‘How can we go on caring when nobody here cares about us?’ Australian public maternity units as contested care sites

A mixed-methods stress audit with midwives in the United Kingdom

PROBLEM

UK midwives report high work-related stress, which can negatively impact their health and wellbeing, with many considering leaving the profession.

BACKGROUND

An occupational stress audit guides the implementation of stress management intervention, by identifying which stressors have the most negative impact and why, and highlighting "at risk" groups.

AIM

To conduct a concurrent mixed-methods stress audit with UK midwives in an NHS Trust.

METHODS

Seventy-one midwives (Mage= 39 years, SD = 11) completed a survey assessing stressors (e.g., relationships), stress appraisals (i.e., challenge vs. threat), coping strategies (e.g., avoidance-focused), and outcomes (i.e., mental health, performance, and intention to leave). Ten midwives (Mage = 42 years, SD = 10) participated in semi-structured interviews.

FINDINGS

Quantitative data revealed that more work-related demands, poorer peer support and relationships, and threat appraisals predicted worse mental health. Moreover, less control and more work-related demands predicted poorer performance, while less control, poorer manager support, more change-related demands, and threat appraisals predicted greater intention to leave. Qualitative data generated three themes: organisational pressures exacerbated by unexpected changes; individualised responses but largely debilitative emotions; and personal coping and power of social support.

DISCUSSION AND CONCLUSION

This study offered a comprehensive and novel insight into the stress experiences of UK midwives, highlighting targets for future stress management interventions, including key stressors (e.g., manager support), underlying mechanisms (e.g., stress appraisals), and "at-risk" groups (e.g., night shift workers). Practical recommendations are provided for stakeholders operating at multiple levels (e.g., midwife, trust, policy) to better support midwives with work-related stress.

A model for improving the learning environment in high-stress and emotion-bound clinical settings

INTRODUCTION

In clinical settings, it is necessary to create a clinical learning environment that provides the ground for the learners to acquire competencies especially in high-stress and emotion-bound clinical settings.

METHODS

In the present study, a model for improving the learning environment in high-stress and emotion-bound clinical settings was designed by conducting a multi-method study in the form of three sub-studies.

RESULTS

This model was designed with 3 pivotal concepts; organizing learning opportunities around safe care, fair participation in learning opportunities and creating a positive emotional climate and 6 peripheral concepts; designing physical space and appropriate equipment for education and care, preparing learners to attend the clinical setting, preparing learners to participate in learning opportunities, balancing the learner role and the care provided by the learners, the presence of a competent educator and providing education to all learners, and acquiring the ability to manage emotions by learners, faculty and staff.

CONCLUSIONS

The implementation of the model obtained from this study provides the basis for solving the challenges of clinical learning environments, especially in high-stress and emotion-bound clinical settings, and improves clinical education and the realization of educational and care outcomes.

The barometer of moral distress in midwifery: A pilot study

BACKGROUND

Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery.

AIM

The aim of this study was to pilot the Barometer of Moral Distress in Midwifery.

METHODS

This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity.

FINDINGS

A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores.

DISCUSSION/CONCLUSION

This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

Group Clinical Supervision for midwives and burnout: a cluster randomized controlled trial

Background

There are major shortfalls in the midwifery workforce which has been exacerbated by the COVID 19 pandemic. Midwives have high levels of burnout and many, often early career midwives, are planning to leave the profession. There are reports of a poor workplace culture in maternity units, including bullying. Support is essential for the welfare of the workforce to be able to cope with the demands of their jobs. Supportive strategies, such as Clinical Supervision, a recognised approach in healthcare, enable reflection in a facilitated, structured way, and can enhance professional standards. The purpose of this research is to study burnout levels in midwives, those exiting their workplace and perceptions of workplace culture in relation to access to, and attendance of, monthly Clinical Supervision.

Methods

This study will be a cluster randomised controlled trial of maternity sites within Sydney and the surrounding districts. Twelve sites will be recruited and half will receive monthly Clinical Supervision for up to two years. Midwives from all sites will be requested to complete 6-monthly surveys comprising validated measurement tools: the Copenhagen Burnout Inventory (CBI), the Australian Midwifery Workplace Culture (AMWoC) tool and the Clinical Supervision Evaluation Questionnaire (CSEQ) (the latter for intervention sites only). Primary outcomes are the levels of burnout in midwives (using the CBI). Secondary outcomes will be the quality of the intervention (using the CSEQ), perceptions of workplace culture (using the AMWoC tool) and midwives’ intention to stay in their role/profession, as well as sick leave rates and numbers of exiting staff. We will also determine the dose effect – ie the impact in relation to how many Clinical Supervision sessions the midwives have attended, as well as other supportive workplace strategies such as mentoring/coaching on outcomes.

Discussion

Through attending monthly Clinical Supervision we hypothesise that midwives will report less burnout and more positive perceptions of workplace culture than those in the control sites. The potential implications of which are a productive workforce giving high quality care with the flow-on effect of having physically and psychologically well women and their babies.

Trial registration

The ACTRN Registration number is ACTRN12621000545864p, dated 10/05/2021, 

Exploring moral distress in Australian midwifery practice

PROBLEM

Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.

BACKGROUND

Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.

AIM

To explore Australian midwives experience and consequences of moral distress.

METHODS

Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.

FINDINGS

Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.

DISCUSSION

It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.

CONCLUSION

This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Moral distress in midwifery practice: A concept analysis

Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers' evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as 'a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments'. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress.

Giving midwives a voice - Qualitative perspectives of an 'empowering decision-making workshop'

AIM/OBJECTIVE

To establish midwives' perceptions of the value of workshops designed to empower their decision-making and leadership skills using validated midwifery clinical reasoning frameworks and appreciative inquiry methods.

BACKGROUND

The medical lens of childbirth can disempower women and midwives. Midwives often face challenges navigating their role as autonomous practitioners and advocates for shared decision-making, particularly when there is tension between women's wishes, governance frameworks and organisational requirements. This can lead to 'Midwifery Abdication' and/or the midwifery voice being silenced.

DESIGN/METHODS

Appreciative inquiry, involving qualitative analysis of 31 midwives' personal reflections during 'Empowering Midwives' Decision-Making' workshops. Standards for reporting qualitative research (SRQR criteria) guided the preparation of this manuscript.

RESULTS

Decision-making tools and 'appreciative' strategies can strengthen leadership attributes, enhance feelings of empowerment and deepen understanding. Reflecting on 'Midwifery Abdication' was perceived as confronting. Workshop activities offered understanding the reasons why 'Midwifery Abdication' may or may not occur. One overarching, key theme was identified: 'Finding my midwifery voice'. This theme encompassed three sub-themes: 'I am not alone', 'Using leadership to promote collaboration to effect change' and 'An onward journey of enlightenment and empowerment'.

CONCLUSION

Midwives need to find their voice and develop skills in both clinical reasoning and transformative reflection. Workshops, using Appreciative Inquiry approaches, that focused on reflection, clinical decision-making and 'Midwifery Abdication', facilitate this and may create feelings of reunification in midwives and rejuvenate inherent passion for the profession.

RELEVANCE TO CLINICAL PRACTICE

Sharing feelings around providing care in the often-contested space that is advocating for women using midwifery philosophy may provide relief from moral distress and a sense of shared identity desperately sought after by midwives struggling to navigate the increasingly complex terrain of maternity care. Findings encourage the need for further discussions around strengthening midwifery leadership which may be achievable using Appreciative Inquiry frameworks and approaches.

Sustainability and resilience in midwifery: A discussion paper

BACKGROUND

midwifery workforce issues are of international concern. Sustainable midwifery practice, and how resilience is a required quality for midwives, have begun to be researched. How these concepts are helpful to midwifery continues to be debated. It is important that such debates are framed so they can be empowering for midwives. Care is required not to conceptually label matters concerning the midwifery workforce without judicious scrutiny and diligence.

AIM

the aim of this discussion paper is to explore the concepts of sustainability and resilience now being suggested in midwifery workforce literature. Whether sustainability and resilience are concepts useful in midwifery workforce development is questioned.

METHOD

using published primary midwifery research from United Kingdom and New Zealand the concepts of sustainability and resilience are compared, contrasted and explored.

FINDINGS

there are obvious differences in models of midwifery care in the United Kingdom and New Zealand. Despite these differences, the concepts of resilience and sustainability emerge as overlapping themes from the respective studies' findings. Comparison between studies provides evidence of what is crucial in sustaining healthy resilient midwifery practice. Four common themes have been identified that traverse the different models of care; Self-determination, ability to self-care, cultivation of relationships both professionally and with women/families, and a passion, joy and love for midwifery.

CONCLUSIONS

the impact that midwifery models of care may have on sustainable practice and nurturing healthy resilient behaviors remains uncertain. The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives 'to toughen up' in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife. The findings invite further examination of contextual influences that affect the wellbeing of midwives across different models of care.

Lying to ourselves: rationality, critical reflexivity, and the moral order as 'structured agency'

A report suggests that United States' army officers may engage in dishonest reporting regarding their compliance procedures. Similarly, nurses with espoused high ethical standards sometimes fail to live up to them and may do so while deceiving themselves about such practices. Reasons for lapses are complex. However, multitudinous managerial demands arising within 'technical and instrumental rationality' may impact on honest decision-making. This paper suggests that compliance processes, which operates within the social structural context of the technical and instrumental rationality manifest as 'managerialism', contributes to professional 'dishonesty' about lapses in care, sometimes through 'thoughtlessness'. The need to manage risk, measure, account, and control in order to deliver efficiency, effectiveness, and economy (technical rationality) thus has both unintended and dysfunctional consequences. Meeting compliance requirements may be mediated by factors such as the 'affect heuristic' and 'reflexive deliberations' as part of the 'structured agency' of nurses. It is the complexity of 'structured agency' which may explain why some nurses fail to respond to such things as sentinel events, a failure to recognize 'personal troubles' as 'public issues', a failure which to outsiders who expect rational and professional responses may seem inconceivable. There is a need to understand these processes so that nurses can critique the context in which they work and to move beyond either/or explanations of structure or agency for care failures, and professional dishonesty.

Perceptions of pregnancy experiences when using a community-based antenatal service: A qualitative study of refugee and migrant women in Perth, Western Australia

BACKGROUND

Equality of care in pregnancy is important for all women, however can be difficult for healthcare providers to achieve. It has been found that culturally and linguistically diverse women born overseas generally have lower satisfaction with pregnancy care than women born in the host country.

AIM

Using a phenomenological framework, and models of care as a conceptual framework, this study explored the perceptions of care experienced by refugees and migrant women of culturally and linguistically diverse backgrounds who had participated in a community-based antenatal programme specialising in maternity care of multicultural women.

METHOD

Informants were twelve women aged between 23 and 44 years of age; one woman was 33 weeks pregnant, other women had given birth in the six months prior to data collection. Semi-structured interviews were conducted, using interpreters for women who spoke little or no English. Data were analysed using thematic analysis.

FINDINGS

Four main themes were identified; Social Support, Gaining of Knowledge, A Holistic Service, and New Opportunities.

CONCLUSION

Using a community-based antenatal service specialising in maternity care of women from culturally and linguistically diverse backgrounds enabled the needs of refugee and migrant women to be recognised and met, and therefore enhanced their perception of the pregnancy experience.

Not addressing the root cause: An analysis of submissions made to the South Australian Government on a Proposal to Protect Midwifery Practice

BACKGROUND

Reports of unregulated birth workers attending birth at home, with no registered midwife in attendance (freebirth), have become more frequent in Australia in recent years. A Coronial Inquiry (2012) into the deaths of three babies born at home in South Australia resulted in a call for legislation to restrict the practice of midwifery to registered midwives. A Proposal to Protect Midwifery Practice in South Australia was issued as a consultation paper in January 2013.

AIM

To report the views of those making a submission to the Proposal to Protect Midwifery Practice in South Australia.

METHODS

Thirty submissions to the South Australian Government were downloaded, read and thematically analysed.

FINDINGS

Twenty-five (81%) submissions supported the legislation, 5 (16%) opposed it and 2 (6%) were neither for nor against. Support for the proposed legislation was strong, however the underlying root causes that have led to the rise of UBWs attending homebirth in Australia were not addressed. Recommendations called for all stakeholders to work with women to develop a better framework of care that respected and met their needs and choices whilst safeguarding maternal and neonatal health.

CONCLUSIONS

The Proposal to Protect Midwifery Practice may promote greater protection of midwifery practice however, Private Indemnity Insurance (PII), collaborative agreements and power struggles associated with the medical domination of childbirth continue to marginalise homebirth and prevent women from accessing the care they want and need. These unresolved issues represent the root causes for UBWs attending homebirth; hence the proposal is only a partial solution.

Critical realism: an important theoretical perspective for midwifery research

BACKGROUND

there is a dearth of papers in midwifery journals exploring the philosophical underpinnings of various research methods. However, explaining and justifying particular ontological and epistemological positions gives coherence and credibility to chosen research methods.

OBJECTIVES

to explore and explain the philosophical underpinning of critical realism and argue for it to be more widely adopted by midwifery researchers, using the exemplar of dystocia research.

DISCUSSION

critical realism as originally espoused by Bhaskar sees reality as layered (realist ontology) and seeks to explore causative mechanisms for what is experienced and observed. In this way it illuminates the complexity of health care, though recognising that knowledge of this complexity is filtered through an interpretive lens (constructionist epistemology). Critical realism encourages a holistic exploration of phenomena, premised on multiple research questions that utilise multiple research methods.

IMPLICATIONS FOR RESEARCH

critical realism as a philosophical underpinning is therefore particularly apposite for researching midwifery issues and concerns.