Mapping the literature of maternal-child/gynecologic nursing

Abstract

Objectives: As part of a project to map the literature of nursing, sponsored by the Nursing and Allied Health Resources Section of the Medical Library Association, this study identifies core journals cited in maternal-child/gynecologic nursing and the indexing services that access the cited journals.

Methods: Three source journals were selected and subjected to a citation analysis of articles from 1996 to 1998.

Results: Journals were the most frequently cited format (74.1%), followed by books (19.7%), miscellaneous (4.2%), and government documents (1.9%). Bradford's Law of Scattering was applied to the results, ranking cited journal references in descending order. One-third of the citations were found in a core of 14 journal titles; one-third were dispersed among a middle zone of 100 titles; and the remaining third were scattered in a larger zone of 1,194 titles. Indexing coverage for the core titles was most comprehensive in PubMed/MEDLINE, followed by Science Citation Index and CINAHL.

Conclusion: The core of journals cited in this nursing specialty revealed a large number of medical titles, thus, the biomedical databases provide the best access. The interdisciplinary nature of maternal-child/ gynecologic nursing topics dictates that social sciences databases are an important adjunct. The study results will assist librarians in collection development, provide end users with guidelines for selecting databases, and influence database producers to consider extending coverage to identified titles.

INTRODUCTION

As part of Phase I of a project to map the literature of nursing, sponsored by the Nursing and Allied Health Resources Section of the Medical Library Association, the purpose of this study is to identify the core journals cited in the maternal-child/gynecologic nursing literature and the indexing services that access these sources. The common methodology, described in the overview article [1], subjects selected core journals in a discipline to citation analysis over a three-year period, 1996 to 1998, and ranks the number of cited references by journal title in descending order to identify the most frequently cited titles according to Bradford's Law of Scattering. From the core of most productive titles, the bibliographic databases that provide best access to these titles will be identified to assist librarians, to provide end users of the literature with guidance for selecting databases to search, and to recommend additional titles to database producers.

Maternal-child nursing is defined as, “The nursing specialty that deals with the care of women throughout their pregnancy and childbirth and the care of their newborn children” [2]. CINAHL's definitions provide a useful framework for the boundaries of this specialty. The subject “maternal-child nursing” has three subordinate terms in the CINAHL subject headings hierarchy: obstetric nursing (“care of normal, uncomplicated pregnancies only”), perinatal nursing (“nursing care of childbearing families who are at risk for increased maternal, fetal, or neonatal mortality”), and pediatric nursing [3]. The related area of gynecologic nursing is treated as a subdivision of medical-surgical nursing in the CINAHL tree structure. Gynecology is defined as “the medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology” [4]. Maternal-child/gynecologic nurses practice in hospital settings, home health agencies, and ambulatory settings [5].

While the combined specialization of maternal-child/gynecologic nursing emerged from the medical model of obstetrics and gynecology, the end of the twentieth century has seen a shift to include added research priorities for the broader and more holistic field of women's health, defined in MEDLINE as “the concept covering the physical and mental conditions of women” [6] and defined broadly in CINAHL as including “materials concerned with physical, psychosocial, physiological, and political issues in health care of women” [3]. Raftos, Mannix, and Jackson note that the term “women's health,” as used in article abstracts, “appears to be a taken-for-granted notion, that is seldom defined, and is used interchangeably and synonymously to refer to reproductive health, maternal health, neonatal health, family health and sexual health” [7]. Yet, the area of sex-based biology has emerged to focus on a much wider view of women's health needs [8]. A call for research papers for JAMA's first theme issue on women's health in almost a decade noted that women's health involves more than “navel to knees” topics [9]. The Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) focuses on reproductive health and newborn health but proposes a wider commitment to research in the areas of women's health that past research has not adequately studied. Diseases such as heart disease and cancer and issues of social origin such as substance abuse, violence, and health care disparities are included in AWHONN's current research agenda [5, 10].

So, while the term “women's health” may be used loosely to refer to gender-based reproductive issues, it is deliberately not used to describe the focus of this bibliometric study. The current study attempts to capture that literature specific to the research and practice of nurses in maternal-child and gynecologic nursing, within the larger scope of women's health. Nurse-midwifery, a distinct specialty of its own, is a separate study in Phase I of this project [11].

HISTORY

The rich history of maternal-child/gynecologic caregivers encompasses the contributions of Lillian Wald and Margaret Sanger [12] and the more invisible contributions of caregivers throughout history. Ulrich's Midwife's Tale provides a record of Martha Ballard and the eighteenth century community she tended, pointing out the scope of caregivers:

[T]he midwives, nurses, afternurses, servants, watchers, housewives, sisters, and mothers … Female practitioners specialized in obstetrics but also in the general care of women and children, in the treatment of minor illnesses, skin rashes, and burns, and in nursing. Since more than two-thirds of the population …was either female or under the age of ten, since most illnesses were “minor,” at least at their onset, and since nurses were required even when doctors were consulted, Martha and her peers were in constant motion. [13]

Modern nursing's beginnings in obstetrics were tied to public health nursing at end of the nineteenth century. Most births—along with antepartum, postpartum, and well child care—took place at home, frequently attended by midwives and the early public health nurses [14]. The movement of childbirth into hospitals at the beginning of the twentieth century was the result of changing sociocultural patterns and an increased demand for medical intervention, asepsis, and efficiency. By the 1930s, physicians became the primary caregivers, as they “medicalized” birth, taking over the role that midwives and public health nurses traditionally performed. Trained as surgeons to look at reproductive processes as “potentially pathologic,” physicians enlisted nurses in their campaign to promote hospital birth, not only as a superior setting for the use of aseptic technique, but as more economic and efficient according to “scientific management” principles [15, 16]. As nursing migrated to the hospital setting and care became more specialized, nurses had opportunities to develop specialized skills and to gain postgraduate training. Advances in technology for premature infants, such as incubators and the use of oxygen demanded the involvement and specialized skills of nurses. The earliest centers using technology to support premature infants were demonstrated in tourist-attraction-type settings such as the World Exposition in Berlin and at New York's Coney Island. The first US hospital center for premature infants was established in Chicago in 1923 [14].

Nursing education moved from hospital diploma and associate degree programs to institutions of higher education with the first master's programs to prepare nursing faculty in the 1940s; baccalaureate programs gained popularity in the 1950s [14, 17]. Post-baccalaureate advanced practice specialization for nurses began in the 1960s with the advent of programs for pediatric nurse practitioners, designed to prepare nurses to perform roles previously in the scope of medical practice. Advanced practice roles for maternal-child/gynecologic nurses began with the first certification examination in 1980 for obstetric/gynecologic nurse practitioners [14]. Specialization for neonatal intensive care nurses, neonatal nurse practitioners, family planners, coordinators of newborn services, and reproductive endocrinology/infertility nurses followed [18].

The issues surrounding the history of nurses caring for women span the spectrum from the “traditional-authoritarian” model, where all decision making is in the hands of the physician, to lay-midwife-attended home birth. In the 1970s, self-help groups and feminist health care began to focus on self-care, wellness, and a holistic perspective. Many patients moved from the status of recipients to that of participants in treatment [19]. The evolution of the role of patients—from draped and restrained to participating, awake with self-control over birth position, presence of support persons during labor for both vaginal and Cesarean deliveries, informed decision making, prevention, breast self-exam, breast cancer support, and improved and alternative methods of pain management—was an outcome of this movement. The professional role of nurses in intrapartum care has been affected by these changes and is inextricably bound to the social history of women, encompassing issues of gender, authority, autonomy, and choice. AWHONN (formerly, the Nurses Association of the American College of Obstetricians and Gynecologists) became an independent professional association in 1993 to encompass a more holistic approach to women's health as well as to provide nurses with a more autonomous organization, separate from the professional organization of physicians [20]. Maternal-child nurses have gained increased autonomy with the advent of education and legislation to support advanced practice specialties and what has been called the “renaissance of nurse midwifery” [21].

Women's health concerns have emerged as prominent policy issues in the national agenda: the continuing debate over the Supreme Court's 1973 Roe v. Wade decision; late term abortions; AIDS research and prevention; issues of managed care such as hospital length of stay for postpartum mothers and infants as well as for post-mastectomy patients; domestic violence; rape; harassment; female genital mutilation; eating disorders; health issues for minority and immigrant women; the biological, ethical, and social issues surrounding reproductive technologies; and postpartum depression. Increased access to information, most notably the advent of electronic networks, launched the trend toward evidence-based practice and affected both professional and lay access to health information as well as the patient-caregiver relationship. At the same time, advances in monitoring technologies for fetal and maternal assessment, increased rates of induced labor and higher nurse-to-patient care ratios profoundly affected the work environment [22]. Maternal-child nursing researchers have collaborated with leaders in medicine and midwifery in areas such as management of labor pain and practice implications [23]. The Centers for Disease Control and Prevention listed “healthier mothers and babies” and “family planning” among the ten great public health achievements of the twentieth century [24].

Looking forward, the nation's Healthy People 2010 initiative, with the overarching goals of “eliminating health disparities” and “increasing quality and years of healthy life,” lists family planning; maternal, infant, and child health; HIV; and sexually transmitted diseases among its twenty-eight focus areas [25]. In this complex and rapidly changing environment, specialists in maternal-child/gynecologic nursing continue to address both the physical and emotional health of women and their families [26].

PREVIOUS BIBLIOMETRIC STUDIES

Several bibliometric studies have been conducted related to the literature of maternal-child/gynecologic nursing. D'Auria's analysis of published maternal-child nursing research was limited to nonspecialty journals and reported on authorship patterns [27]. Gannon, Stevens, and Stecker's analysis of the content of major English-language obstetrics and gynecology journals was critical of the emphasis on reproduction and the exclusion of the “nonpregnant” and “nonfertile” and did not focus on the nursing literature [28]. O'Neill's citation analysis of nursing literature explored the extent of communication between research and practice components as evidenced by citation patterns [29]. While the core journals for the current study—JOGNN: The Journal of Obstetric, Gynecologic, and Neonatal Nursing; Journal of Perinatal & Neonatal Nursing (JPNN); and MCN: The American Journal of Maternal Child Nursing— were included in O'Neill's study, the studied variables included author education and affiliation and the citing relationships between research and practice articles. No bibliometric studies of maternal-child/gynecologic nursing have identified core journals for the specialty.

METHODS

The methodology of this study, described in detail in the overview article [1], requires selecting “source” journals for analysis. The interdisciplinary nature of maternal-child/gynecologic nursing made selection problematic. Obstetric nursing cannot be separated from gynecologic and neonatal nursing. Maternal-newborn care is not easily teased from the literature concerning reproductive issues or pediatrics. Clinicians caring for antepartum, laboring, and postpartum clients also care for the neonate, and they interact with partners and family members. The interactions between nurse and client and parent and child and the many psychosocial aspects of health and illness cannot be separated as a specialty. JOGNN, AWHONN's official journal, was selected as the first source journal because of its clear focus on nursing care and obstetrics, the neonatal period, and gynecology. It has been published under several titles bimonthly since 1972. The bimonthly MCN was selected as the second core title for analysis. Published since 1976, it was and remains the only professional nursing journal aimed at both perinatal and pediatric nurses [30]. While the specialty of pediatric nursing is distinctly separate, the journal has a cross-disciplinary focus and emphasizes the neonatal period. The quarterly JPNN, published since 1987, was selected as the third source title for analysis. While each issue covers a single topic in critical care, obstetrics, neonatal intensive care, intervention outcomes, home care, professional development, or state-of-the-art technological advances, the author predicted that a three-year analysis of citations would provide a cross-section of topics [31].

All of the source journals contained a mix of both practice and research articles. For the years 1998 to 2000, JOGNN contained approximately 40% research, MCN approximately 24%, and JPNN approximately 11% [32]. These figures are increasing as the editors set goals to increase research content in these titles [33]. For the years 2001 to 2003, JOGNN contained approximately 44% research, MCN approximately 29%, and JPNN approximately 23% [34]. In 2002, all 3 source journals were listed in the Brandon/Hill list of recommended nursing titles, with JOGNN and MCN starred for initial purchase [35].

It is clear that a separate specialty exists for nursing in neonatal intensive care units. Neonatal Network: The Journal of Neonatal Nursing was not selected for this study because of its stated focus on clinical issues relevant to level II and III neonatal intensive care units. Birth: Issues in Perinatal Care was not selected because its focus is more interdisciplinary, aiming beyond a nursing audience to a wider group of health professionals, educators, and parents [36]. Citation data for Birth is covered in ISI's Social Sciences Citation Index.

RESULTS

As shown in Table 1, 2,213 citations from articles in JPNN, 6,012 citations from articles in JOGNN, and 1,911 citations from articles in MCN were tabulated, for a total of 10,136 citations. Journals were the most frequently cited format, accounting for 74.1% of the total number of citations. Book citations constituted 19.7% of the total, leaving just 4.2% of the citations as miscellaneous and 1.9% as government documents.

Table 1 Cited format types by source journal and frequency of citations

Table 2 shows the age of citations by format types. Nearly 10% of the total citations in all formats were 3 or fewer years old. For the 3-year period analyzed, 1996 to 1998, citations from the years 1990 to 1995 (1 to 8 years old) were the most heavily cited (54.1% of the total), regardless of the format type. Citations from 1980 to 1989 (6 to 18 years old) were consistently second in terms of percentage of citations and accounted for another 28.8% of the cited references. Literature more than 15 years old was rarely cited.

Table 2 Cited format types by publication year periods

The total of 7,514 cited journal references in 1,308 titles were arranged in descending order by title and divided into 3 approximately equal zones to apply Bradford's Law of Scattering. The zones were adjusted slightly to keep citations from journal titles being split between zones. Table 3 displays the distribution of the titles by zone. Zone 1, containing 2,494 citations, was dispersed over 14 journal titles, which represented just 1.1% of the total number of titles. Zone 2, with 2,513 citations, was more widely dispersed over 100 titles (7.6% of the total number of titles). Zone 3, with 2,507 citations was dispersed over the remaining 1,194 titles (91.3% of the total number of titles). Table 4 displays the cited journal titles in Zones 1 and 2 and the distribution arranged in descending order of frequency. (Titles in Zone 3 are not displayed but are available from the author by request.) The top-ranked 67% of the citations were concentrated in just 8.7% of the journal titles (114 titles).

Table 3 Distribution by zone of cited journals and references

Table 4 Distribution and database coverage of cited journals in Zones 1 and 2

Database coverage for the core titles identified in Zone 1 and Zone 2 was determined using the common methodology described in the project overview article [1], assigning a relative score to each title based on the percentage of articles indexed in a bibliographic database for the year 1998. PubMed/MEDLINE provided the best overall coverage of titles in Zone 1 for maternal-child/gynecologic nursing, followed by Science Citation Index and CINAHL, respectively (Table 4). In Zone 2, PubMed/MEDLINE, Science Citation Index, and EMBASE ranked higher than CINAHL and Social Sciences Citation Index. The combined average scores for both Zones 1 and 2 ranked the biomedical databases PubMed/MEDLINE, Science Citation Index, and EMBASE above CINAHL and Social Sciences Citation Index.

DISCUSSION

The results demonstrate the expected phenomenon described by Bradford: a small core of journals is highly productive (Table 4). As expected, “journal article” was the most frequently cited format. All three of the original source journals (JOGNN, MCN, and Journal of Perinatal & Neonatal Nursing) are found in Zone 1, along with two other nursing journals (Nursing Research and Neonatal Network), seven medical journals, and two titles aimed at a more diverse audience (Birth and American Journal of Public Health).

Seven of the fourteen titles in Zone 1 were also present in Zone 1 of the project's Phase I study of nurse-midwifery (Obstetrics and Gynecology, American Journal of Obstetrics and Gynecology, New England Journal of Medicine, JAMA, Lancet, American Journal of Public Health, and Birth). Journal of Midwifery and Women's Health (formerly, Journal of Nurse Midwifery) narrowly missed ranking in Zone 1. The nurse-midwifery mapping study ranked Journal of Midwifery and Women's Health at the top of Zone 1 [11].

In Zone 2 (Table 4), nursing and medical journals have floated to the top of the zone, with titles in the behavioral sciences occurring more frequently in lower ranks. Child Development, ranked at number twenty-four, was the first behavioral science title to surface, followed by Infant Behavior and Development, tied with other titles at number forty-nine. Other titles such as Social Science and Medicine and Infant Mental Health Journal ranked nearby.

Table 4 displays the relative score assigned for database coverage of journals. Given the preponderance of medical journals identified as core for maternal-child/gynecologic nursing in Zone 1, it was not surprising that PubMed/MEDLINE and Science Citation Index emerged as more comprehensive bibliographic database sources than CINAHL. While 100% of the Zone 1 titles were indexed in OCLC ArticleFirst, the data were found to be unreliable due to the way meeting abstracts were counted. In CINAHL, all meeting abstracts in a journal issue were indexed as a whole (one record), rather than separately, leading to individual title index coverage scores similar to those for PubMed/MEDLINE. Similarly, Science Citation Index and Social Sciences Citation Index provided separate coverage of meeting abstracts and book reviews, which acted to increase the scores for these databases. Therefore, scores for indexing coverage—even for a nursing journal such as Nursing Research—were higher when a database was not as selective when determining article formats to index.

The journals identified as core for this nursing specialty point out that the literature of maternal-child/ gynecologic nursing, while known to draw from many disciplines, cites frequently from medical journals. As a specialty that supports the medical model of obstetrics and gynecology—focused on the pathologic aspects of pregnancy, birth, and the neonatal period— this is not surprising. It has been noted that the experience of “normalcy” in women's health is not well examined or documented [16].

Given the strong presence of medical journals in Zone 1, it follows that, for the thesaural databases, PubMed/MEDLINE provides more comprehensive coverage than CINAHL. The social sciences databases rank lower as sources for this specialty. Yet, while PubMed/MEDLINE and Science Citation Index rank higher in terms of articles indexed, the journal titles and associated databases do not tell the whole story. Topics in this nursing specialty draw from psychosocial as well as biologic research. At the article level, perusing the table of contents of any of the source journals reveals an abundance of interdisciplinary topics, such as “Gynecologic Care for Women with Mental Retardation” or “Behavioral Characteristics of Very Low Birth Weight Infants of Varying Biologic Risk at 6, 15, and 24 Months of Age.” A searcher should always use more than one database to ensure coverage of psychosocial aspects of a nursing topic. A combined approach to database searching using both CINAHL and PubMed/MEDLINE is recommended, given that Science Citation Index and OCLC ArticleFirst are not based on controlled vocabularies. Databases with an underlying hierarchical thesaurus of terms provide searchers with the necessary link to relevant research. When a topic involves the psychosocial aspects of nursing practice, PsycINFO and Social Sciences Citation Index might prove more valuable for locating research.

CONCLUSION

This study provides a snapshot of the literature for a three-year period (1996 to 1998) by analyzing the presence of citations, applying Bradford's Law of Scattering to identify a core of those journal titles most frequently cited, and identifying the bibliographic databases that access those titles. The quantitative picture indicates a remarkably high concentration of the literature in biomedical journals, accessible via biomedical databases. But scholars searching the literature on a topic in maternal-child/gynecologic nursing will want to access the bio-psychosocial, economic, and policy aspects tangential to an information need, mandating that a search strategy should go beyond biomedical databases. A search on a behavioral aspect of maternal-child/gynecologic nursing could find biomedical databases of little use, with strong coverage of the literature provided by sources such as CINAHL and Social Sciences Citation Index. Further study is needed to examine how authors use the literature they cite and what other methods of scholarly communication they use in the current, increasingly electronic, environment.

The beginning of the twenty-first century has seen dramatic changes in the areas of medical and information technology, educational programs preparing nurses for advanced practice, research in psychosocial areas, qualitative research, and funding for nursing research [37]. The results of this study suggest other nursing specialty areas for mapping using the same methodology. Women's health has been only recently viewed more holistically and should be mapped as a separate emerging specialty for nurses. Pediatric nursing has been mapped as a specialty in Phase III of this study [38]; neonatal intensive care nursing should be mapped separately as well.