The experiences of new graduate midwives working in midwifery continuity of care models in Australia

Everyone should have their own midwife: Women's and staff experiences during the implementation of two midwifery continuity of care models in regional Australia

PROBLEM

Midwifery Continuity of Care (MCoC) remains inaccessible for most Australian women; this is especially true in rural and regional areas.

BACKGROUND

Strong evidence demonstrates MCoC models improve experiences for women and their babies and are also shown to improve midwifery workforce wellbeing. However, implementation and upscale remains limited.

AIM

To explore the views and experiences of implementing MCoC for both staff and women, understanding their experiences, concerns and solutions in a regional context.

METHODS

Qualitative data was collected via focus groups with women and healthcare staff, at six and twelve month post implementation. Data was thematically analysed using Braun and Clarke six step process.

FINDINGS

The findings support that 'women love it' and midwives working in the new MCoC model 'loved their job'. The major concern was that not all women could access the model and disconnected communication was problematic during implementation. 'Sharing stories' was a solution to overcoming these issues and promoting the positive impact of MCoC - in particular ways of working and adaption to an all-risk midwifery group practice.

DISCUSSION

This study supports widespread evidence that MCoC is valued by both women and staff. In a regional context it is important to recognise challenges faced during implementation and identifying solutions that other maternity services could consider when implementing MCoC.

CONCLUSION

The study offers strong recommendation for regional areas to consider MGP to maintain safe, quality local maternity services.

Understanding attrition of early career midwives in Australia

PROBLEM

There is a lack of understanding of the experiences of early career midwives which lead to workforce attrition.

BACKGROUND

In the Australian midwifery setting, workforce attrition in conjunction with the ageing profile of the workforce is of increasing concern. Midwives in the earliest stages of their career are most vulnerable to career attrition, however limited research specifically engages with this cohort.

AIM

To understand the professional and social circumstances that led early career midwives to leave clinical practice, how their midwifery background influenced career trajectories, and what would compel them to return to clinical practice.

METHODS

Semi-structured interviews were conducted with 11 early career midwives who had left the profession within 5 years of qualification. Transcripts underwent thematic analysis.

FINDINGS

Three themes described early career midwives' experiences: transition to professional practice, an untenable workplace culture, mental health impacts of early clinical midwifery practice. Two further themes emerged about experiences post-midwifery careers: influence of midwifery on subsequent career, and conditions for re-entry.

DISCUSSION

Challenges with transitioning to professional midwifery practice in conjunction with untenable workplace culture led to such deterioration in wellbeing that remaining within the profession became unfeasible for early career midwives. Desire to remain within health care was apparent, however re-entry to the profession was deemed by most to be out of the question.

CONCLUSION

Early workforce retention strategies should be the focus of future workforce planning and policy. Larger scale inquiry foregrounding early career midwives is necessary to inform strategies for midwifery workforce retention in Australia.

Early career midwives' job satisfaction, career goals and intention to leave midwifery: A scoping review

OBJECTIVE

To scope and synthesise literature around the job satisfaction of early career midwives - those in their first five years of post-qualification practice - including the effect on their career aspirations and intention to leave the profession.

DESIGN

Scoping review.

METHODS

Relevant databases were searched for published research studies and grey literature. Literature were selected through adherence to pre-set inclusion and exclusion criteria to ensure relevance. Literature was included that was published from 2012. Selected literature were tabled and common themes were mapped to look for similarities and differences in findings.

FINDINGS

Ten papers were included - seven original research studies, a fact sheet, a non peer-reviewed article, and a conference paper. Negative themes - lack of support, workload stress, and job dissatisfaction, and positive themes - passion for midwifery, collegial relationships, and autonomy - were found across many of the included papers.

KEY CONCLUSIONS

Many midwives are considering leaving their profession due to the stress of their work, role dissatisfaction, and a lack of support. This is more common amongst early career midwives. There were some protective factors such as having pride in the midwifery profession. More research is needed to identify and address the needs specific to early career midwives.

How do new midwives' early workforce experiences influence their career plans? An integrative review of the literature

AIM

To explore how the early workforce experiences of new midwives influence their career plans.

BACKGROUND

Each year, thousands of new midwives graduate from entry-to-practice midwifery courses, gain professional registration, and enter the workforce. Despite this, the world continues to face a shortage of midwives. The first five years of clinical practice, commonly referred to as the early career period, can be highly stressful for new midwives, contributing to early attrition from the profession. Supporting the transition from midwifery student to registered midwife is vital if we are to grow the workforce. Whilst the early career experiences of new midwives have been more broadly explored; little is currently understood about how these can influence their career plans.

METHODS

Following Whittemore and Knafl's (2005) five-stage process, an integrative review was conducted. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Nineteen studies met the criteria for inclusion. Thematic analysis was undertaken to organise and present the findings.

FINDINGS

Thematic analysis, guided by the review question led to the identification of three overarching themes: 'the need for support', 'sustaining health and wellbeing', and 'being able to provide safe and effective midwifery care'.

CONCLUSION

Very little research to date has specifically explored how the early career experiences of new midwives influence their career plans, particularly within the Australian context. Further research is required to better understand how the early workforce experiences of new midwives can either strengthen their commitment to the profession or contribute to the decision to leave midwifery prematurely. This knowledge would provide a basis for the development of appropriate strategies to minimise early attrition from the midwifery profession and promote career longevity.

Nurturing our new midwives: A qualitative enquiry of mentor's experiences of supporting new graduate midwives working in continuity of care models

PROBLEM

Limited opportunity exists for new graduates in Australia to be employed in continuity of care midwifery models.

AIM

To explore the perspectives of midwifery mentors supporting new graduate midwives employed in continuity of care models.

METHODS

An interpretive, qualitative study was conducted. Semi-structured interviews and focus groups with senior midwifery staff who mentored new graduate midwives during their transition to practice within a continuity of care model were undertaken. Digitally recorded and transcribed verbatim, data were thematically analysed. Data collection ceased once theoretical saturation had been achieved. NVIVO software was used to assist with coding and data management.

FINDINGS

Twelve mentors participated. Mentors provided valuable feedback to optimise the supportive mechanisms to enable the success of the rotation of new graduate midwives in continuity of care models during their transition to practice period. Three key themes were constructed, including: Getting it right in the first place; Nurturing our new midwives; and The cultural void.

DISCUSSION

Consistent with the wider literature, effective implementation, sound support structures and wider acceptance of new graduate midwives transitioning to practice within continuity of care models is crucial to its success and sustainability.

CONCLUSION

Mentors are responsible to nurture, respect and guide new midwives through this crucial period, as they transition from midwifery student to registered midwife. Mentors believe in the transition of new graduate midwives in continuity of care models.

Learning through relationships: The transformative learning experience of midwifery continuity of care for students: A qualitative study

BACKGROUND

Midwifery curricula in Australia incorporate 'Continuity of care experiences' (CoCE) as an educational strategy based on an assumption that midwifery students will learn skills and knowledge about woman-centred care that they may not learn in the typical fragmented care system. However, exactly what skills and knowledge they are expected to 'learn' and how these can be assessed have never been specifically identified.

AIM

To explore midwifery students' continuity of care learning experiences within pre-registration midwifery education.

METHODS

Focus groups were conducted with first, second and third year Bachelor of Midwifery students (n = 12), who were undertaking CoCE in rural and regional tertiary hospitals in NSW, Australia.

FINDINGS

The overarching theme, 'Learning through relationships', was made up of three interrelated themes: Meeting women and making connections, Being known, and Understanding holistic care.

DISCUSSION

The findings from this study contribute to understanding the educational effects of CoCE. The CoCE relationship provided safety and freedom to learn which was seen as foundational for midwifery students' vision of their future practice and can be seen as a self-determined transformational approach to learning.

CONCLUSION

This study adds insight into midwifery students' experience of CoCE, and demonstrates that transformative learning occurs through developing a relationship with both the woman and the midwife. For midwifery to develop as a profession and maintain its focus on woman-centredness, it is important that this aspect of midwifery education remains embedded within midwifery program philosophies and learning outcomes.

A pilot study: Transitioning into a new graduate midwife - perspectives about a unique student-led practice

OBJECTIVE

To explore midwifery students' (and as new graduates') experiences and level of satisfaction about a student-led midwifery model of care.

METHODS

This was a qualitative study to elicit rich descriptive data from the participants. Thematic analysis was used. The students were interviewed at the end of their final year of study and they were subsequently interviewed at the end of their graduate year.

RESULTS

Two overarching themes were identified from the qualitative findings from the first and second interviews including the students building and sustaining important relationships and transitioning from a student to new graduate.

CONCLUSIONS

The midwifery students valued the opportunity to spend one year in a student-led model of care so that they could build and sustain important relationships with women and their team including the mentor midwife as new graduates. The students developed confidence by being respected by midwives and enabled them to advocate for women.

Challenges experienced by newly qualified nurse-midwives transitioning to practice in selected midwifery settings in northern Malawi

BACKGROUND

Literature shows that newly qualified nurse-midwives face challenges integrating into the workforce during their transition period from education to practice. However, little is known about the needs and challenges of Malawian nurse-midwives during their transition from education to practice. The aim of the study was to explore the transition experiences of newly qualified nurse-midwives working in selected midwifery units in Northern Malawi.

METHODOLOGY

A qualitative descriptive approach was used. Data were collected through in-depth interviews using semi-structured interview guides from a purposive sample of 19 participants (13 newly qualified nurse-midwives and 6 key informants). The researchers developed two interview guides; one for the newly qualified nurse-midwives and another one for the key informants. The interview guides had questions related to newly qualified nurse-midwives experiences of transitioning to practice and the support they received. Participants were from three selected hospitals in the Northern part of Malawi that have maternity units. Data were analysed manually using thematic analysis.

FINDINGS

Five themes related to challenges faced by newly qualified nurse-midwives during their transition to practice in midwifery units emerged from the thematic analysis of the data. These included (1) Theory-practice gap, (2) Lack of confidence and skills, (3) Inadequate resources, (4) Transition support system, and (5) Workplace conflict.

CONCLUSION

Newly qualified nurse-midwives in Malawi encounter many challenges while transitioning from education to practice. The study findings underscore the need to develop a national framework support system that could not only help newly qualified midwives adjust positively to their new role but also create more opportunities for learning and developing and strengthening a collaborative partnership between colleges and hospitals.

The concept, importance and values of support during childbearing and breastfeeding - A discourse paper

BACKGROUND

Professional support in childbearing has beneficial effects on childbirth experience, interactions within the family, breastfeeding and medical outcomes. However, more knowledge is needed about prerequisites for professional support to be valuable and satisfactory during childbearing.

AIM

The aim of this discourse paper is to describe and explore prerequisites for professional support that are of value for women and their families during childbearing as well as how healthcare organizations can be formed to facilitate these prerequisites.

DESIGN

Discourse paper.

METHODS

This discourse paper is based on our own experiences and is supported by literature and theory.

RESULTS

Well-functioning structures and processes facilitate professional support that leads to safe, secure, calm and prepared parents with the ability to handle the challenges of childbearing and parenting. When organizing care in childbearing, prerequisites for support needs must also be considered.

Midwife experiences of providing continuity of carer: A qualitative systematic review

PROBLEM

Continuity of carer models present positives and challenges for midwives working in them, and are difficult to sustain.

BACKGROUND

Research shows midwifery continuity of carer improves perinatal outcomes and experiences, and is considered the optimal model of care.

AIM

To synthesise existing research on midwives' experiences of providing continuity of carer and generate further understanding of what sustains them in practice.

METHODS

Protocol for the review was developed using PRISMA guidelines and registered with PROSPERO. 22 studies were included with original themes and findings extracted using JBI tools and synthesised using meta-ethnographic techniques. GRADE CERQual assessment of review findings showed high confidence.

FINDINGS

Midwives identified working in continuity of carer models as both fulfilling and challenging. Professional autonomy and ability to develop meaningful relationships were the most commonly cited positives, while lack of work life balance and conflict with the wider maternity team were the main challenges. 15 studies identified strategies employed by midwives which sustained them in practice.

DISCUSSION

Midwife experiences of providing continuity are impacted by personal and professional factors. Of paramount importance to sustainability of the model is the support of the wider organisation, and their alignment with principles of person-centred, relational care.

CONCLUSION

Relational models of care are desired by midwives, service users and are recommended in policy. Relational models of care must be responsive to midwives needs as well as birthing people, and therefore need to be designed and managed by those working in them and supported by the whole organisation to be sustainable.

Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students' perspectives

BACKGROUND

Internationally, midwifery education and maternity services are evolving to promote midwifery continuity of care. It is unclear whether current Australian midwifery education programs are graduating a midwifery workforce prepared and motivated to work in this way.

AIM

To discover how well midwifery students in Australia feel they have been prepared and motivated to work in midwifery continuity of care when they enter practice.

METHODS

A pragmatist approach was used. Participants were final year midwifery students at one Australian university participating in the Midwifery Student Evaluation of Practice (MidSTEP) project over three consecutive years. Descriptive analysis of selected scaled and free text responses was undertaken to ascertain how students' clinical practice experiences had influenced their learning, development and career aspirations.

RESULTS

Exposure to midwifery continuity of care had profound impact on students' learning, enabling them to provide woman-centred midwifery care whilst increasing confidence and preparedness for practice. The majority were motivated to work in midwifery continuity of care upon graduation. A small minority of participants felt unprepared to work in midwifery continuity of care, attributing this to their family commitments, a sense of needing more experience or unsupportive workplace cultures.

SUMMARY

Midwifery continuity of care experiences are highly valued by midwifery students and positively influence confidence, preparation and motivation for beginning practice. It is necessary to review education standards to ensure quality, consistency, and adequacy of these experiences throughout pre-registration midwifery education. This will assist in generating a midwifery workforce prepared and motivated to deliver the goals of maternity service reform.

Exploring the value and acceptability of an antenatal and postnatal midwifery continuity of care model to women and midwives, using the Quality Maternal Newborn Care Framework

BACKGROUND

Having a known midwife throughout pregnancy, birth and the early parenting period improves outcomes for mothers and babies. In Australia, midwifery continuity of care has been recommended in all states, territories and nationally although uptake has been slow. Several barriers exist to implementing midwifery continuity of care models and some maternity services have responded by introducing modified models of continuity of care. An antenatal and postnatal continuity of care model without intrapartum care is one example of a modified model of care that has been introduced by health services.

OBJECTIVES

The aim of this study was to explore the value and acceptability of an antenatal and postnatal midwifery program to women, midwives and obstetricians prior to implementation of the model at one hospital in Metropolitan Sydney, Australia.

METHODS

A qualitative descriptive methodology was undertaken to discover the value and acceptability to the implementation of the model. Data was collected via focus groups and one to one interviews from the service users (pregnant women and two partners) and service providers (midwives and obstetricians). We also collected demographic data to demonstrate the diversity of the setting. The Quality Maternal Newborn Care (QMNC) Framework was used to guide the focus groups and analyse the data.

FINDINGS

Four themes emerged from the data that were named feeling safe and connected, having more quality time and being confident, having a sense of community and respecting cultural diversity. The findings were analysed through the lens of the quality components of the QMNC framework. The final findings demonstrate the value and acceptability of implementing this model of care from women's, midwives and obstetrician's perspective.

CONCLUSIONS/IMPLICATIONS

Providing midwifery continuity of care through the antenatal and postnatal period without intrapartum care, is being implemented in Australia without any research. Using the QMNC framework is a useful way to explore the qualities of a new emerging service and the values and acceptability of this model of care for service providers and service users.

Understanding workforce experiences in the early career period of Australian midwives: insights into factors which strengthen job satisfaction

OBJECTIVE

The aim of this study was to explore the experiences of early career midwives in Australia and identify the organisational, work environment, personal factors and stressors that influence workforce participation.

DESIGN AND SETTING

A qualitative study, using in-depth semi-structured interviews, was undertaken with midwives 6 - 7 years post-qualification. Qualitative content analysis identified key themes and sub-themes.

PARTICIPANTS

Twenty-eight midwives from one Australian university (graduating years 2007 and 2008) were included. Their pre-registration education was via either a Bachelor of Midwifery (direct-entry) or a Gradate Diploma of Midwifery (post-nursing degree).

FINDINGS

Three themes were generated: (i) 'sinking and swimming'; (ii) 'needing a supportive helping hand'; and (iii) 'being a midwife … but'. The initial transition into midwifery was overwhelming for most participants, particularly when providing intrapartum care. Job satisfaction was strongly related to having a well-developed midwife-woman relationship in clinical care and being able to work to their full scope of practice. Dissatisfaction stemmed from remuneration concerns, inflexibility of rostering, high workloads, and poor managerial approaches. Experiences of bullying were ubiquitous. Factors inducing midwives to stay in their profession were not the absence of those that caused dissatisfaction. The midwife-woman relationship sustained their practice despite those factors that caused dissatisfaction.

KEY CONCLUSIONS

Building strategies that strengthen job satisfaction in midwives is vital. Strategies that provide relational aspects of midwifery practice, ongoing support, rostering flexibility, induce psychological wellbeing, and address workplace bullying, may assist in the early career transition. Access to continuity of midwifery care models as new graduates is warranted.

IMPLICATIONS FOR PRACTICE

Continued professional development and career progression strategies are needed for midwives to cultivate their midwifery skills and work to their potential.

Mentoring in the clinical training of midwifery students - a focus study of the experiences and opinions of midwifery students at the Medical University of Warsaw participating in a mentoring program

BACKGROUND

The current system of clinical training for midwifery students in Poland is in need of considerable revision to adapt it to the global standards and the expectations of healthcare providers, healthcare users and student midwives themselves. Aim of this study was to report the experiences of midwifery students participating in a mentor-led clinical training program and their opinions of mentoring as a novel training method.

METHODS

A qualitative descriptive study that used a focus group was undertaken in the period from October 2017 to June 2019. The participants were 12 s- and third-year midwifery students at the Medical University of Warsaw who at various times during the study period had their clinical training in the Department of Obstetrics, Solec Hospital in Warsaw, Poland. All students had previous experience of clinical training other than clinical mentorship. At the end of the study, a focus group interview was conducted with all 12 participants. Five questions were selected to guide the focus group discussion: Did you get any valuable learning experience during your clinical training? How did this clinical training differ from your previous clinical training? What was your experience of one-on-one mentoring? Did the mentoring program meet your expectations? What do you think could be changed to make the proposed mentor-led clinical training more effective?

RESULTS

Four themes were identified. The study demonstrated that mentoring was perceived by the participants as an innovative and effective method of clinical training for midwifery students. All students positively evaluated the quality of the mentor-led clinical training which allowed improving their clinical skills and building new competencies. Students believed they could effectively use their clinical skills and make informed decisions in a safe and supportive clinical learning environment. They felt that their inclusion in the therapeutic team contributed to better patient care.

CONCLUSIONS

The use of innovative forms of clinical training at undergraduate level improves its effectiveness and in the future should be reflected in a high-quality maternity care. Mentoring has its advantages for both, mentor and mentee, but the main goal is to develop and improve professional competencies of the junior partner.

Midwives' views of caseload midwifery - comparing the caseload and non-caseload midwives' opinions. A cross-sectional survey of Australian midwives

BACKGROUND

Midwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.

AIM

To compare views of caseload midwifery - those working in caseload models and those in standard care models in hospitals with and without caseload.

METHODS

A national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.

FINDINGS

Responses were received from 542/3850 (14%) midwives from 111 hospitals - 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.

CONCLUSIONS

There was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives' views.

Midwives' Experiences of Transitioning Into Private Practice With Visiting Access in Australia: A Qualitative Descriptive Study

BACKGROUND

A national review of maternity services in Australia in 2009 resulted in legislative changes which provided midwives with an unprecedented opportunity to offer continuity of care as a private practitioner with visiting access to a public maternity hospital. However, very few midwives have taken up this opportunity.

AIM

To explore the experiences of midwives who transitioned into private practice with visiting access to a public hospital.

METHOD

Using a qualitative descriptive approach, six midwives participated in digitally recorded in-depth interviews. Data was analyzed using thematic analysis.

FINDINGS

Transitioning to private practice enabled midwives to align their core midwifery values with their practice. Midwives reported taking “a leap of faith” by venturing into private practice. Although seeking visiting access and running a small business was initially daunting, midwives were rewarded by being able to practice autonomously and provide continuity of woman centered care within a caseload model. The legislative restrictions, especially around employing other midwives posed significant challenges.

DISCUSSION AND CONCLUSIONS

Private practice with visiting access provided midwives with a service model that aligned their core midwifery values with their clinical practice. The model facilitated their ability to work as lead care professionals, provide woman centered care, and access a collaborative network of healthcare professions. However, the midwives continued to experience structural barriers that threaten the scalability and sustainability of the model. Structural barriers to midwives working to their full scope of practice and in alignment with a midwifery philosophy are a global issue. Further reforms are needed.

Evaluation of a student-led midwifery group practice: A woman's perspective

BACKGROUND

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OBJECTIVE

To evaluate women's experiences of a student-led midwifery group practice.

DESIGN

A mixed methods design was used to examine women's experiences and level of satisfaction about a student-led midwifery model of care. An on-line survey elucidated women's levels of satisfaction and experiences with the student-led midwifery group practice. The online survey was sent to all women (n = 25) who were receiving care from third year Bachelor of Midwifery students in 2018 via email up to 6 weeks postnatally. The online survey was distributed in the first instance to obtain baseline information about the importance of this student-led midwifery group practice and so the survey information was linked to the in-depth interview in the analysis for the purpose of identifying if the women were primiparous or multiparous. Women (n = 9) were invited to participate in an in-depth interview by self-opting on the survey and this extra data provided a richer understanding about the level of satisfaction about woman-centred care led by midwifery students. Retrospective data were also collected from the Maternity database - E-Maternity about birth outcomes.

SETTING

A tertiary teaching public hospital in New South Wales (NSW).

PARTICIPANTS

Fifteen women participated in an online survey. Five primiparous and four multiparous women opted to be involved in the in-depth interviews on the online survey.

MEASUREMENTS AND FINDINGS

Analysis in SPSS provided descriptive statistics including frequencies and percentages of data including birth outcomes. Simple correlations enabled associations to be established between levels of satisfaction, individualised care, quality of care, benefits and anxiety during pregnancy. The overarching themes from the qualitative findings identified the students' presence for the women as the most important component of the women's journey. The four main themes that emerged from the study included: familiarity of the caregiver, staying informed on the journey, feeling supported and reassured by their expertise, and control and decisions over birth events.

KEY CONCLUSIONS

For a variety of reasons, women valued the presence of the students throughout their childbearing journey, including valuing the woman's private space during labour and her time with her partner. This combination of pedagogical approaches provides an alternative to the current placement approach, which includes working shifts in all areas of maternity. This approach will better support midwifery students to achieve the skills necessary to provide a continuity of care experience (CoCE) amongst a small team by a student-led midwifery group practice that is supported by a registered midwife in the antenatal clinic. The midwifery student is able to develop a relationship with the woman as a component of the CoCE under the guidance of a registered midwife and this is an important underpinning of the philosophy of woman-centred care.

IMPLICATIONS FOR PRACTICE

This model of care provides evidence that women do value the students' support and presence throughout their experience and that the benefits of this model should be offered to all women as a normal component of their midwifery care.

Normalisation process theory as a conceptual framework for continuity of carer implementation

PROBLEM

Despite long standing strategic level ambitions to increase access to continuity of carer (CoC) models in maternity services, implementation of CoC in the United Kingdom (UK) has been generally small-scale and short lived. This indicates problems in implementing and sustaining CoC as the main model of care provision, and as such a need to better understand the process of implementation itself.

AIM

To use normalisation process theory (NPT) to underpin development of a conceptual implementation framework for CoC in order to improve understanding of the implementation process.

METHODS

Literature review on CoC implementation and NPT development and use, combined with immersion in the implementation of CoC context.

RESULTS AND DISCUSSION

A conceptual framework for the implementation of CoC is developed and individual components discussed, with a view to better understanding the implementation process for CoC models. The will of a critical mass of midwives to work in a CoC model and the provision and maintenance of the 'organisational space' required for CoC within the National Health Service (NHS) emerge as key barriers to mainstreaming CoC in the UK.

CONCLUSION

There is utility in NPT as a means of understanding and conceptualising large scale implementation of CoC. With testing and further development into a practical tool, the conceptual framework developed here could become a useful aid to those involved in implementing and evaluating CoC in the context of renewed strategic direction and Governmental level support in the UK.

The initiation of Dutch newly qualified hospital-based midwives in practice, a qualitative study

In the Netherlands, a percentage of newly qualified midwives start work in maternity care as a hospital-based midwife, although prepared particularly for working autonomously in the community.

AIM

This study aimed to explore newly qualified Dutch midwives' perceptions of their job demands and resources during their initiation to hospital-based practice.

DESIGN

We conducted a qualitative study with semi structured interviews using the Job Demands-Resources model as theoretical framework.

METHODS

Twenty-one newly qualified midwives working as hospital-based midwives in the Netherlands were interviewed individually between January and July 2018. Transcripts were analyzed using thematic content analysis.

FINDINGS

High workload, becoming a team member, learning additional medical procedures and job insecurity were perceived demands. Participants experienced the variety of the work, the teamwork, social support, working with women, and employment conditions as job resources. Openness for new experiences, sociability, calmness and accuracy were experienced as personal resources, and perfectionism, self-criticism, and fear of failure as personal demands.

CONCLUSION

Initiation to hospital-based practice requires from newly qualified midwives adaptation to new tasks: working with women in medium and high-risk care, managing tasks, as well as often receiving training in additional medical skills. Sociability helps newly qualified midwives in becoming a member of a multidisciplinary team; neuroticism and perfectionism hinders them in their work. Clear expectations and a settling-in period may help newly qualified midwives to adapt to practice. The initiation phase could be better supported by preparing student midwives for working in a hospital setting and helping manage expectations about the settling-in period.

Using a quality care framework to evaluate user and provider experiences of maternity care: A comparative study

OBJECTIVE

The Quality Maternal and Newborn Care Framework describes the components and characteristics of quality care and emphasises relational and continuity elements. Continuity of care is increasingly a focus of maternity care policy in the United Kingdom. While some outcomes have been shown to be improved, there is uncertainty about why certain models of care are more effective. Our overall objective is to develop a maternity care evaluation toolkit which incorporates this Framework along with other outcome evaluations. An initial step in developing this toolkit was to use the adapted Framework to evaluate perceptions and experiences of maternity care. Our specific objective in this study was to test this adapted Framework in a series of focus groups with key stakeholders, and to compare findings between different groups. Findings related to service users (pregnant women and new mothers) are reported in our accompanying paper; this paper presents findings from focus groups with service providers (midwives and obstetricians), and then compares user and provider perspectives.

DESIGN

A qualitative comparative enquiry involving three focus groups with 26 midwives (eight newly qualified; eight working in a community midwifery unit; and ten senior tertiary-based) and two focus groups with twelve obstetricians of all grades. We used a six-phase thematic analysis to derive then compare the focus groups' principal sub-themes; we then mapped these to the original Quality Maternal and Newborn Care Framework and compared these service providers' responses with those from the pregnant women and new mothers.

SETTING

Two health boards in Scotland.

PARTICIPANTS

Midwives and obstetricians who had experience of various models of maternity care.

FINDINGS

There were significant areas of overlap in their perceptions of providing maternity care. All groups reported 'limited resources and time'; the community midwifery unit and senior midwives and one group of obstetricians provided a critique of the system. Achieving tailored care was acknowledged as a problem by the senior midwives and one group of obstetricians. Only obstetricians discussed strategies for improvement. The newly qualified midwives were most positive in their responses. There was both overlap and contrast when comparing the views of service users and providers. We found most agreement when participants discussed some of the Framework's characteristics of care in negative terms, such as (in) accessible care, (lack of) adequate resources, and (absence of) tailored care.

KEY CONCLUSIONS

Being able firstly to map the participants' responses to the Quality Maternal and Newborn Care Framework, and then to identify strengths and gaps in the provision of quality maternity care, suggests to us that the Framework, derived as it is from a comprehensive analysis of the global evidence on quality care, can indeed be used to inform an evaluation toolkit. While aware that we cannot generalise from this limited qualitative study, we are currently undertaking similar work in other countries by which we hope to confirm our findings and further develop the toolkit.

The future in their hands: Graduating student midwives' plans, job satisfaction and the desire to work in midwifery continuity of care

BACKGROUND

Midwife-led continuity of care models benefit women and the midwives who work in them. Australian graduate midwives are familiar with, and educated to provide, continuity of care to women although the opportunity to work exclusively in positions providing continuity of care on graduation is uncommon.

AIM

To explore the immediate and aspirational employment plans and workforce choices, reasons for staying in midwifery and perceptions around factors likely to influence job satisfaction of midwives about to graduate from one Australian university during the years 2012-2016.

METHODS

This longitudinal study draws on survey responses from five cohorts of midwifery students in their final year of study.

FINDINGS

Ninety five out of 137 midwifery students responded to the survey. Almost nine out of ten respondents either aspired to work in a continuity of care model or recognised that they would gain job satisfaction by providing continuity of care to women. Factors leading to job satisfaction identified included making a difference to the women for whom they care, working in models of care which enabled them to provide women with 'the care I want to give', and having the ability to make autonomous midwifery decisions.

CONCLUSION

Aligning early graduate work experiences with continuity of care models may have a positive impact on the confidence and professional development of graduate midwives, which in turn may lead to greater satisfaction and retention among a workforce already committed to supporting the maternity healthcare reform agenda.

Perceived job demands and resources of newly qualified midwives working in primary care settings in The Netherlands

OBJECTIVE

The objective of this study is to identify perceived job demands and job resources of newly qualified midwives (NQMs), working in primary midwifery care during their first years in practice.

DESIGN/SETTING

A qualitative study, with semi-structured group interviews was conducted. Midwives working less than three years in primary midwifery care in the Netherlands were invited to join a focus group interview.

MEASUREMENTS AND FINDINGS

Five focus group interviews were with 31 participants. Interviews were transcribed and analyzed. Data were analyzed thematically by using the different characteristics of the Job Demands Resources model. Working as a locum midwife is demanding for Dutch NQMs, due to a large number of working hours in different practices and a lack of job security. Decision-making and adapting to local guidelines and collaborations demand a high cognitive load. These aspects of the work context negatively impact NQMs' work and private life. Working with clients and working autonomously motivates the newly graduates. Support from colleagues and peers are important job resources, although colleagues are also experienced as a job demand, due to their role as employer. Strictness in boundaries, flexibility and sense of perspective are NQMs' personal resources. On the other hand, NQMs perceived perfectionism and the urge to prove oneself as personal demands.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Dutch NQMs' first years in primary midwifery care are perceived as highly demanding. In primary care, NQMs usually work as locum midwives, self-employed and in different practices. Working in different practices requires not only working with different client populations and autonomous decision-making, but also requires adaptation to different local working arrangements. Building adequate support systems might help NQMs finding a balance between work and private life by having experienced midwives available as mentors. Furthermore, training and coaching of NQMs help them to become aware of their personal resources and demands and to help them strengthen their personal resources. Improving NQMs' working position through secure employments require changes in the organization of maternity care in the Netherlands.

Models of maternity care: evidence for midwifery continuity of care

There has been substantial reform in the past decade in the provision of maternal and child health services, and specifically regarding models of maternity care. Increasingly, midwives are working together in small groups to provide midwife-led continuity of care. This article reviews the current evidence for models of maternity care that provide midwifery continuity of care, in terms of their impact on clinical outcomes, the views of midwives and childbearing women, and health service costs. A systematic review of midwife-led continuity of care models identified benefits for women and babies, with no adverse effects. Non-randomised studies have shown benefits of midwifery continuity of care for specific groups, such as Aboriginal and Torres Strait Islander women. There are also benefits for midwives, including high levels of job satisfaction and less occupational burnout. Implementing midwifery continuity of care in public and private settings in Australia has been challenging, despite the evidence in its favour and government policy documents that support it. A reorganisation of the way maternity services are provided in Australia is required to ensure that women across the country can access this model of care. Critical to such reform is collaboration with obstetricians, general practitioners, paediatricians and other medical professionals involved in the care of pregnant women, as well as professional respect for the central role of midwives in the provision of maternity care. More research is needed into ways to ensure that all childbearing women can access midwifery continuity of care.

The challenge of employing and managing new graduate midwives in midwifery group practices in hospitals

AIM(S)

This study explores the views of midwifery managers and key stakeholders, regarding the facilitators and barriers to employing new graduate midwives in midwifery continuity of care models.

BACKGROUND

Maternity services in Australia are shifting towards midwifery continuity of care models, where midwives work in small group practices, requiring a change to the management of staff. Public policy in Australia supports maternity services to be reconfigured in this way. Historically, experienced midwives work in these models, as demand grows; new graduates are employed to staff the models.

METHOD(S)

A qualitative descriptive approach exploring the manager's experience of employing new graduate's in the models. Managers, clinical educators and hospital midwifery consultants (n = 15) were recruited by purposeful sampling.

RESULTS

Drivers, enablers, facilitators and barriers to employing new graduates in the models were identified. Visionary leadership enabled the managers to employ new graduates in the models through initial and ongoing support. Managing the myths stemming from fear of employing new graduates to work in midwifery continuity of care models was challenging.

CONCLUSION

Managers and other key stakeholders provide initial and ongoing support through orientation and providing a reduced workload.

IMPLICATIONS FOR NURSING MANAGEMENT

Visionary leadership can be seen as critical to supporting new graduates into midwifery continuity of care models. The challenges for management to overcome include managing the myths stemming from fear of employing new graduates to work in a flexible way around the needs of the women within an organisation culture.

Assessment of the implementation of the model of integrated and humanised midwifery health services in Chile

OBJECTIVE

in 2010, a pilot study was conducted among women who were attended by midwives in the public sector in Santiago, Chile. The purpose of that study was to evaluate the implementation of the 'Model of Integrated and Humanized Health Services', and the Clinical Guide for Humanized Attention during Labour and Childbirth. Results of that study indicated 92.7% of women had medically augmented labours (artificial rupture of the membranes, oxytocin and epidural analgesia). One third of the women reported discontent with the care they received. This study replicated the pilot study (2010) and was conducted in seven regional hospitals across Chile. The objectives were to : (i) describe selected obstetric and neonatal outcomes of women who received care according to this new guide, (ii) identify the level of maternal-neonatal well-being after experiencing this modality of attention, and (iii) explore professionals' perceptions (obstetricians and midwives), as well as consumers' perceptions of this humanised assistance during labour and childbirth.

DESIGN

this is a cross sectional and descriptive, mixed methods study, conducted in two phases. The first phase was quantitative, measuring midwifery processes of care and maternal perceptions of well-being in labour and childbirth. The second phase was qualitative, exploring the perceptions of women, midwives and obstetricians regarding the discrepancy between the national guidelines and actual practice.

SETTING

maternity units from seven regional hospitals from the northern, central and southern regions and two metropolitan hospitals across Chile.

PARTICIPANTS

1882 parturient women in the quantitative phase (including the two Metropolitan hospitals published previously). Twenty-six focus groups discussions (FGD) participated from the regional and metropolitan hospitals for the qualitative phase. MEASUREMENTS/FINDINGS: all women started labour spontaneously; 74% of women had spontaneous vaginal childbirth. Caesarean section was the outcome for 20%, and 6% had childbirth assisted with forceps. A high number of medical interventions continued to be performed in all regions, deviating widely from adherence to the national clinical guidelines. Most of the women did not receive any oral hydration, almost all received intravenous hydration; most were under continuous foetal monitoring and medically augmented labour. The majority of women received artificial rupture of membranes, epidural anaesthesia and episiotomy. Most delivered in the lithotomy position. Two thirds of women surveyed perceived adequate well-being in labour and childbirth. Findings from focus group discussions of women (FGD=9; n=27 women), midwives (FGD=9; n=40) and doctors (FGD=8; n=29) indicated lack of infrastructure for family participation in birth, inadequate training and orientation to the national guidelines for practice, and lack of childbirth preparation among women. Some women reported mistreatment by personnel. Some midwives reported lack of autonomy to manage birth physiologically.

KEY CONCLUSIONS

birth is managed by midwives across the public sector in Chile. Despite evidence-based guidelines published in 2007 by the Ministry of Health, birth is not managed according to the guidelines in most cases. Women feel that care is adequate, although some women report mistreatment.

IMPLICATIONS FOR PRACTICE

efforts to provide midwife-led care and include women in participatory models of antenatal care are recommended to promote women-centred care in accordance with the Chilean national guidelines.

The mentoring experiences of new graduate midwives working in midwifery continuity of care models in Australia

The aim of this paper was to explore the mentoring experiences of new graduate midwives working in midwifery continuity of care models in Australia. Most new graduates find employment in hospitals and undertake a new graduate program rotating through different wards. A limited number of new graduate midwives were found to be working in midwifery continuity of care. The new graduate midwives in this study were mentored by more experienced midwives. Mentoring in midwifery has been described as being concerned with confidence building based through a personal relationship. A qualitative descriptive study was undertaken and the data were analysed using continuity of care as a framework. We found having a mentor was important, knowing the mentor made it easier for the new graduate to call their mentor at any time. The new graduate midwives had respect for their mentors and the support helped build their confidence in transitioning from student to midwife. With the expansion of midwifery continuity of care models in Australia mentoring should be provided for transition midwives working in this way.