Renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour

Supporting first-time parents in their homes: an informal setting enabling interprofessional collaboration

BACKGROUND

Home visiting programmes aiming to support parents and promote more equal health amongst young children have grown in Sweden and in other countries. These programmes involve interprofessional teams. Teamwork in interprofessional contexts often requires setting boundaries, but professionals' boundary work in the home setting is unexplored. Therefore, this article focuses on interprofessional teams comprising child healthcare nurses, midwives, social workers, and dental hygienists in a home visiting programme for first-time parents in Sweden; it aims to explore how the professionals performed boundary work that enabled collaboration and to investigate important contextual conditions for this kind of boundary work.

METHODS

The data were drawn from semi-structured interviews with twelve professionals from the four different disciplines. Content analysis was used to explore their boundary work.

RESULTS

The findings show that the professionals performed three forms of collaborative boundary work. They maintained boundaries by clarifying their distinct roles and expertise. However, the differences were viewed as complementary, and the professionals worked together humbly to complement each other's knowledge and perspectives. Lastly, they tended to drop perceptions of prestige and blurred the boundaries to accommodate their overlapping knowledge. Important conditions for the success of collaborative boundary work were meetings prior to the home visits, the opportunities for discussion and reflection after the home visits, and the informal character of the home setting. Consequently, the professionals were able to jointly contribute to a holistic view of the visited families, which increased the possibilities to meet these families' needs.

CONCLUSIONS

This study contributes knowledge on boundary work in interprofessional collaborations in the home setting. The informal character of the home setting seemed to facilitate collaboration and contributed to creating informal professional roles. The findings suggest that having interprofessional teams in the home setting enabled collaboration as well as reinforced support for first-time parents, which emphasizes the merit of home visit programmes.

Experiences with neonatal jaundice management in hospitals and the community: interviews with Australian health professionals

INTRODUCTION

Worldwide, neonatal jaundice accounts for considerable morbidity and mortality. Although severe adverse outcomes, such as hyperbilirubinaemia and kernicterus, are uncommon in high-income countries, these outcomes do occur, have enormous lifelong personal, health and social costs, and may be preventable. Evidence-based practice commonly relies on clinical guidelines; however, their implementation can be difficult. Implementation of neonatal jaundice care has been adversely affected by issues with professional boundaries, competing professional priorities and poor understanding of neonatal jaundice. This paper focuses on the perceptions and experiences of Australian health professionals involved in the management of neonatal jaundice.

METHODS

Using a qualitative descriptive approach, semistructured interviews were undertaken to gain understanding of the experiences of health professionals in Australia across the scope of care for jaundiced newborns through an interpretivist approach and to identify possible gaps in the delivery of evidence-based care. Health professionals from a range of disciplines and care settings were recruited by purposive maximum variation sampling. Interviews were conducted face-to-face or by telephone with detailed notes taken and a field journal maintained. Interview scripts were verified by participants and imported into NVivo software. Data were analysed for major themes according to type and contexts of practice.

RESULTS

Forty-one health professionals from six broad discipline areas were interviewed. Two major themes and explanatory subthemes were found. The first theme, falling through the gaps, highlighted gaps in evidence-based care, as described by four explanatory subthemes: professional boundaries, blindness to possibility of adverse outcomes, competing professional development priorities and unintended consequences.The second major theme, we know what should happen-but how?, described participant perceptions that it was known what was required to improve care but how to achieve such changes was unclear. The two subthemes are: improvements in education and training, and standardised policies and protocols.

CONCLUSIONS

Multiple barriers to the provision of evidence-based care related to neonatal jaundice management are experienced by health professionals in Australia. Clinical guidelines are not sufficient to support health professionals deliver evidence-based care in the complex contexts in which they work. Implementation strategies for evidence-based practice need to take account of the experiences of health professionals and the challenges they face. Such strategies need to focus on improving collaboration between different disciplines for the well-being of those needing care. In the case of neonatal jaundice management, consideration is also needed in how to raise awareness of the importance of avoiding severe adverse outcomes, even when they might be rare, and how this might be done. Addressing issues that lead to disjointed care or poor knowledge of neonatal jaundice among health professionals is essential.

Navigating interprofessional boundaries: Midwifery students in Canada

The literature on professional socialization focuses on how students adopt and internalize professional identities and values, and assumes that boundary work is essential to learning how best to practice their profession. However, a focus on boundary work in the context of midwifery training - which is embedded in the gendered and hierarchical landscape of maternity care - is lacking. Thus, this article examines how Canadian student-midwives learn to navigate and negotiate interprofessional boundaries. Grounded in a symbolic interactionist approach, it draws on 31 semi-structured qualitative interviews from a mixed-methods national study on midwifery retention, explores how midwifery students make sense of the tensions among midwives, physicians, and nurses, and describes what strategies they utilize when navigating boundaries. Our analysis, based in constructivist grounded theory, revealed that participants learned about interprofessional tensions in clinical placement encounters via direct or indirect interactions with other healthcare professionals, and that strategies to navigate these tensions included educating others about midwifery training and adopting a learner identity. This article proposes that the process of professional socialization enables to reshape professional boundaries and that students are not only learners but also agents of change. These findings may yield practical applications in health education by highlighting opportunities for improving interprofessional collaborations.

Collaborative model of intrapartum care: qualitative study on barriers and facilitators to implementation in a private Brazilian hospital

INTRODUCTION

A collaborative (midwife-obstetrician) model of intrapartum care (CMIC) is associated with lower caesarean section (CS) rates than physician-led models. In 2019, the largest private maternity hospital in Latin America (14.000 deliveries/year, 89% CS) created a quality improvement initiative to optimise intrapartum care and safely reduce CS in low-risk women managed by its internal team of healthcare providers (HCP). We conducted formative research to identify potential barriers and facilitators to the implementation of a CMIC.

METHODS

Three groups of stakeholders participated in focus groups and interviews: hospital managers and clinical coordinators, HCP working in labour/delivery wards and pregnant women intending to give birth in the hospital. We explored participants' views about the acceptability of implementing a CMIC where a nurse-midwife (NM) on shift would be the main intrapartum HCP, with continuous support/supervision of a dedicated, in-house, obstetrician-gynaecologist (OB-GYN). A thematic analysis approach was used.

RESULTS

12 HCPs, 5 clinical coordinators, 2 hospital managers and 7 women participated. OB-GYNs, coordinators and managers highlighted health system, organisational and structural factors (NMs' limited experience/skills, professional roles, financial reimbursement) as potential barriers. NMs identified logistical and human resources as additional barriers. Women viewed the CMIC with perplexity and insecurity because of cultural beliefs about the dominant role of OB-GYNs, and limited information about NM's capabilities. All professionals agreed that women's acceptance of a CMIC will require educational interventions and communication strategies to inform potential users about the advantages and safety of this model.

CONCLUSION

There are important barriers and facilitators to implement a CMIC in a private Brazilian maternity hospital. Factors related to health system structure and organisation may have the greatest impact. A CMIC is more likely to succeed if stakeholders' concerns about responsibilities, power and financial revenues are addressed, and educational interventions targeted at users are deployed prior to its implementation.

Slovenian midwifery professionalization: Perception of midwives and related health professions

INTRODUCTION

This article presents research into the professionalization of midwifery in Slovenia. Since recognition by related occupations is important for professions, this comparative study asked doctors and nurses in Slovenia about their perceptions of the status of midwifery.

METHODS

A questionnaire survey was conducted with 300 Slovenian midwives, 666 nurses and 416 obstetricians. The questionnaire included statements covering traditional sociological notions of the profession (ethics, theory, power), and three notions based on new elements of professionalism (reflective practice, interdisciplinary working, and partnership with clients).

RESULTS

Findings suggest that nurses perceived themselves to be less autonomous than midwives, and this partly explains why most nurses thought that midwifery should be a specialized course of study, after the general nursing diploma. Obstetricians claimed to support midwives, however, they did not give midwives credit for basic midwifery competencies and did not feel midwifery to be equal to their profession. Midwives revealed not to feel autonomous; they felt that nursing and obstetrics is jeopardizing independent midwifery practice.

CONCLUSIONS

Slovenian midwifery was poorly evaluated in some attributes of professionalism, especially knowledge and autonomy. Even midwives themselves consider midwifery more occupation than profession. The autonomy of midwifery will be hard to achieve in the institutions of medical dominance. The study revealed that participants of all three groups are in a competitive relation and are poorly aware of the roles and competencies of the other two professions. Therefore, partially joined education might be beneficial in order to promote interprofessional collaboration in the future.

Zasnova prototipa informacijskega sistema za klinično pot otročnice in novorojenca v zgodnjem poporodnem in neonatalnem obdobju

Uvod: Klinična pot je metodologija, ki celotnemu zdravstvenemu timu omogoča racionalno in na primerih dobre prakse utemeljeno obravnavo, spremljanje opravljenega dela ter poenoteno in poenostavljeno dokumentiranje. Cilj je bil identificirati klinično pot za učinkovito obravnavo otročnice in razviti prototip informacijskega sistema, ki bi olajšal izvajanje omenjene poti.Metode: S sistematičnim pregledom literature je bila identificirana obstoječa klinična pot. Z metodo modeliranja in s strukturiranimi intervjuji šestih deležnic v fokusni skupini je bil oblikovan prototip informacijskega sistema. Evalviran je bil s prepoznavanjem vzorcev in ključnih tem iz kliničnega okolja.Rezultati: Kriteriji presojanja deležnic fokusne skupine pri  evalvaciji prototipa kažejo, da lahko prototip informacijskega sistema ustrezno podpre omenjeno klinično pot. Predlogi za izboljšavo, ki so jih podale deležnice fokusne skupine, so bili v razviti prototip vključeni naknadno.Diskusija in zaključek: Za obravnave znotraj sistema klinične poti v zgodnjem poporodnem obdobju so pomemben vezni člen prav medicinske sestre. Z uvedbo obravnav po sistemu klinične poti, ki je podprta s predlaganim informacijskim sistemom, se lahko bistveno izboljša način dokumentiranja obravnav pri izvajanju omenjene klinične poti. Z reduciranjem nepotrebnega dvojnega beleženja bi medicinske sestre pridobile več časa, ki bi ga lahko koristneje porabile. 

Development of a Breech-Specific Integrated Care Pathway for Pregnant Women: Protocol for a Mixed Methods Study

BACKGROUND

The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section.

OBJECTIVE

This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women's experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback.

METHODS

A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals' knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time.

RESULTS

Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete.

CONCLUSIONS

The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23514.

'We Don't Want You to Diet': Bariatric professionals' boundary work and negotiation of pleasure and control

Although patients who undergo weight-loss surgery (WLS/bariatric surgery) must follow severe eating restrictions in a manner similar to that of dieting, professionals strive to demarcate distinctions between the approaches and methods of WLS and diet. Drawing from ethnographic research, this study focuses on the content and interpretative dimensions of professionals' boundary work as well as its meaning and implications for patients. The post-surgical body is revealed as a site of dispute. Professionals portray the logic of diet as one that assumes individuals ought to discipline themselves - and not 'give in' to pleasure - in order to achieve an ideal body. In contrast, WLS is depicted as a more advanced and balanced method that negotiates pleasure and control. Professionals construct boundaries by shifting the causes for obesity from the individual to the context, by expanding the meaning of success and by portraying food as healing. These findings join recent critical literature that shows that the lived experiences of care practices contest the prevailing framing of obesity care as solely about exerting disciplinary power and control. WLS professionals negotiate fat stigma and question dominant discourses regarding body size, thin ideals and responsibility.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

Implementing disruptive technological change in UK healthcare: exploring development of a smart phone app for remote patient monitoring as a boundary object using qualitative methods

PURPOSE

Developing technological innovations in healthcare is made complex and difficult due to effects upon the practices of professional, managerial and other stakeholders. Drawing upon the concept of boundary object, this paper explores the challenges of achieving effective collaboration in the development and use of a novel healthcare innovation in the English healthcare system.

DESIGN/METHODOLOGY/APPROACH

A case study is presented of the development and implementation of a smart phone application (app) for use by rheumatoid arthritis patients. Over a two-year period (2015-2017), qualitative data from recorded clinical consultations (n = 17), semi-structured interviews (n = 63) and two focus groups (n = 13) were obtained from participants involved in the app's development and use (clinicians, patients, researchers, practitioners, IT specialists and managers).

FINDINGS

The case focuses on the use of the app and its outputs as a system of inter-connected boundary objects. The analysis highlights the challenges overcome in the innovation's development and how knowledge sharing between patients and clinicians was enhanced, altering the nature of the clinical consultation. It also shows how conditions surrounding the innovation both enabled its development and inhibited its wider scale-up.

ORIGINALITY/VALUE

By recognizing that technological artefacts can simultaneously enable and inhibit collaboration, this paper highlights the need to overcome tensions between the transformative capability of such healthcare innovations and the inhibiting effects simultaneously created on change at a wider system level.

Facilitators and barriers to the implementation of a physiological approach during labour and birth: A systematic review and thematic synthesis

OBJECTIVES

To explore facilitators and barriers to the implementation of a physiological approach to care during labour and birth in obstetric settings. To explore how facilitators and barriers located at three levels: organisation, professional groups (midwives and obstetricians) and women, interact to influence the implementation of a physiological approach.

METHOD

A systematic review of the literature, identified 32 eligible studies from four databases reporting relevant qualitative data. Findings from these studies were thematically synthesised in three phases: line by line coding of findings from primary studies, development of descriptive themes and analytical themes. This review is reported in line with PRISMA guidelines.

FINDINGS

At an organisational level, centralisation of care in obstetric units limited time for labouring and professional care to support a physiological labour and birth. Risk management strategies ostensibly designed to promote safety sustained a risk-based approach. At a professional level, important barriers include hierarchical decision-making led by obstetricians, midwifery acquiescence, obstetric and midwifery risk preoccupation, rationalisation of the routine use of clinical intervention and an erosion of midwifery skills and knowledge. At the level of the woman, barriers include a lack of knowledge and reliance on professional decision-making. Facilitators include collaborative working by midwives and obstetricians, a valuing of midwifery autonomy and women's questioning of inappropriate intervention use.

KEY CONCLUSIONS

Contrary to evidence-based guidelines that recommend a physiological approach, a risk-based approach informs practices in obstetric units. Primary research has mainly identified barriers to implementing a physiological approach at a professional level, and this has been studied largely from a midwifery perspective. To aid comprehensive investigations of facilitators and barriers and their interactive influences, this review identifies important research gaps for study across all levels: organisation, professionals (midwives and obstetricians) and women.

IMPLICATIONS FOR PRACTICE

Risk preoccupations and rationalisation, with negative influences on knowledge and skills in the use of a physiological approach, must prompt reflection and action amongst professional groups. Power imbalances between midwives and obstetricians need to be addressed, drawing on experiences in units where collaborative working and midwifery autonomy is fostered.

Exploring variation in the use of feedback from national clinical audits: a realist investigation

Background

National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians’ time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation.

Methods

We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism = Outcome configurations.

Results

We identified five mechanisms that explained provider interactions with NCA feedback: reputation, professionalism, competition, incentives, and professional development. Professionalism and incentives underpinned most frequent interaction with feedback, providing opportunities to stimulate quality improvement. Feedback was used routinely in these ways where it was generated from data stored in local databases before upload to NCA suppliers. Local databases enabled staff to access data easily, customise feedback and, importantly, the data were trusted as accurate, due to the skills and experience of staff supporting audit participation. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity across providers. Challenges accessing supplier data in a timely way and concerns about the quality of data submitted across providers were reported to constrain use of this mode of feedback.

Conclusion

The findings suggest that there are a number of mechanisms that underpin healthcare providers’ interactions with NCA feedback. However, there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely, providing opportunities to stimulate quality improvement, within clinical services resourced to collect accurate data and to maintain local databases from which feedback could be customised for the needs of the service.

Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis

OBJECTIVE

To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans.

DESIGN

Qualitative evidence synthesis.

SETTING

Studies undertaken in high-income, middle-income and low-income settings.

DATA SOURCES

Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar.

STUDY SELECTION

Qualitative or mixed-method studies reporting health professionals' views.

DATA EXTRACTION AND SYNTHESIS

Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed.

RESULTS

17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision.

CONCLUSION

For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans.

PROSPERO REGISTRATION NUMBER

CRD42017059455.

Midwives' attitudes towards pregnant women using substances: Informing a care pathway

OBJECTIVE

The purpose of this study was to identify midwives' attitudes towards women using substances during pregnancy, which informed the development of an integrated care pathway for the provision of optimal care.

METHODS

A mixed methods research design was used, that included an online survey via the online survey tool Qualtrics™ which collected quantitative data, and interviews and focus groups were used to collect qualitative data.

FINDINGS

Participants held a positive or neutral view towards women who used substances during pregnancy, and the participants had an empathetic perception of the issue of substance use within pregnancy, believing that women were using substances due to the environment and circumstances that they lived in, and that they had been raised and socialised in.

CONCLUSION

Caring for women during pregnancy with substance misuse issues is complex and requires coordination and multidisciplinary care. Midwives have the capacity to provide sensitive midwifery care but require the framework to ensure women needing additional resources during pregnancy receive the services available and specific to their needs. The midwives in this study were supportive of developing an integrated care pathway to allow for collaborative care, and to enable a specialised midwifery approach.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

OBJECTIVE

When medically indicated, caesarean section can prevent deaths and other serious complications in mothers and babies. Lack of access to caesarean section may result in increased maternal and perinatal mortality and morbidity. However, rising caesarean section rates globally suggest overuse in healthy women and babies, with consequent iatrogenic damage for women and babies, and adverse impacts on the sustainability of maternity care provision. To date, interventions to ensure that caesarean section is appropriately used have not reversed the upward trend in rates. Qualitative evidence has the potential to explain why and how interventions may or may not work in specific contexts. We aimed to establish stakeholders' views on the barriers and facilitators to non-clinical interventions targeted at organizations, facilities and systems, to reduce unnecessary caesarean section.

METHODS

We undertook a systematic qualitative evidence synthesis using a five-stage modified, meta-ethnography approach. We searched MEDLINE, CINAHL, PsychINFO, EMBASE and grey literature databases (Global Index Medicus, POPLINE, AJOL) using pre-defined terms. Inclusion criteria were qualitative and mixed-method studies, investigating any non-clinical intervention to reduce caesarean section, in any setting and language, published after 1984. Study quality was assessed prior to data extraction. Interpretive thematic synthesis was undertaken using a barriers and facilitators lens. Confidence in the resulting Summaries of Findings was assessed using GRADE-CERQual.

RESULTS

8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993-2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes: Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.

CONCLUSIONS

Non-clinical interventions to reduce caesarean section are strongly mediated by organisational power differentials and stakeholder commitment. Barriers may be greatest where implementation plans contradict system and cultural norms.

PROTOCOL REGISTRATION

PROSPERO: CRD42017059456.

Factors influencing the clinical decision-making of midwives: a qualitative study

Background

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives’ decisions are based on more than the evidence based medicine (EBM) model – i.e. clinical evidence, midwife’s expertise, and woman’s values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.

Methods

We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives’ clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.

Results

We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives’ clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.

Conclusion

Midwives’ clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Workforce flexibility - in defence of professional healthcare work

Purpose The desirability of having a more flexible workforce is emphasised across many health systems yet this goal is as ambiguous as it is ubiquitous. In the absence of empirical studies in healthcare that have defined flexibility as an outcome, the purpose of this paper is to draw on classic management and sociological theory to reduce this ambiguity. Design/methodology/approach The paper uses the Weberian tool of "ideal types". Key workforce reforms are held against Atkinson's model of functional flexibility which aims to increase responsiveness and adaptability through multiskilling, autonomy and teams; and Taylorism which seeks stability and reduced costs through specialisation, fragmentation and management control. Findings Appeals to an amorphous goal of increasing workforce flexibility make an assumption that any reform will increase flexibility. However, this paper finds that the work of healthcare professionals already displays most of the essential features of functional flexibility but many widespread reforms are shifting healthcare work in a Taylorist direction. This contradiction is symptomatic of a failure to confront inevitable trade-offs in reform: between the benefits of specialisation and the costs of fragmentation; and between management control and professional autonomy. Originality/value The paper questions the conventional conception of "the problem" of workforce reform as primarily one of professional control over tasks. Holding reforms against the ideal types of Taylorism and functional flexibility is a simple, effective way the costs and benefits of workforce reform can be revealed.

Healthcare professionals' assertions and women's responses during labour: A conversation analytic study of data from One born every minute

OBJECTIVE

Communication during labour is consequential for women's experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate 'decisions' during labour.

METHODS

Interactions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction.

FINDINGS

HCPs initiate decision-making using interactional practices that vary the 'optionality' afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through 'assertions'. An 'assertive' turn-design (e.g. 'we need to…') conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions.

CONCLUSION

The expectation of agreement set up by an assertive initiating turn can reduce women's opportunities to participate in shared decision-making (SDM).

PRACTICE IMPLICATIONS

When decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts.

Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study

BACKGROUND

There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter.

METHODS

This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged.

RESULTS

Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness.

CONCLUSIONS

This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.

Encourages and guides, or diagnoses and monitors: Woman centred-ness in the discourse of professional midwifery bodies

OBJECTIVE

the purpose of this study was to conduct a preliminary exploration of the language used by midwifery professional bodies to define the scope of practice of midwives in relation to woman-centred care.

DESIGN

this is a qualitative study in which Critical Discourse Analysis and Transitivity Analysis from the Systemic Functional Linguistics tradition were used. Data were sampled from nine international midwifery professional bodies.

FINDINGS

three general types of definitions of scope of practice were identified; a formal type which focused on midwifery practice in which the midwife and woman were largely absent as agents, a second, less formal type which focused on the midwife as agent, from which the woman was largely absent as an active participant and one exception to the pattern which featured the woman as agent. The main type of verb used in the definitions was Doing Processes such as monitor, diagnose. Saying (advise), Sensing (identify), and Being (be able to) processes were much less frequent in the data. The definitions of scope of practice explored in this study (with one exception) revealed a general lack of woman-centeredness and more of a focus on an orientation to birth as a medically managed event.

KEY CONCLUSIONS

definitions of scope of practice statements by professional bodies are systematically developed through much conscious thought and discussion by the writers on behalf of a community of practice and are formulated specifically for the purpose of being available to the general public as well as midwives. It can be assumed that the choices of wording and content are carefully constructed with public dissemination in mind. These ideologies communicated via the professional body texts emanate from a socio-cultural context that varies from country to country and professional bodies construct the definitions by drawing on the available, circulating discourses. Although woman-centred care is a key focus in contemporary maternity care, many definitions of scope of practice reveal a continuing orientation to a medical model of pregnancy and birth and a synonymisation of midwife-led care with woman centred care.

IMPLICATIONS FOR PRACTICE

by analysing statements of scope of practice by professional bodies and the contexts in which they are produced, we can continue to reveal the underlying social, political, and historical forces that influence midwifery practice. This paper examines some key examples of the professional discourse of midwifery in relation to the definition of the midwife and scope of practice in order to reflect on what these examples may tell us about the professional culture of midwifery and the implications for woman-centred care.

Explorando las emociones de la mujer en la atención perinatal. Un estudio cualitativo

Objetivo: explorar las emociones que emergen en la mujer durante el embarazo, parto y el puerperio a lo largo del itinerario asistencial de atención primaria y hospitalaria. Método: estudio cualitativo basado en la Teoría Fundamentada. Se realizaron dos grupos de discusión a profesionales: obstetras, matronas y enfermeras. Igualmente, se desarrollaron entrevistas en profundidad a mujeres en el puerperio. Resultados: las emociones de la mujer en la atención perinatal aparece como categoría central. A partir de ésta, las emociones negativas emergen por la interacción de cinco metacategorías: a) Miedo: dolor al parto y desajuste de expectativas, b) Ansiedad e incertidumbre: enfrentándose a la amenaza del riesgo y la desinformación, c) Vergüenza: comprometiendo la privacidad, d) Ira y Desamparo: asimetría en la estructura relacional, e) Soledad: discontinuidad en la atención asistencial. Las emociones positivas surge de la metacategoría: f) Tranquilidad y confianza: construyendo una interacción clínica simétrica y humanizada. Conclusiones: se constata una variabilidad emocional debido a la coexistencia de los modelos tecnocrático y biopsicosocial. Este proyecta humanidad en los cuidados perinatales, frente a un modelo biomédico marcado por una estructura relacional paternalista y asistencia fragmentada; ambos serán determinantes en la emergencia de emociones en la atención perinatal.

'You're looking for different parts in a jigsaw': foetal MRI (magnetic resonance imaging) as an emerging technology in professional practice

Magnetic resonance imaging (MRI) was first introduced into clinical practice during the 1980s. Originally used as a diagnostic tool to take pictures of the brain, spine, and joints, it is now used to visualise a range of organs and soft tissue around the body. Developments in clinical applications of the technology are rapid and it is often viewed as the 'gold standard' in many areas of medicine. However, most existing sociological work on MRI tends to focus on the profession of radiology, little is known about the impact of MRI on a broader range of clinical practice. This article focuses on MRI use in pregnancy, a relatively new application of the technology. Drawing on empirical research with a range of health professionals (from radiologists to pathologists) in the North of England, this article asks: how do different types of health professionals engage with the technology and to what end? It will argue that MRI use in pregnancy offers an increasingly important piece of the diagnostic jigsaw, often acting as a bridging technology between medical specialties. The implications of this will be explored in the context of broader sociological debates on the 'visualisation' of medicine and its impact on professionals.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

The struggle for inter-professional teamwork and collaboration in maternity care: Austrian health professionals' perspectives on the implementation of the Baby-Friendly Hospital Initiative

BACKGROUND

The health benefits of breastfeeding for mothers and babies are well documented in the scientific literature. Research suggests that support of breastfeeding during pre- and postnatal maternity care is an important determinant of breastfeeding initiation and duration. To support and promote breastfeeding on maternity units, the Baby-Friendly Hospital Initiative (BFHI) was launched in 1991. In Austria, however, less than one fifth of hospitals with a maternity unit are currently BFHI-certified. Implementation of BFHI and adjunct changes in work practices seem to represent a major challenge to maternity units. This article builds upon previous research that has identified a number of facilitators of and barriers to BFHI implementation in Austria. A major barrier has been the lack of intra- and inter-professional collaboration. Therefore, this article investigates the ways in which different healthcare professionals struggle to work together to successfully integrate the BFHI into practice.

METHODS

In this study, a qualitative research approach was used. Thirty-six semi-structured interviews with 11 midwives, 11 nurses, 13 physicians, and one quality manager, working across three maternity units, were interviewed on-site. Data analysis followed thematic analysis.

RESULTS

Midwives, nurses, and physicians had diverse approaches to childbirth and breastfeeding (medicalization vs. naturalness) and worked along different jurisdictions that became manifest in strict spatial divisions of maternity units. In their engagement within the BFHI, midwives, nurses, and physicians pursued different strategies (safeguarding vs. circumvention strategies). These differences hindered inter-professional teamwork and collaboration and, therefore, the integration of BFHI into practice.

CONCLUSIONS

Differing approaches to childbirth and breastfeeding, deep seated professional jurisdictions, as well as spatial constraints, challenge inter-professional teamwork and collaboration on maternity units. Inter-professional teamwork and collaboration are widely espoused goals of contemporary healthcare improvement strategies. Yet, critical debate on how these goals can be integrated into practice is needed. To enable collaboration and facilitate the implementation of programs such as BFHI, the different perspectives of health professionals should be brought together and the potential for integrating different forms of knowledge and practices should be considered.

Specialist services in the community: a qualitative study of consultants holding novel types of employment contracts in England

The aim of this study was to understand, from consultants' experiences, the potential benefits and limitations of specialists being employed by a community organisation. We carried out a qualitative study using semi-structured interviews with consultants holding novel contracts across three specialties: geriatric, respiratory and palliative medicine. Consultants in our study reported that community-based roles offered a number of potential benefits. They felt better able to take a population perspective, to treat patients in a holistic sense and to form good working relationships with community-based colleagues. A number of challenges were also evident, including a lack of clarity about their role, professional isolation and, for those in geriatric and respiratory medicine, a lack of training and career development opportunities. Our study suggests that community-based consultant posts are often taken up by highly motivated individuals who report the benefits in terms of being able to provide more appropriate care for patients but that the long-term development of these posts may be constrained by a number of factors. Their idiosyncratic nature, the lack of clarity around the role, challenges to professional identity and lack of training opportunities or professional development suggest that current approaches to their development may not be sustainable.

Gatekeeping access to the midwifery unit: Managing complaints by bending the rules

While poor communication between service users and front-line staff causes many service user complaints in the British National Health Service, staff rarely reflect on the causes of these complaints. We discuss findings from an action research project with midwives which suggest that the midwives struggled to fully understand complaints from women, their partners and families particularly about restricted visiting and the locked door to the midwifery unit. They responded to individual requests to visit out of hours while maintaining the general policy of restricted visiting. In this way, the door was a gatekeeping device which allowed access to the unit within certain rules. The locked door remained a barrier to women and their families and as a result was a common source of informal complaints. We argue that the locked door and restricted visiting to the midwifery unit were forms of gatekeeping and boundary making by midwives which reveals a tension between their espoused woman-centred care and contemporary midwifery practice which is increasingly constrained by institutional values.