Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study.

BACKGROUND: Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear. AIM: To study the significance of relationships in rural midwifery and provide insights to inform midwifery education. METHODS/DESIGN: Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data. FINDINGS: Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships. CONCLUSIONS: To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice. IMPLICATIONS: Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education.

Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.

Exploring midwives' interactions with mothers when labour begins: A study using participatory action research.

OBJECTIVE: to explore the interactions between mothers and midwives when labour begins with a focus on midwives and unexpected birth out of hospital. DESIGN: participatory action research (PAR) that sought to understand and improve interactions between mothers and midwives through interviews, focus groups and a joint workshop. SETTING: maternity services in the north of England, in a district general hospital with one obstetric unit and two birth centres, across two sites and where there was a birth rate of 6000. PARTICIPANTS: a total of 72 participants took part in the study. Thirteen mothers and five midwives were interviewed. Seven mothers were interviewed who had contacted a midwife in labour and subsequently given birth unexpectedly out of hospital. Thirty-one mothers and twenty-three midwives took part in a series of ten focus groups. KEY FINDINGS: three major themes were identified from the midwives' data: 'Formulaic discourse as self-protection', 'One to one or one to everyone' and 'Interactions and time'. The latter theme is discussed in this paper showing that when midwifery activity was high and they did not have enough time, midwives experienced a high degree of conflicting emotions such as fear, helplessness and frustration, which stretched their personal and professional integrity and triggered changes in their thinking and behaviour. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: current maternity services appear constrained by a reduced midwifery workforce that is expected to meet excessive organisational demands whilst coping with reduced bed capacity. These pressures can promote changes in midwives' behaviour and thinking which disconnects them from mothers rather than focussing on their needs. Safety depends on a high degree of midwife to mother continuity. However, a business model approach, prioritising throughput and process promotes fragmented care and can potentially threaten the safety of mothers and babies. In this study, there appears to be a link between disconnected interactions when labour begins and mothers giving birth unexpectedly out of hospital.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland.

OBJECTIVE: the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN: online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS: 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS: underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS: rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE: findings will inform the preparation of midwives for rural midwifery practice.

A systematic review of evidence relating to clinical supervision for nurses, midwives and allied health professionals.

AIM: The aim of this study was to systematically review evidence relating to clinical supervision for nurses, midwives and allied health professionals. BACKGROUND: Since 1902 statutory supervision has been a requirement for UK midwives, but this is due to change. Evidence relating to clinical supervision for nurses and allied health professions could inform a new model of clinical supervision for midwives. DESIGN: A systematic review with a contingent design, comprising a broad map of research relating to clinical supervision and two focussed syntheses answering specific review questions. DATA SOURCES: Electronic databases were searched from 2005 - September 2015, limited to English-language peer-reviewed publications. REVIEW METHODS: Systematic reviews evaluating the effectiveness of clinical supervision were included in Synthesis 1. Primary research studies including a description of a clinical supervision intervention were included in Synthesis 2. Quality of reviews were judged using a risk of bias tool and review results summarized in tables. Data describing the key components of clinical supervision interventions were extracted from studies included in Synthesis 2, categorized using a reporting framework and a narrative account provided. RESULTS: Ten reviews were included in Synthesis 1; these demonstrated an absence of convincing empirical evidence and lack of agreement over the nature of clinical supervision. Nineteen primary studies were included in Synthesis 2; these highlighted a lack of consistency and large variations between delivered interventions. CONCLUSION: Despite insufficient evidence to directly inform the selection and implementation of a framework, the limited available evidence can inform the design of a new model of clinical supervision for UK-based midwives.

The medicalization of body size and women's healthcare.

In this article we explore the issue of what it means to be "fat" for women in Western (British/North American) society. Contemporary gendered biomedical discourse currently dominates attitudes toward body shapes and sizes (Bordo, 1995). Further, under the rhetoric of "health," a large body size has come to be symbolic of self-indulgence and moral failure. In this article we argue this may lead women to question both their sense of self and their rights to adequate health care. Our aims are threefold: first, to challenge rigid hegemonic biomedical perspectives on "fatness" and the oppressive unequal power relations they may create; second, to examine the process by which such perspectives come to be the only legitimate discourse; third, to consider the impact of pathological medicalised definitions of "obesity" on women's perceptions of their bodies and experiences of health services.

An action-research study exploring midwives' support needs and the affect of group clinical supervision.

OBJECTIVE: To explore community midwives' views and experiences of their support needs in clinical practice, and then to identify how they would wish to receive such support. Further objectives were to redress the imbalance identified by planning and facilitating a model of clinical supervision devised by the participating midwives. DESIGN: A qualitative study using an action-research approach based on collaboration and participation. Action research has the potential to facilitate understanding of, and is able to adapt to, changing situations within clinical practice. Data were collected in three phases using in-depth interviews and focus groups. SETTING: A large maternity unit in the north of England, UK. PARTICIPANTS: Eight National Health Service (NHS) community midwives working in the same team. FINDINGS: Recent and ongoing organisational change and increased demands placed on the midwives by their managers were found to be detrimental to the process of clinical supervision and working relationships with their peers and clients. These pressures also inhibited the process of change. The midwives' behaviour and coping strategies revealed an apparent lack of understanding on their part, and that of their midwifery managers, of the regulation of emotion and the amount of energy this generated. Pseudo-cohesion and resistance to change were key defence mechanisms used by the participating midwives. KEY CONCLUSIONS: A large amount of published literature supported the existence of stress and burnout in midwifery, but no research addressed ways of alleviating this situation. Effective facilitation of midwifery support is needed, which can be met through support mechanisms such as clinical supervision. During the process of clinical supervision, strong messages emerged about the necessity to ensure that midwives are prepared educationally for the difficult situations that are brought about through collaborative working. There are also messages about the cultural legacy of NHS midwifery and how this can inhibit autonomous behaviour by midwives. IMPLICATIONS FOR PRACTICE: Developing and increasing self-awareness is still not viewed as being intrinsic to the work of the midwife, and midwives are being asked to undertake a level of work for which they have not been adequately prepared. The bureaucratic pressures of working in a large maternity unit exaggerate this further. In this situation, the system is seen as more important than the midwives.

A critical ethnographic approach to facilitating cultural shift in midwifery.

OBJECTIVE: to improve understanding of local midwifery morale, inform development and reorganisation of a maternity unit, and enhance midwifery involvement in strategic planning. PARTICIPANTS: a randomised stratified sample of 20 midwives working in a UK National Health Service (NHS) hospital and its surrounding community area. METHOD: within a critical ethnographic framework, focus groups were tape-recorded and transcribed, and analysed using a thematic content analysis approach. FINDINGS: key areas affecting midwifery morale were identified, in particular staffing levels, working relationships and organisational issues. One year later, despite many changes having taken place, midwifery morale was still low but participants were more politically analytical of, and actively involved in changing their situation. The findings of the study indicate that there are complex and long-standing cultural inhibitions to the effective development of midwifery care but, if these are made explicit through a planned collaborative process, such as in this study, a process of cultural shift can be seen to begin. IMPLICATIONS FOR PRACTICE: focus groups can be a useful tool in moving midwifery culture forward within a local context.