JAN
JOURNAL OF ADVANCED NURSING
CONCEPT ANALYSIS
A concept analysis of watchful waiting among providers caring for
women in labour
Nicole S. Carlson & Nancy K. Lowe
Accepted for publication 8 June 2013
Correspondence to N.S. Carlson:
e-mail: [email protected]
Nicole S. Carlson MS CNM RN
PhD student
College of Nursing, University of Colorado
Denver, USA
Nancy K. Lowe PhD CNM FAAN
Professor
College of Nursing, University of Colorado
Denver, USA
C A R L S O N N . S . & L O W E N . K . ( 2 0 1 3 ) A concept analysis of watchful waiting
among providers caring for women in labour. Journal of Advanced Nursing
00(00), 000–000. doi: 10.1111/jan.12209
Abstract
Aim. This paper is a report of an analysis of the concept of watchful waiting.
Background. Little is known about differences between the intrapartum care
processes of midwives and physicians. In this time of growing rates of surgical
birth outcomes, intrapartum care processes are a key area for research and
improvement. Watchful waiting is a common care plan used by both midwives
and physicians that involves the timing of interventions in labour.
Design. Rodgers’ Evolutionary Model was used to conduct a concept analysis of
the term watchful waiting.
Data sources. Scientific literature authored by, and about, midwives and
physicians, as located via an intrapartum-focused database search inclusive of
years 1922–May 2012. Thirty English-language articles from nine different
countries were located, representing the midwifery and physician scientific
literature focusing on watchful waiting in labour and provider decision-making
processes.
Review method. Attributes, consequences, antecedents and affecting themes were
identified through a thematic analysis of the identified articles.
Results. Data analysis reveals that many midwives and physicians define watchful
waiting differently, based on their philosophies of care.
Conclusion. The care of women in labour is complicated as a result of different
understandings by some providers of common processes of intrapartum care.
Keywords: intrapartum, labour, midwife, physician, provider, watchful waiting
Introduction
The developed nations of the world have seen a sharp
rise in the number of women who end their pregnancies
with caesarean delivery in the past 20 years, with current
© 2013 John Wiley & Sons Ltd
caesarean delivery rates over 30% in many countries
(Lauer et al. 2010, Lumbiganon et al. 2010, Luz et al.
2010, Menacker et al. 2010) and over 50% in some markets with private insurance (Rebelo et al. 2010, Patah &
Malik 2011). This trend has occurred despite repeated
recommendations from the World Health Organization
for total caesarean rates to stay between 10–15% (Lauer
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N.S. Carlson and N.K. Lowe
et al. 2010). The process of labour management by
women’s healthcare providers is identified as a source of
substantial variation in caesarean rates (Hanley et al.
2010) and therefore as a key area for improvement in
the caesarean trend. Most investigations of the intrapartum process of care, to date, have focused on which
interventions are used in women’s labours, rather than
analysing when interventions are used by providers (Davis
et al. 1994, Albers et al. 1997, Jackson 2003, Smyth
et al. 2007, Hatem et al. 2008, Nguyen et al. 2009).
However, the timing of interventions in labour has been
shown to be important in women’s risk for eventual caesarean delivery, with most caesareans performed for the
indication of labour dystocia, or ‘abnormally slow labor’
(Gifford et al. 2000, Jackson 2003, Abenhaim & Benjamin 2011).
The use of more liberal timelines in intrapartum management is associated with lower caesarean delivery rates
(Olatunbosun et al. 2002). Collaborations between physicians and nurse-midwives are known to produce lower
rates of caesarean delivery when compared with physician-only management of labour, while maintaining
neonatal outcomes that are similar (Davis et al. 1994, Fullerton et al. 1996, Hatem et al. 2008, Shaw-Battista et al.
2011). Midwives are more likely than obstetricians to
delay hospital admission and to avoid or delay the use of
technological interventions like synthetic oxytocin administration, artificial rupture of membranes and epidural
(Jackson 2003, Reime et al. 2004, Johantgen et al. 2011).
Especially low rates of caesarean are seen in practices
using liberal labour timelines within the midwifery context
of care (Davis et al. 1994, Leeman & Leeman 2003,
Shaw-Battista et al. 2011), although few studies have
examined the specific process of intrapartum care present
within a midwifery context (Kennedy & Lyndon 2008,
Johantgen et al. 2011). Of course, not every midwife
incorporates more liberal timelines in labour, just as not
every physician practises with more conservative timelines.
However, the significant differences found in multiple
studies on intervention timing and labour outcomes, predicted by provider profession, point to the question of
why many midwives manage labour differently from many
obstetricians.
This concept analysis focuses on the term watchful waiting. This term is commonly used by both midwives and
obstetricians with reference to intrapartum processes. However, watchful waiting can mean different things to different providers. This concept analysis will attempt to clarify
the concept of watchful waiting within the two professions
of medicine and midwifery.
2
Background
The term watchful waiting has been used in the healthcare
setting as far back in history as scientific literature databases extend and is defined as ‘a policy of taking no immediate
action with respect to a situation or course of events, but of
following its development intently’ (Merriam-Webster
2012). The concept of watchful waiting in labour is one
that is discussed by physicians and midwives in both clinical settings and in scientific literature (Bolaji & Meehan
1993, Barrett et al. 2009, McCourt 2009c, Jordan & Farley
2008, Kennedy & Lyndon 2008, Rayment 2011). Both
types of professionals often work in the same birth settings
and frequently are involved in discussions of intrapartum
processes around collaborative efforts. However, physicians
and midwives come from different educational programmes
and may have different philosophies of care as a result.
Individual physicians or midwives may adhere to a philosophy of care for women that is outside their profession, but
the philosophy of professional origin supplies important
context for most intrapartum providers as they think and
talk about labour management (Bryers & van Teijlingen
2010). If midwives denote something different when they
talk about watchful waiting from what a physician understands when using the same term, the resulting confusion
has wide-ranging implications for interdisciplinary cooperation and optimization in intrapartum care. Just as important as labour management is the use of watchful waiting
as a concept in research and scientific discourse around intrapartum care processes. It is therefore important that the
concept of watchful waiting be clarified as it is used by
midwives and physicians around intrapartum processes of
care.
This concept analysis of watchful waiting uses Rodgers’
Evolutionary Model to better understand areas where disciplines agree and disagree about a term (Rodgers & Knafl
2000). Rodgers’ method was chosen for several reasons:
first, the evolutionary concept analysis involves a rigorous
analysis that involves inductive inquiry that is rooted in a
particular realm for data collection. For this concept analysis, the scientific literature of midwifery and medicine was
used as data in the attempt to develop clarity on the meaning of watchful waiting across these professional disciplines.
Second, Rodgers’ method emphasizes the importance of
context in the analysis of a concept. This analysis of watchful waiting as used in the scientific literature of these two
professions clarified the origin of the concept and the values
and perspectives of the two professions through their use of
the concept. Third, Rodgers’ evolutionary method of concept analysis is a first step in the development of a concept
© 2013 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
Watchful waiting among intrapartum providers
that is of interest to nursing and allows for future research
that classifies and characterizes phenomena.
Data sources
Figure 1 Focused literature search of
watchful waiting.
© 2013 John Wiley & Sons Ltd
167 records identified
through database
searching
10 additional records
identified through reverse
citation & survey of lit
108 records
screened
71 records excluded as
off-topic
Eligibility
108 records after duplicates
removed
37 full-text articles assessed
for eligibility
7 full-text articles
excluded
for no discussion of
watchful waiting
included
Screening
Identification
Data were collected for this concept analysis through a
search of the scientific literature on watchful waiting. This
search was conducted using the term watchful waiting to
survey indexed literature for the broad healthcare use of the
term within the context of pregnancy and birth (Rodgers &
Knafl 2000). For the purposes of this concept analysis, no
date range exclusions were used, as one goal of the analysis
was to trace the historical use of the term. Depending on
the database used, publications as early as 1922 were
accessed in these searches (1922–2012). This literature
search was limited to English language, with studies from
any country included.
Literature searches were conducted using Pubmed, CINAHL, Ovid/MEDLINE and Google Scholar databases in
May 2012. Pubmed and Ovid/MEDLINE databases were
used to identify medical scientific literature. The CINAHL
database was used to identify any nursing or midwifery literature not already captured through the other databases.
Finally, Google Scholar searches were used to access book
chapters, social science literature, more midwifery literature
and thesis work on the concept. No attempt was made to
search the popular literature for use of the concept watchful
waiting because this concept analysis concerns the use of
the concept by professionals, not the recipients of care.
Social science literature was accepted if the subject of the
article was physicians or midwives in intrapartum settings.
The literature survey used search term of ‘watchful waiting’ as all-text cross-searched against the secondary search
all-text term of ‘labor’ or ‘labour’ for the inclusive dates
1922–2012 (Figure 1). Duplicates were discarded and articles were screened for content. After screening, articles were
discarded if they did not address labour care. Full-text copies of all remaining articles were obtained through online
proxies or library reserve.
Reverse citation searching on several key articles located
foundational work on the concept of watchful waiting
(Simonds 2002, Oakley 2004, van Teijlingen 2005,
McCourt 2009a). Other additional articles focused on the
healthcare use of the term watchful waiting were located
via the survey of the literature (Penson 2009, Driffield &
Smith 2007, Nelson et al. 2009, Elkin et al. 2004, Rosenbaum 2011, Hemmerich et al. 2012). Although these articles did not specifically address labour care, they were
included in this concept analysis secondary to their focus
on medical decision-making in general.
Once obtained, articles were separated by professional
source of primary author and read a first time to identify
30 studies included in
analysis
From: Moher D, Liberati A, Altman DG, The PRISMA Group (2009). Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS
Med 6(6): e1000097, doi: 10·1371/journal.pmed1000097
3
N.S. Carlson and N.K. Lowe
how the concept of watchful waiting was used in the article. A few articles were discarded at this final stage that did
not discuss, nor use, the concept of watchful waiting in any
significant way (Figure 1). Articles were then read a second
time, coded by the components of the concept identified in
each (attributes, antecedents, consequences, affecting factors) and analysed for major themes in accordance with the
methodology outlined in Rodgers’ evolutionary model
(Rodgers & Knafl 2000). Articles were also analysed for
their use of terms associated with watchful waiting to create a picture of the mental cluster surrounding the concept.
Sample for analysis
The final sample included 30 studies with publication dates
ranging from 1993–2012 (Table 1). Sixteen of these articles
were authored by physicians, seven by nurses or midwives
and seven by sociologists, anthropologists or statisticians.
Thirteen of the 30 of the studies were published in the past
two years (2010–2012). Among the medical articles, the
majority (10/16) originated from Europe (Netherlands,
Sweden, UK, Ireland, France, Italy) with the rest (6/16)
from the USA. With the exception of one article discussing
watchful waiting in an intrapartum setting (Scott 2005), all
of the medically authored articles about watchful waiting in
labour were from outside the USA. Most of the midwifery
or nursing literature originated from the USA (5/7), with
additional work from the UK and New Zealand. The
majority of the social science work originated in the UK
(4/7), with the remaining articles coming from the USA.
Results
Related and surrogate terms
Several terms were found in the included studies to be used
in place of, or were suggested to be better descriptions
than, watchful waiting to describe labour management.
Medical literature tended to emphasize the importance of
repeated monitoring during periods of watchful waiting and
as a result gravitated towards terms that were felt to better
describe this action on the part of the physician. ‘Watchful
monitoring’ (Barrett et al. 2009), ‘expectant management’
(Boers et al. 2010, Jangsten et al. 2011, Maso et al. 2011,
Torre et al. 2012) and ‘expectant monitoring’ (Vijgen et al.
2010) were used as surrogate terms (Rodgers & Knafl
2000) for watchful waiting in the medical literature. As
was mentioned in Penson’s 2009 article, watchful waiting
was used as a management option for early-stage prostate
tumours starting in the early 1990s, resulting in the perception by many physicians that it is not enough to wait – the
doctor must be doing something, in addition to postponing
surgery, with a patient (Penson 2009). Penson proposed the
term ‘active surveillance’ to better capture medicine’s active
vs. passive nature while managing patients.
Midwives, especially US nurse-midwives, embrace the
term watchful waiting as part of their philosophy of caring
for women (Kennedy & Lyndon 2008, McCourt 2009c).
‘Doing nothing’ and ‘non-intervention’ (Romano 2009,
Everly 2012) were used in midwife-focused literature as surrogate terms for watchful waiting. Related terms (Rodgers
Table 1 Articles included in concept analysis of watchful waiting, classified by profession of primary author.
Medicine
Midwifery/nursing
Social Sciences (Sociology, Anthropology, Statistics)
Driffield and Smith (2007)
Penson (2009)
Scott (2005)
Bolaji and Meehan (1993)
Nelson et al. (2009)
Elkin et al. (2004)
Rosenbaum (2011)
Boers et al. (2010)
Bryers and van Teijlingen (2010)
Everly (2012)
Romano (2009)
Jordan and Farley (2008)
Kennedy and Lyndon (2008)
Davis and Walker (2010)
Brucker (2001)
Oakley (2004)
van Teijlingen (2005)
Simonds (2002)
Rayment (2011)
Koblinsky et al. (2006)
Davis (2006)
McCourt (2009a)
McCourt (2009c,b), McCourt and Dykes (2009),
Downe and Dykes (2009), Winter and Duff (2009)
Maso et al. (2011)
Shennan and Hezelgrave (2010)
Jangsten et al. (2011)
Vijgen et al. (2010)
Moriarty (2011)
Barrett et al. (2009)
Torre et al. (2012)
Hemmerich et al. (2012)
4
© 2013 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
Watchful waiting among intrapartum providers
& Knafl 2000) found in the literature include ‘supportive
care’ and ‘therapeutic presence’ (Jordan & Farley 2008,
Romano 2009).
Attributes
A diagram of the components of the concept watchful waiting in a labour setting was built using themes collected
from the included articles in this analysis (Figure 2). Each
component of the concept is presented in the diagram and
in discussion below, with themes identified for both midwives and physicians. Attributes are the essential part of
the concept analysis, involving the ‘breaking apart of a
thing to identify its constituent components’ (Rodgers &
Knafl 2000). Analysis of the data identified three themes
describing what the provider does, where the provider is
located and the source of action during periods of watchful
waiting in labour.
The first attribute of watchful waiting during labour by a
provider describes what is being done. For physicianauthored literature, watchful waiting describes a period
when the patient is observed with periodic testing for the
progression of an illness while deciding if immediate curative treatment is warranted (Driffield & Smith 2007). In
pregnancy, watchful waiting typically includes regular,
repeated examinations to assess for changes, laboratory
testing, continuous foetal monitoring and occasionally
imaging studies (Nelson et al. 2009, Elkin et al. 2004, Barrett et al. 2009, Maso et al. 2011). In contrast, identified
literature included a midwifery philosophy of care that
interprets watchful waiting as the provider’s observation of
the labouring woman’s behaviour, emotional state and
Antecedents
Physician
Midwife
Labor is often abnormal Labor is usually normal
Affecting Factors
3rd party/hospital/national
guideline influence
Mind/body separation
Mind/body/spirit emotion
connection
Labor progress is
generalizable from
woman-woman
Labor events can be
generalized or unique to
the woman
Longer labor time =
pathology
Longer labor can be
normal
Hospital setting
Healthcare Team
Attributes
Woman’s desires
Provider anxiety
Physician
Surveillance, repeated
vaginal exams, labs, fetal
monitoring
Physical separation from
woman to allow for
objective re-assessment
Action by Physician
Midwife
Observation of behavior/
emotions, avoid exams
Therapeutic presence
with woman
Action by woman/
midwife
Consequences
Physician
Inefficiency
Figure 2 Concept analysis of watchful
waiting as used by midwives and physicians in labour.
© 2013 John Wiley & Sons Ltd
Midwife
Optimal health outcomes
for mother and child
Unfair allocation of time Possible unfair allocation
to one woman
of time to one woman
Emotional connection
Risk of litigation/poor
outcome
woman to midwife
Avoidance of irreversible Enhanced experience for
mother
option (surgery)
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N.S. Carlson and N.K. Lowe
environment. Repeated vaginal examinations are discouraged, as they can be uncomfortable and upsetting to
women, thus hindering labour progress (Rayment 2011).
Literature about midwifery care also expressed the idea that
labour progress can usually be accurately tracked through
the woman’s behaviour, thus making internal examinations
unnecessary except in cases of ‘mixed signals’. Foetal monitoring is continued, but it is carried out intermittently to
allow for the woman’s unrestricted movement in labour
(Romano 2009). Laboratory and imaging tests are not mentioned as part of a period of watchful waiting within a midwifery approach to labour care. Verbal and physical
support is provided by the midwife in keeping with her
‘therapeutic presence’ in the woman’s labour from the
understanding that the midwife can help a woman correct
labour problems by offering the support forged through a
trusting relationship.
The second attribute involves the ‘where’ of the provider
during a time of watchful waiting. Physician-authored literature advocated physical separation from the patient to
allow for objective assessment of change during the period
of surveillance. By virtue of the fact that the patient is being
left without direct medical supervision, it is assumed that
she is appropriate for either self-care or care by the inpatient nurse during periods of watchful waiting (Boers et al.
2010). In contrast, the midwifery perspective expressed by
authors emphasized the importance of the provider’s ‘therapeutic presence’ during periods of watchful waiting in
labour (Jordan & Farley 2008, Winter & Duff 2009). Therapeutic presence is described as the provider sitting with
the woman, often not talking to her, but offering comfort
as needed and creating an ‘atmosphere of calm’ (Rayment
2011). Simonds (2002) also emphasized the importance of
this calm presence during watchful waiting to promote normal labour progress.
The final attribute is the source of action during periods
of watchful waiting in labour. Analysis of medical literature
depicts action performed by the provider on the patient
(Boers et al. 2010, Shennan & Hezelgrave 2010, Vijgen
et al. 2010, Maso et al. 2011). Active surveillance involves
the provider (or the nurse who carries out the provider’s
orders) entering and leaving the labour room, with visits
bringing moments of decision by the provider as to the plan
of care. The provider is active, rather than passive (Penson
2009). Importance is placed on normal labour progress,
with regular interventions being required in the form of
vaginal examinations to track this progress (Simonds 2002).
From a midwifery perspective, periods of watchful waiting
have the woman’s action at their centre (Jordan & Farley
2008, Romano 2009). Because the provider practising from
6
this perspective stays nearby during watchful waiting, her
entrance and exit is not associated with surveillance.
Although the midwife stays vigilant for signs of complications in labour, emphasis is on the provider being present
with the woman and having the potential to act only when
necessary (Rayment 2011).
Antecedents
Physician and midwifery literature also differed in antecedents to watchful waiting. The first major antecedent to
watchful waiting identified was the provider’s view of
labour normality. Physicians tended to take the perspective
that labour processes are often abnormal enough to require
intervention, while midwives believed the opposite – that
labour was inherently normal and could be left to proceed
with no intervention except in rare cases (Bryers & van
Teijlingen 2010). For example, Boers et al. (2010) recommend induction of labour when discussing the implications
of their clinical study (which showed no difference in immediate outcomes between watchful waiting for labour vs.
induction of labour in the mothers of intrauterine growthrestricted babies), even after pointing out a previous study
showing some long-term neurological protective effect on
children whose mothers were allowed to wait for labour.
This recommendation is logical in light of the medical view
that ‘the normal condition is now the ‘experiment’ and the
intervention is the ‘control’ in perinatal care’ (Romano
2009). In contrast, the literature presented midwifery beliefs
that childbirth is a natural physiological event and that
most pregnant women will require little or no medical
intervention to have a normal and safe birth (Oakley
2004).
A second antecedent is the provider’s view of mind/body
interaction. Physician-authors discussed labour from a biological, cause-and-effect perspective, where mind and body
act independently of one another (Boers et al. 2010, Davis
& Walker 2010, Maso et al. 2011). Literature about midwives presented the view of progress during labour as a
result of hormonal, physiological and psychological interactions between the mother, her baby and the greater
environment (Downe & Dykes 2009).
Labour progress is another key antecedent of watchful
waiting among providers. Physician-authored literature presented labour progress and outcomes as something that can
be generalized from woman to woman, forming the basis
of evidence-based medicine (Boers et al. 2010, Jangsten
et al. 2011, Maso et al. 2011). Some midwifery literature
also presented this perspective, making recommendations
for clinical practice based on these generalizations (Brucker
© 2013 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
2001). Other midwifery literature presented an alternative
view that each woman’s labour is unique, referring often to
the importance of considering the individual woman in
assessment of labour (Downe & Dykes 2009, Davis &
Walker 2010).
Finally, physician and midwifery perspectives in the scientific literature differ on the watchful waiting antecedent of
labour length. After her review of medical texts, sociologist
Simonds (2002) concluded that physicians view slow labour
progress as evidence of pathology. Women’s bodies are
viewed within this perspective as ‘prone to error, but correctable’; however, strict time limits are presented as the primary
way to monitor women for this correction to be applied
(Downe & Dykes 2009). In contrast, midwife-focused articles reviewed here tended to view times of slower labour
progress as a period of rest, when women can regroup
energy (Simonds 2002). The process of labour is more
important than how long it takes (Winter & Duff 2009).
Consequences
As a consequence of a period of watchful waiting, intrapartum providers anticipate different results. From a physician’s perspective, watchful waiting brings the possibility of
several negative and one possible positive consequence (Figure 2). Physician-authors expressed concern that watchful
waiting would result in healthcare inefficiency, with the
related risk for more costly care stemming from surveillance
costs (Driffield & Smith 2007). With the extensive surveillance required as part of most medical approaches to
watchful waiting, monetary costs are often higher than
immediate induction or surgery (Nelson et al. 2009,
Shennan & Hezelgrave 2010, Vijgen et al. 2010, Torre
et al. 2012). Authors presented the perspective of some
physicians, who do not see this increased cost as reason for
avoiding watchful waiting or expectant management
(Shennan & Hezelgrave 2010, Moriarty 2011). Related to
the healthcare inefficiency, some physicians (Scott 2005,
Shennan & Hezelgrave 2010, Torre et al. 2012) and midwives (Rayment 2011), who value clinical efficiency, referenced the unfair allocation of their time and effort among
patients as a consequence of watchful waiting. Even more
worrisome than inefficiency, however, was the perceived
risk of litigation and poor outcome some of the physicianauthored literature presents as a result of watchful waiting
(Penson 2009, Boers et al. 2010, Rosenbaum 2011). The
alternative to watchful waiting from a physician’s view is
surgery or intense medication therapy (Bolaji & Meehan
1993, Elkin et al. 2004, Koblinsky et al. 2006, Maso et al.
2011, Torre et al. 2012). It is for this reason that providers
© 2013 John Wiley & Sons Ltd
Watchful waiting among intrapartum providers
practising from a conservative perspective see a positive
consequence of watchful waiting in labour to be the deferral of a decision to allow time and more information that
may cause avoidance of ‘expensive, irreversible, or risky
treatments’ (Driffield & Smith 2007). Important in these
provider’s decisions is the perceived risk of the woman
undergoing surgery vs. remaining pregnant (McCourt
2009c).
Midwifery-focused scientific literature referred to different
consequences of watchful waiting in labour from physicianfocused literature, with most being positive. Watchful
waiting was seen as an optimal approach to labour, with the
best outcomes for the mother and baby the likely result
(Koblinsky et al. 2006). Because watchful waiting is possible
only with the close personal connection between midwife
and labouring woman, an emotional connection between the
two is also seen as a consequence of this practice in labour
(Davis & Walker 2010). In the case of labouring women
who do not readily accept the advice of the midwife, this
emotional connection can be unpleasant to the midwife
(Rayment 2011). Finally, midwife-focused literature emphasized the consequence of an enhanced experience for the
woman. Because the practice of watchfully waiting for some
midwives is based on their view that women are strong and
normal in labour, midwives see a consequence of this practice as the woman’s experience of her own strength and
capability through labour, thus preparing her for the challenges of motherhood (Oakley 2004, van Teijlingen 2005).
Affecting factors
Several factors emerged from the reviewed literature as factors affecting the relationship of watchful waiting antecedents to the attributes and consequences (Figure 2). Medical
insurance companies, liability insurance, national guidelines
and other outside organizations have the potential to
change the way that watchful waiting is practised in a
particular community or setting (Bryers & van Teijlingen
2010, Rayment 2011, Rosenbaum 2011). Both physicians
and midwives felt that the setting where care is provided
has a profound influence on watchful waiting practices
(Jordan & Farley 2008, Rayment 2011, Rosenbaum 2011,
Everly 2012). In settings that were not supportive of practices of watchful waiting, the providers admitted to practising sabotage by falsifying examination findings and reports
(Simonds 2002, Rayment 2011). Providers practising in settings that did not support their practices could be subject to
pressure from co-workers in the form of sanctions and
bullying when their clinical decisions did not adhere to the
workplace norm (McCourt 2009c). The individual
7
N.S. Carlson and N.K. Lowe
What is already known about this topic
•
•
Intrapartum providers of different educational backgrounds may have different philosophies guiding their
care of women.
Intrapartum providers of different educational backgrounds can have different outcomes of care in
matched samples of women.
et al. 2012). Providers’ past experiences of poor patient
outcomes can also evoke anxiety during labour management, with effects on judgement that are largely unrecognized by the providers themselves (Hemmerich et al. 2012).
This anxiety could be especially potent in the work of providers who have had many past exposures to poor outcomes, including providers who are primarily trained in
high-risk services, with little exposure to low-risk pregnancy
and birth care.
What this paper adds
•
•
•
The concept of watchful waiting is defined differently
in some medical and midwifery scientific literature.
Different definitions of watchful waiting arise from the
divergent philosophical perspectives of some physicians
and midwives around intrapartum care processes.
Both physicians and midwives perceive the importance
of affecting factors like third-party healthcare agencies,
setting, healthcare team, provider anxiety and woman
preference on the concept of labour management.
Rodgers’ evolutionary method for concept analysis includes
an exemplar taken from the surveyed literature of the concept. Given this concept analysis comparing a midwifery
and medical perspective on timing in birth processes via
watchful waiting practices, contrasting exemplars would be
needed. However, no suitable exemplars of physician
watchful waiting management were located.
Implications for practice/policy
Discussion
•
This concept analysis of watchful waiting as discussed in
scientific literature from or about physicians and midwives
was conducted to create new insight on the concept
(Rodgers & Knafl 2000). The analysis reveals that most
midwives and physicians envision very different things
when they refer to watchful waiting in labour. Although
first used by physicians, watchful waiting was adopted as a
concept by midwives and refined to signify a fundamentally
different activity. For many midwives, watchful waiting is
defined as providing calm, non-invasive therapeutic support
to a woman in labour, so as to facilitate her work. For
many physicians, watchful waiting is defined as a period of
observation undertaken to avoid immediate surgery while
active surveillance of labour progress and maternal/foetal
stability is enacted. The antecedents, attributes, consequences and affecting factors of watchful waiting, as
revealed by the scientific literature, reflect a middle-range
explanatory theory of this concept in these two disciplines
(Figure 2). The use of this term in the scientific literature
reveals the very different underlying theories held by some
midwives and physicians regarding the care of women in
labour. Physicians’ belief in objectivity, mind/body separation and labour abnormality leads many to regard ‘watchful
waiting’ as a potentially inefficient, risky management
choice undertaken to avoid intensive medical or surgical
outcomes. On the other hand, midwives’ belief in subjectivity, mind/body connection and labour normality leads many
of them to regard watchful waiting as an essential part of
•
Better understanding of the very different, disciplinespecific uses of watchful waiting in labour is needed to
prevent miscommunication between physicians, midwives and nurses who care for labouring women.
Future research is needed to compare different processes and outcomes of labour management, including
investigation of: provider physical presence with the
labouring woman, labour interventions, influence of
provider surveillance vs. presence in labour, impact of
higher risk status women on provider’s management of
labour, and how affecting factors like setting and provider anxiety impact labour management among birth
providers.
approach of physicians, midwives and nurses assembled
around labouring women was also seen as an affecting factor in the literature of watchful waiting (Jordan & Farley
2008, Kennedy & Lyndon 2008, Rayment 2011, Everly
2012). Some midwives could be more inclined towards a
conservative approach to watchful waiting, while some
physicians could practise with a more liberal approach.
Finally, the past experiences and preferences of the individual provider and labouring woman were discussed as
factors affecting watchful waiting. Women who have strong
preferences about their labour and birth can exert powerful
influences on providers as they consider using watchful
waiting (Bryers & van Teijlingen 2010, Everly 2012, Torre
8
Exemplar
© 2013 John Wiley & Sons Ltd
JAN: CONCEPT ANALYSIS
their care, leading to optimal maternal/child health outcomes, emotional connection with the woman and an
enhanced experience for the mother as she initiates new
motherhood. Literature from/about both physicians and
midwives identifies similar affecting factors on the concept
of watchful waiting, including third-party healthcare influences, birth setting, healthcare team, woman’s preference
and provider anxiety.
Limitations
Limitations of this concept analysis include the process for
selection of the literature included as data. Themes important to the concept of watchful waiting may have been
missed if some of the important scientific literature using
this term was missed on database query. This analysis is
also limited by the fact that a single person (NC) performed
all reviewing, coding and thematic analysis. Optimally,
having a second researcher perform a data analysis of this
concept could have provided an opportunity for more discussion, bringing additional clarity to the process of theme
identification.
Watchful waiting among intrapartum providers
surveillance (frequent vaginal examinations, etc.) on labour
progress, impact of higher risk status women on provider’s
management of labour (how does a provider’s belief in normal change with higher risk women?) and how affecting
factors such as setting and provider anxiety impact labour
management among birth providers.
Finally, this concept analysis illustrates the importance of
intrapartum provider educational programmes. The physicians and midwives who authored, or were the subject of,
the scientific literature surveyed for this concept analysis
worked regularly with members of the other discipline, yet
expressed very different perspectives of intrapartum care
processes. The optimal care of women requires clear communication, truthful action and best practices. Different
kinds of birth providers will better serve all women if they
are educated with an understanding of the other provider’s
perspective and work in healthcare settings that value them
equally.
Acknowledgements
We thank Marie Hastings-Tolsma, PhD, CNM for her
encouragement and dedication to nurse-midwifery.
Conclusions
This concept analysis of watchful waiting has important
implications for clinical practice, research and education.
Although the terms watchful waiting and surrogate expressions (expectant management, supportive care, etc.) are
used frequently by providers when working with labouring
women, this concept analysis reveals that very different
activities are potentially being envisioned with these terms,
depending on the provider’s background and philosophical
perspective. The midwife and physician attributes of watchful waiting are different enough to result in significant
miscommunication with the unexplained use of the term.
Future work to further clarify this and other commonly
used intrapartum care practices is needed to facilitate better
interdisciplinary perinatal care.
Rodgers’ methodology was chosen because this analysis
is intended to yield the development of knowledge through
the adequate characterization of a phenomenon (Rodgers &
Knafl 2000). This concept analysis of watchful waiting
gives one view into the different care practices and philosophies of birth providers. Future research is needed to compare the effectiveness of different processes and outcomes
of intrapartum care, including investigation of: provider
physical presence with women in labour, components and
outcomes of therapeutic presence in labour, emotional connection between woman/provider in labour, influence of
© 2013 John Wiley & Sons Ltd
Funding
Primary author was partially funded by grants from HRSA
and the University of Colorado Denver’s ‘Touched by a
Nurse’ scholarship during the process of conducting this
analysis.
Conflict of interest
The authors have no conflict of interest to declare.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria (recommended by the
ICMJE: http://www.icmje.org/ethical_1author.html):
• substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;
• drafting the article or revising it critically for important
intellectual content.
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