handbook with color images to support the health information presented in the teaching modules.The program was written in a simple English language, the educational program was divided into three modules.In the first educational module, the researcher illustrated information regarding the introduction and definition of RMC, the relationship between RMC and quality of care, the timeline of the RMC movement globally, universal rights of childbearing women, and domains of RMC followed by a summary of the module and a take-home assignment.The second module illustrated common disrespectful and abusive practices, the prevalence of disrespect and abuse globally, and factors associated with disrespectful and abusive practice followed by a summary of the module and a takehome assignment.The third module illustrated the consequences of disrespectful and abusive practice, strategies to promote RMC, resources required to promote RMC, and examples of how to provide RMC followed by a summary of the module and a take-home assignment.Official permission was obtained from the university and administrative personnel at Minia University Hospital.Then the researchers interviewed all students who were trained in the internship year of Bachelor of Nursing individually in the teaching room on the third floor of the hospital and they were asked to take part in the research.After receiving their signed agreement, the researchers briefed the nursing interns about the objective of the study and the time commitment necessary for participation.The sample of the study (N = 96) was divided into 12 groups each including 8 participants.After interviewing, the researchers obtained baseline data related to personal characteristics data and clinical orientation details: such as duration of clinical orientation in the labor area, number of observed childbirths, and number of births assisted in labor area through using the structured interviewing questionnaires schedule.After that, the researchers started to judge the baseline assessment of internship nursing students' were reported observation of any disrespectful or abusive care behaviors during their labor clinical orientation by using the observed disrespect and abuse checklist; and assessing the internship nursing students' perceptions toward RMC by using students' perceptions of respectful maternity care scale.For each nursing intern, it needed roughly 20 to 30 minutes to finish this assessment.Students were commanded to finish one module in one session per week (the three modules in 3 weeks) and each session runs for 1 to 2 hours.In order to accomplish the goals of each session, a variety of teaching techniques were employed, including discussion, interactive lectures, and the use of PowerPoint presentations as visual aids to aid in the clarification of the content delivered.The researchers used the teach-back technique during the training session, asking the nursing interns to repeat what they had learned in their own terms.The internship nursing students were encouraged to ask questions at the end of each educational module.After the completion of the two sessions, the colored respectful maternity care booklet that was presented during the sessions was given to the students.The effect of the educational program was determined by assessing the internship students' perceptions of respectful maternity care according to the SPRMC Scale.In addition, the influence of the RMC education intervention was assessed using perceptions of changed knowledge, attitude, and practice of students after the intervention scale.The evaluation tools were distributed two weeks after the third session to measure the retention of knowledge.

Statistical Analysis:
The personal computer was utilized to save and examine data.Statistical Package for the Social Science program version 26.0 (SPSS, Chicago, IL) was utilized for the statistical analysis of the data.Data was collected, coded, and, entered into the computer, and then data were tested for coding and recording error.Descriptive as well as inferential statistics were utilized to analyze data related to the study.A continuous variable was presented like mean ± SD (standard deviation) for parametric data.The two paired study groups were compared by using a paired sample t-test.to detect whether the mean difference between two sets of observations is zero.In a paired sample ttest, each subject or entity is measured twice, resulting in pairs of observations.The statistical significance was pre-set at 0.05 level.A p-value < 0.05 indicates a significant result.

Results
The findings of this study are displayed in four main parts: I. General characteristics of the internship nursing students, II.Internship nursing students" were reported observation of disrespectful and abuse of women during labor, III.Internship nursing students" perceptions of respectful maternity care (SPRMC), and IV.Perceptions of changed knowledge, attitude, and practice after intervention.The general characteristics of the internship nursing students in Table 1 revealed that the mean age of internship students was 22.48±0.75years.Concerning residence, more than half (56.25%) of the internship nursing students came from rural areas.Concerning pre-university education, more than three-quarters of the internship nursing students (78.1%) had general secondary education.As regards the duration of orientation in the labor area, 41.7% of internship students completed between 5 and 8 weeks, with a mean of 6.23 2.12 weeks.About one-third (31.2%) of internship students observed 2 births.In addition, 40.6% of internship nursing students assisted in one childbirth process.Figure (1) illustrated that a high percentage of the internship nursing students (88.5%) reported observing disrespectful or abuse behavior towards women by healthcare providers during childbirth.Table (2) showed that almost all forms of disrespectful and abusive behavior were described by the internship students, with the most disrespectful and abusive behavior being shouting at a woman, performing a procedure without a woman"s consent (97.6%, 90.6%, respectively), neglecting the care of a woman, not offering a woman a companion during childbirth, and performing a procedure without maintaining privacy (89.4%, 84.7%, and 81.2%, respectively).Table , (3) presented that there was a highly statistically significant difference in the mean total students" perceptions of respectful maternity care scores in the pretest as compared to the post test within internship nursing students, (61.52 Vol. 31.No. 4 (Suppl 1) ,November 2023 ±8.29, 67.83 ±6.26 respectively, (t=-5.951,p=<0.001).A Paired t-test revealed a statistically significant difference between the mean scores in the pretest as compared to the post test in relation to respectful care, safety & comfort, and supportive care subscales(t/p:6.494/<0.001,5.357/<0.001,2.830/0.005 respectively).Table (4) displayed that 57.3%of the internship nursing students reported that they had a good understanding of respectful maternity care and greater awareness of disrespectful care by other health providers during their clinical orientation (labor area).More than half of the internship students stated that they had positive views about respectful maternity care and intended to use the obtained knowledge about respectful maternity care in their practice (53.1%, 52.1% respectively).

Discussion
Obstetric nurses and midwives have a significant and beneficial effect on the care provided to women during birth.Different methods have been utilized to be aware of respectful maternity care (28) .The current study aimed at evaluating the effect of respectful maternity care educational program on the perception of internship nursing students.This section will discuss the results of the current study, comparing it with other correlated studies, and recent literature besides the researcher"s explanation regarding similar and contradictory findings.To accomplish the a fore mentioned aims, the following study Vol.31.No. 4 (Suppl 1) ,November 2023 hypothesis was created and tested:"Internship nursing students who complete the respectful maternity care educational program will have higher mean posttest perception score than the mean of pretest perception score".The current study findings stated that the majority of the internship nursing students were reported observation of disrespectful or abuse behavior to women by health care professionals during birth.From the point of view of the researchers, the disrespectful or abusive behavior toward women by healthcare professionals during childbirth is still present may be due to lack of awareness regarding the RMC.So, this confirms the importance of RMC educational program for internship nursing students.
Regarding the examples of the disrespectful and abuse behavior observed by internship nursing students, the current study results found that the most of internship nursing students were reported observation of shouting at a woman, conducting a procedure without a woman"s approval, neglecting the care of a woman and the majority of them observed not suggesting a companion to a woman during childbirth.The researchers are suggesting that internship nursing students" practice in an environment where disrespectful and abuse care giving behaviors are common may have a negative impact on their ability to provide RMC in the future.This conclusion supports WHO's worries over the persistence of abuse against women and the urgent demand to stop such behaviors.These results supported by Dhakal et al., (2022) (28) who conducted study aimed to assess "Development of a tool to assess students" perceptions of RMC " and found that, students observed disrespectful and abusive behavior of women during delivery commonly shouting at women.Also, these findings are supported by a study done by Ghimire et al., (2021) (33) they studied "women's experience of disrespect and abuse during institutional delivery in Biratnagar, Nepal".They reported that three-thirds of women suffered at least one form of disrespect and abuse during birth.As well these findings are in harmony with a study carried out by Thapaliya et al., (2021) (34) they assessed "Disrespect and abuse during facility-based childbirth in Pokhara metropolitan city".They reported that most women suffered at least one form of disrespect and abuse during delivery.While, these findings are similar with Asefa et al., (2020) (35) who conducted a study aimed to assess lessons learned from respectful maternity care training and its implementation and reported that in Ethiopia, over two-fifths of medical professionals saw staff members doing vaginal exams in public, and around onethird were abusing and threatening women and their companions and separated mothers from their babies after delivery.Similarly, Bohren et al., (2019) (2) they examined how women have been treated during facility-based childbirth in four countries.They reported that more than two-fifths of women were observed during delivery, and more than one-third of evaluated women experienced disrespectful and abusive care.Regarding the internship nursing students" perceptions of respectful maternity care, the results of the present study revealed that there was a highly statistically Vol. 31.No. 4 (Suppl 1) ,November 2023 significant difference in the mean total students" perceptions of respectful maternity care scores in the pretest as compared to the post test after an educational program.So, the study hypothesis was accepted.These results declared that the RMC educational program was more effective, it provides information for internship nursing students and had positive impact on internship nursing students" ability to provide RMC to women in the future.These findings are compatible with the results of Dhakal et al., (2022) (28) who found that there was a statistically significantly improvement in total respectful maternity care scores within the study group from pre-test to post-test (p ≤0.001).The study had a significant effect on respectful maternity care scores after controlling baseline differences.Similarly, Dzomeku et al., (2021) (36) in their study they examined midwives" experiences of applying respectful maternity care knowledge in daily maternity care practices after joining in a four-day respectful maternity care training.They reported that there was a statistically significant improvement in midwives" knowledge scores about respectful maternity care within knowledge in posttest compared to the pre-test.These findings are likewise with the results of Wilson-Mitchell et al., (2018) (37) who conducted study to assess educating respectful maternity care via an intellectual partnership model in Tanzania.They stated that midwife learners' social innovation ideas relating to RMC were creative, innovative, and context specific when supported by respectful facilitators.
Concerning the effect of RMC educational program on internship nursing students in improving perceptions of knowledge, attitude, and practice.The current findings of the study revealed that more than half of the internship nursing students had a good understanding of respectful maternity care, reported having positive attitudes regarding respectful maternity care, intended to use the obtained knowledge about respectful maternity care in their training, and had greater awareness of disrespectful care by other health care providers during their clinical placement.From the point of view of the researchers, the educational program regarding RMC had benefits for the internship nursing students such as awareness of disrespectful care that contributed toa positive practice and attitude toward women during labor process as well as improving the quality of maternity care.Similarly, Dhakal et al., (2022) (28) reported that the study groups provided feedback on the effects of RMC instruction.Thirty students said that they understood RMC well; the majority had favorable opinions about it; and two-thirds said that they would employ what they knew about RMC in their practice.During their clinical practicum, more than half of the students became more conscious of disrespectful actions by healthcare workers.Furthermore, this result is similar to Dzomeku et al., (2021) (36) they stated that the use of RMC by midwives following training enhanced their rapport with women.Also, these results supported by the study conducted in maternity care in Ghana by Dzomekur et al., (2020) (38) .Who discovered the feasibility of using was made up of four study-specific questions on a five-point Likert scale that asked participants, "To what extent did the education intervention improve your knowledge about RMC, to what extent did it change your attitudes towards RMC, to what extent do you intend to use the knowledge you have learned about RMC in your practice, and to what extent do you think you will be aware of disrespectful care by other health professionals during your clinical orientation?".

S, Lawrie TA, Finlayson K, Oladapo OT. Effectiveness
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