The grounded theory of Coalescence of Perceptions, Practice and Power: An understanding of governance in midwifery practice

AIMS

This study aimed to understand midwifery care during labour, particularly decision-making processes, within Australian health systems.

BACKGROUND

Midwifery, founded on a wellness model of motherhood, is at risk of being medicalized. Whilst medical intervention is lifesaving, it requires judicious use. Governance provides oversight to care. Exploring decision-making contributes to understanding governance of practices.

METHOD

Straussian grounded theory using semi-structured interviews. Eighteen Australian registered midwives were interviewed about their practice when caring for women during labour.

RESULTS

Midwives were caught between divergent positions; birth as natural versus birth as risk. Experienced midwives discussed focussing on the woman, yet less experienced were preoccupied with mandatory protocols like early warning tools. Practice was governed by midwives approach within context of labour. The final theory: The Coalescence of Perceptions, Practice and Power, comprising three categories: perceptions and behaviour, shifting practice and power within practice, emerged.

CONCLUSIONS

Coalescence Theory elucidates how professional decision making by midwives during care provision is subject to power within practice, thereby governed by tensions, competing priorities and organizational mandates.

IMPLICATIONS FOR MIDWIFERY MANAGERS

Midwifery managers are well positioned to negotiate the nuanced space that envelopes birthing processes, namely, expert knowledge, policy mandates and staffing capability and resources, for effective collaborative governance. In this way, managers sustain good governance.

Multi-incident analysis of reviews of serious adverse clinical events in children with serious bacterial infection and/or sepsis in Queensland, Australia between 2012 and 2017

AIM

To report on findings from a multi-incident analysis of reviews of serious paediatric adverse clinical events related to serious bacterial infection and/or sepsis (hereafter referred to as sepsis for brevity) in Queensland, Australia, between 2012 and 2017.

METHODS

The Queensland Paediatric Quality Council reviewed documentation from reviews of serious adverse events occurring in children (<18 years) with a diagnosis of sepsis at Queensland public hospitals between 2012 and 2017, including clinical details, coronial reports, autopsy reports and root cause analysis documents. A multi-incident tool was designed and used by an expert panel to identify patient and facility demographics, contributing factors, and human and system factors associated with paediatric serious adverse events.

RESULTS

There were 28 serious adverse clinical events reported related to paediatric sepsis, characterised by a high proportion of deaths (23) and a predominance of children aged under 4 years. Approximately half of all facilities were classified as rural and remote health services. Contributing factors included difficulty in recognising and responding to the deteriorating patient, inadequate management/treatment, diagnostic error (mainly diagnostic delay) and escalation delay/failure. Major system factors included communication issues, incorrect use of the early warning tool, inadequate coordination of care planning, policy/protocol/guideline failures and workforce problems.

CONCLUSION

Multi-incident analysis is a useful tool for identifying themes that recur in similar events and presents opportunities for system-wide improvement. Common themes and contributing factors were identified which may provide possibilities for earlier identification and intervention in childhood serious bacterial infection and/or sepsis.