Experiences and witnessing of nursing students about respectful maternity care from Turkey: a qualitative study

Background: This study was conducted to explore the experiences and views of nursing students on respectful maternity care in their professional practice. Methods: This study employed an exploratory, descriptive qualitative design using an interpretive approach. The study was conducted with 15, third-year nursing students between March and April 2023. Semi-structured interviews were conducted with students who met the research criteria and were selected using the purposeful sampling method. Data analysis was performed using thematic analysis methods. Results: The results indicated three main themes and related sub-themes, which included: i) barriers to respectful maternity care, ii) suggestions for respectful maternity care , iii) reflections of respectful maternity care. Conclusion: Due to reasons such as the changing institution policies during clinical practice, care philosophies, and individual differences, the students were found to experience and witness both disrespectful care and supportive care. Besides, the importance of organizing the work environments, increasing institution-hospital cooperation, having experienced and competent personnel, and transferring evidence-based knowledge into practice has been emphasized to enhance respectful maternity care.

Submit a manuscript: https://www.tmrjournals.com/inBackground The International Council of Nurses expressed the professional values of nursing as respect, justice, empathy, responsiveness, caring, compassion, trustworthiness and integrity [1].However, the priority of these professional values may change according to individual factors, education, clinical working conditions, duration of working, and position (clinical, administrator, student, etc.).Experiences obtained in the clinical field are effective in terms of reinforcing theoretical knowledge, understanding why professional values are important, and gaining professional values [2].The main care philosophy of the nursing profession includes respect for human dignity and encouragement of privacy and human rights.In this regard, respectful maternity care (RMC) also involves expectations concerning the care in nursing professional values as a fundamental human right [3].For this reason, teaching the concept of RMC to nursing students, who are the nurses of the future, is of great importance [1].
The experiences of students during their education shape their professional life by affecting their experiences and professional attitudes and approaches in the future.However, studies show that although students agree about the importance of , they also present justifications that could legitimate the disrespectful or abusive practices that they witnessed or were involved in (e.g., maternal and child health) [4,5].Some studies even report that students were also involved in these kinds of practices that normalize disrespect and abuse during labor.Therefore, it is important to instill values for respect for care behaviors starting from students' undergraduate education [6].
Most studies report that respect is among the biggest expectations of women from health professionals [7].These respectful care behaviors needed by women (enhancing privacy, respecting preferences, communication, physical/emotional support, etc.) are consistent with the ones defined in other studies and are recommended by the World Health Organization [8].Perceptions, experiences, and emotions of women, including students who work in the delivery environment, are important factors in the provision of the psychosocial support needed by the woman and the perception of labor as positive or negative.In this regard, the roles of nurses and midwives are recommended to be imagined as the advocators of women's right to high-quality and respectful care [6].For this purpose, an investigation of the cases witnessed by health professional candidate students about RMC and experiences in cases are considered to contribute to the literature.

Aim
This study aims to explore nursing students' views about RMC and the cases they witnessed during clinical practices.

Design
This study utilized a descriptive phenomenological design to explore nursing department students' experiences of RMC during intrapartum care in their clinical practice.A phenomenological approach is used for describing individuals' emotions, thoughts, perceptions, and experiences about the phenomenon under investigation [9].The common points in the participants' explanations demonstrate the essence and meaning of the phenomenon.This study used Giorgi's research framework that focused on defining the same phenomenon as manifested in different individuals [10].The study utilized the Consolidated Criteria for Reporting Qualitative Research for reporting the study [11].

Sample
This study was conducted between March and April 2023.The sample of the study included students who were enrolled in the third year and received the Obstetrics and Gynecology Nursing course (theoretical and practical) at the Nursing department of a Health Sciences Faculty in a public university located in southern Turkey.The study utilized the criterion sampling method, one of the purposeful sampling methods.Criterion sampling is the selection of participants who meet the criteria previously determined by the researcher.In light of this information, the selection of the participants to be involved in the study was based on criteria that included giving informed consent, having received the Obstetrics and Gynecology course, and having clinical practice in the delivery room and postnatal service."Obstetrics and Gynecology Nursing" is a compulsory course instructed in the school where the study was conducted in the fall semester of the 3rd year.Within the scope of this course, students have a 16-hour clinical experience weekly throughout 14 weeks in the fall semester.Intrapartum care is mainly provided by midwives in the public hospital where the students went for clinical practice; in this process, students were expected to maintain supportive care, observe nurses/midwives, and be involved in the care.The literature does not indicate a specific number of participants to be included in qualitative studies, yet theoretical sampling is one of the methods used.In this method, data are collected when the concepts and processes to form responses to the research questions begin to repeat and reach a saturation point [12].The saturation point was reached at the 13th student in this study, and the study was completed with 15 students (n = 15).Data Collection Tools Data were collected using the socio-demographic characteristics form and the semi-structured interview form developed by the researcher.Socio-demographic Characteristics Form.The form is composed of questions such as the participant's age, gender, number of childbirths observed in the clinic, etc. Interview Form.The semi-structured form was prepared by the researcher in line with the literature.The form included the following questions: 1) As a nursing student, what was your experience with RMC in the labor process?2) Can you talk about the cases you witnessed regarding the RMC provided by nurses/midwives/doctors during clinical practice?3) What are the barriers to the provision of RMC services?4) What are the factors facilitating the provision of RMC services?5) What are your suggestions for increasing the awareness of health personnel and students about RMC services?The questions that aimed at clarifcation included: "Please describe more about your answer.";"How did you feel then?"; "Can you please give an example?"; and "What did you mean?" Data Collection Data were collected using the individual in-depth interview method.Telephone numbers were received from those who agreed to participate in the study, and the date and time of the interviews were set.The interviews were conducted by meeting each participant face-to-face at the date/day/hour determined before, and the participants signed the informed consent form for the interviews.The interviews were conducted by the researcher face-to-face, in a classroom which had good light and ventilation conditions and was known by the students in the health sciences faculty building where they could express themselves comfortably.The author who conducted the interviews held a Ph.D. degree, was experienced, and worked as an assistant professor doctor at a university during the time the study was conducted.Each participant was interviewed once, and additional non-leading questions such as 'What do you mean by this?', 'Can you explain a little more?' were asked to make an in-depth exploration of the participant's views about the topic.Pre-interviews were conducted with two students to test the comprehensibility and suitability of the questions for the purpose of the study, and the data obtained from these interviews were not included in the analysis.The interviews took about 30-55 minutes and were voice-recorded.At the end of the quotations, the number of the interviewed student is given between brackets; for example (S-7).

Data Analysis
Inductive thematic analysis was used for the analysis of the data.Thematic analysis is a qualitative descriptive approach used for Submit a manuscript: https://www.tmrjournals.com/indetermining, analyzing, and reporting the themes from categories [13].Verbatim transcription was performed for voice recordings on the days the interviews were conducted.After the data were transcribed, inductive analysis was performed by following certain steps, which included the followings: familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.Initially, comparisons were made for the words, idioms, and sentences, and meaningful units showing the patterns were determined.For the consistency of the codes, views were received from two instructors who were independent of each other and were not involved in the study; agreement and consistency were aimed to be reached in case of the presence of different views.Secondly, the concepts were determined by using open coding, and the sub-themes were formed and defined.Thirdly, the sub-themes were analyzed to determine the conceptual patterns and the presence of any relationships between them using tables and diagrams.Fourthly, the researchers discussed their findings.In line with the feedback provided by the experts concerning the themes, the overlapping themes were excluded and reorganized.Clear definitions and names were given their final form for the themes.The analysis results were reported by the researcher; they were shared with the students; and feedback was received for the accuracy of the themes.Confidentiality was protected by using the numbers given to the students during the interviews instead of their real names [13].
The reliability of the findings was achieved by adopting the strategies determined by Colorafi and Evans credibility, transferability, dependability, and confirmability [14].The researcher had a Ph.D., attended courses and received education about qualitative research and were experienced in this type of research.To achieve dependability, all the interviews were conducted by the same researcher.Obtained data were analyzed by two researchers independently.To ensure credibility, the participants were encouraged to express their opinions comfortably.The interviews were conducted online in an atmosphere where only the researcher and the participant were available and felt comfortable.During the interviews, sufficient time was allocated for each participant so that they could express what they thought.The interviews were ended when the same data repeatedly appeared and when the satisfactory point was reached.Regarding the validity of the study, purposive sampling was used.Originality of the data was kept and the data was reported extensively and in the accompaniment of direct quotes from the participants.

Ethical Considerations
The research was approved by Non-Interventional Research Ethics Committee (number: 2022/947).Participating students were informed about the purpose of the study; and the participants' written and verbal consent was received.The research was conducted according to the World Medical Association Declaration of Helsinki.

Results
The average age of the participants was found 20.6 (min: 22; max: 24).While 3 students were male, 12 students were female.The students observed at least three childbirths during the clinical practice (min: 3 max: 5).The interviews conducted with the students revealed three themes: 1) barriers to respectful maternity care 2) suggestions for respectful maternity care, and 3) reflections of respectful maternity care.The three themes determined in the study also included sub-themes (Table 1).Barriers to respectful maternity care Table 1 demonstrates the barriers to the provision of RMC in the clinic.The students reported the individual differences they witnessed during practice which were particularly caused by the health personnel.One student (S-7) said, "The doctor constantly shouted at the mother and nurses when one case needed to receive an emergency cesarean section; he did not establish healthy communication, which was wrong".Another student (S-5) said "I observed that expectant mothers felt more comfortable with friendly doctors/nurses/midwives, so they could express their fears, understand and perform what they should do in the labor process, and realize the delivery more comfortably.If the case was not so, I observed difficult labor experiences".
The students stated that while some health personnel had a more positive approach, some others were harsh and had disrespectful communication with women."In one case, although the cervical dilation was not adequate, the mother was made to constantly push rapidly and harshly; childbirth was realized in less than one hour.The mother had many tears and lost a lot of blood ."(S-9) "They did not want to administer anesthesia again during the episiotomy stitch, so they had the stitches while the woman was crying loudly.However, no problems were experienced when I observed another midwife."(S-12) Some students stated that their disrespectful behaviors could be related to health personnel's professional ethics: "Some health personnel behave people strictly and do not empathize because they do not love their job.What they are doing does not match up with professional ethics, ethics, or personal ethics.(S-8) The participating students stated that care and some interventions were administered without the mothers' consent or information."As the labor process is very hectic, I do not think that the mother is provided with adequate respect or explanation.Things we were taught in lessons were not implemented".(S-6) "I witnessed the doctor check dilation and effacement harshly and without informing the mother.I also witnessed that she had crystals maneuver."(S-5) Apart from these barriers, the students also reported problems most of which were caused particularly by the working environment.One student said,"Barriers to the presentation of respectful care could be related to factors such as nervousness and anxiety of the patient and patient relatives, desire for rapid movements by doctors/nurses/midwives, and long working hours of health professionals."(S-4)

Suggestions for Respectful Maternity Care
The majority of the participating students emphasized that improvement and provision of RMC services required empathy, the use of simple and clear language, candid communication, and the strengthening of interpersonal communication skills.The students indicated the importance of these skills both during undergraduate education and within professional life.
"Labor is a difficult process, and the mother is very stressed and anxious in this process.I observed that the mother did not feel lonely and could experience her emotions comfortably when she was provided with RMC and good communication with empathy".(S-1) "For instance, as students, we have difficulties communicating with patients and we do not know what to express during labor.Having practices such as simulation lab before clinical practice could be more effective."(S-15) Participating students mentioned the importance of health personnel who are educated and followed the latest information as well as appropriate working conditions to be provided for health personnel.
"I could not see much effort of midwives and nurses for reducing mothers' fears and worries.Supportive care was missing; all the team should be supported or informed about this issue" (S-9) "The service should not be provided according to the personnel; standard practices should be provided as reported in the literature".(S-2) "Better communication, job experience, and a better working environment could be facilitators for nurses/doctors/midwives".(S-8) Participating students indicated that increasing school-hospital cooperation, increasing the number of practice days, and observing more cases could contribute to the provision of RMC for themselves.
"The labor team at the hospital and the university do not have the same understanding.Therefore, we cannot practice what we learned in our courses".(S-10) "Number of practice days can be increased so that we can observe more cases, and the nurses in the hospital should help us more about this." (S-3) Reflection of the Respectful Maternity Care Participating students stated that the respectful maternity care services were reflected on women positively and they observed that women felt safer, more comfortable, and more courageous.Some statements are as follows: "Some examples of the respectful maternity care I witnessed included the explanations given about all procedures during clinical examination by the midwives and nurses and not involving us as student nurses in the labor process without the mother's consent to protect the mother's privacy in the labor process.".(S-3) "I observed that a calm and peaceful environment during labor helped the woman to feel safe and that the women were happy to hear explanations about the things administered".(S-6)

Discussion
This study, which aimed to determine the experiences of nursing students about RMC and witnessing it in the labor process, found that all the students were aware of the importance of RMC, yet they encountered some barriers during practice.In this regard, the first theme that emerged in the study was barriers to the provision of RMC services, and these barriers were mainly composed of individual differences caused by health professionals.Participating students reported that some health professional was respectful, while some others were disrespectful and harsh and demonstrated verbal violence during the intrapartum care process.Qualitative and quantitative studies in the literature conducted with health professional or women also emphasize individual differences and the attitudes of the personnel as barriers to the provision of the service [15][16][17].Besides, factors such as health professional's professional ethics, communication skills, and personality traits also affect this situation.Particularly the professional and ethical values possessed are considered to affect the visibility and acceptability of violence in the work environment [18].
Another barrier emphasized by participating students was the environment of the delivery room.Intrapartum care is a dynamic process, and hasty and impatient approaches in this environment could cause women to feel worthless [19].Health professional, due to the nervous environment of the delivery room or their own nervousness, tend to establish insensitive communication with laboring women.The participating students stated that providing a supportive clinical environment is important for both women and health professional to provide RMC consistently.However, various factors such as lack of personnel, workload, lack of resources, lack of policies, and lack of management could prevent RMC [5,16,20].Despite all these preventive factors, it is essential to enhance and maintain privacy in intrapartum care, which is a dynamic process [21].However, participating students stated that sometimes they were present as 6-7 student in the delivery room at the same time to observe labor, which could affect the laboring woman negatively.This finding is supported by other study findings indicating that women's privacy perceptions are affected negatively and they felt like an object [15,22].However, although the students in this study were worried about laboring women's privacy, they did not want to miss the opportunity of observing or practicing their nursing skills in this field due to factors such as the lack of cases and the presence of many students in the clinical field.
Another factor indicated by the students based on their observations was the interventions performed without receiving consent or informing the woman.The students emphasized particularly vaginal examination and fundal pressure practices performed without giving information.Various studies on this issue, similar to the findings in this study [15,17,20].Many students reported a gap between the information in theoretical courses and observations in the delivery room, and they reportedly could not understand why even the simplest practices or explanations are not performed in the clinic.This finding is supported by other findings in the literature [23,24].A study conducted with midwives in Ghana reported that midwives were aware of RMC, yet there was a gap between knowledge and practice due to motivational, institutional, and socio-cultural barriers [5].
This study found that despite all these barriers, the students reported that there is a need for educated personnel, improvements in the working environment and interpersonal communication skills, and increases in school-hospital cooperation.As reported in the literature, supporting and maintaining RMC requires courteous interferences [25].Reversing the normalization of disrespectful and abusive care requires changes involving a multi-component structure with the participation of both society and health professional at organizational, professional, and educational levels [3,26].Another study in the literature recommended empathizing with women as a micro-level strategy and interpersonal relationship strategies such as receiving education to have command of the current literature to prevent disrespectful and abusive care [27].
Improving interpersonal relationships was among the most frequently indicated suggestions by the students in this study.Effective communication between health professional and women is a key component for providing dignified and respectable labor care [19,28].Besides, providing students with simulation labs to improve communication skills starting from their undergraduate education could become a facilitator for the RMC to be provided by students before the clinical practice.
Participating students stated the importance of following current information and providing evidence-based care for RMC.Including all health professional in evidence-based education besides the undergraduate students is considered to help to encourage respectful care [22].Positive change and awareness in students' perceptions Submit a manuscript: https://www.tmrjournals.com/inabout RMC following educational interventions and the increase in the knowledge level of health professional are believed to be reflected in the clinic positively, which is believed to prevent the care differences between schools and hospitals [5,22].
Participating students reportedly witnessed that RMC helped women to feel comfortable, safe, and courageous and had positive reflections during labor.With the presence of providing effective communication and supportive care, making women feel strong, increasing autonomy, making women feel safe, etc., the labor team in which students are also present is believed to affect women's perceptions of RMC positively [8,29,30].Through their observations during the clinical practice, the students witnessed that not only physical but also psychological support was important and they improved women's labor experiences.

Limitations
Our study provides an important contribution to the literature, yet one of the limitations is that the results cannot be generalized as the study was conducted in a single center and only with students who had clinical practice in a public hospital.

Conclusion
This study found that participating students experienced and witnessed both respectful and disrespectful care during labor.This difference was caused by the individual (communication, personality traits, professional ethics, etc.), institutional (working environment, workload, etc.), and motivational factors.The findings of this study show that the students are aware of the importance of RMC, but there is a gap between the theoretical information they learned in lessons and the things they observed in practice.Therefore, suggestions such as organizing the working environments, increasing institution and hospital cooperation, having experienced and competent personnel, and transferring evidence-based information to practice areas are believed to increase awareness and provision of RMC among both students and health professional.Students' experiences during education shape their professional life.In this regard, suggestions provided by nursing students, who are the future providers of labor care, are important.Therefore, there is a need for more descriptive, interventional, and longitudinal studies to be conducted with different sample groups and clinical practice areas.As encouraging RMC includes multidimensional interventions, it is recommended to include respectful labor care in the curriculum starting from the undergraduate education and maintain it through in-service trainings in the clinical process.The results of this study are believed to raise awareness about RMC among students, instructors, and health professional working in health institutions.

Table 1 .
Nursing students' experiences of respectful maternity care Nervous and indifferent behaviors of the personnel and our presence as a group of 6-7 students for observation might have caused women to feel bad." (S-6) Reflection of the Respectful Maternity Care Positive reflection on women Submit a manuscript: https://www.tmrjournals.com/in"