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Encountering the culture of midwifery practice on the postnatal ward during Action Research: An impediment to change
Women and Birth (2009) 22, 112—118
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
Encountering the culture of midwifery practice on the postnatal ward during Action Research: An impediment to change Lois McKellar a,b,*, Jan Pincombe b, Ann Henderson c a
School of Population Health and Clinical Practice, The University of Adelaide, Australia School of Nursing and Midwifery, University of South Australia, Australia c Centre for Continuing Education, Children, Youth & Women’s Health Service, Australia b
Received 22 December 2008; received in revised form 12 February 2009; accepted 12 February 2009
KEYWORDS Midwifery; Postnatal care; Action research; Institutional change; Midwifery culture
Summary Background: The reduction of time available to midwives during the hospital postnatal stay suggests that there is a need to review postnatal care. Innovative strategies are required which give attention to specific family needs and assist in the transition to parenthood. Nevertheless, new ideas and changes are not always readily accepted in midwifery practice. Aim: To enhance the provision of postnatal care to parents in the early postnatal period given time constraints for parents’ hospital stay. Methods: Action research was employed to explore the educational experiences of parents in the postnatal period. An action research group (ARG) was established, comprising predominantly of midwives. Based on data collected from parents through questionnaires, focus groups and interviews, three actions were developed and implemented on a postnatal ward. Results: The actions were evaluated by 122 parents through self-report questionnaires. Midwives working on the postnatal ward and midwives involved in the ARG provided feedback regarding the actions through separate focus group discussions. The parents who participated in the study and, the midwives involved in the ARG, were positive about the actions and perceived them to be beneficial in preparing parents for parenthood. Many of the ward midwives, however, were negative about the actions and questioned their benefit for midwifery practice. Discussion: The negativity of the ward midwives regarding the innovations implemented in the study contrasted strikingly with the positive responses from both parents and the action research midwives. Two themes emerged which may explain the response of midwives to the actions, notably, a lack of ownership of the actions and the problematic nature of the current culture of the postnatal-care environment.
* Corresponding author at: Discipline of Nursing, School of Population Health and Clinical Practice, Level 3, Eleanor Harrald Building, The University of Adelaide, SA 5000, Australia. Tel.: +61 8 8303 3866; fax: +61 8 8303 3594. E-mail address: [email protected] (L. McKellar). 1871-5192/$ — see front matter # 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.wombi.2009.02.003
Encountering the culture of midwifery practice on the postnatal ward
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Conclusion: It appears that the provision of hospital postnatal care has been influenced by an underlying culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care. # 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Background The length of postnatal hospital stay within contemporary western society has declined significantly in the last twenty years.1 In Australia, the majority of women continue to give birth in hospital and are discharged within two to three days unless complications exist.2,3 Most of these mothers will receive a visit from a midwife within several days of discharge.1,4 This change in practice, known as early discharge, is largely due to efforts to control rising health-care costs and as a countering response to the medicalisation of childbirth.5 A number of studies have been conducted to determine the benefits and risks associated with early discharge. The findings suggest that there is no increase in maternal and infant morbidity and recommend that early discharge should be ‘‘considered as an acceptable alternative to a longer duration of care in hospital’’ (5 pp., 807).1,4,5,6 Nevertheless, the policy remains controversial and early discharge presents a number of challenges to the provision of postnatal care in hospital. Specifically, the delivery of education and support are acknowledged as areas considerably affected by shorter hospital stays.7,8,9 Once discharged from hospital, many parents do not have adequate experience or help available to them and find themselves at home unprepared for the dayto-day realities of parenthood.4,10 Traditionally, hospital midwives have been relied upon as a major source of information and support. Many midwives claim that the reduction of time available during the postnatal hospital stay impedes their ability to provide this type of care.11,12,13 It appears that medically based routines and non-midwifery duties challenge the use of time, resulting in education being offered to parents in a manner that is rushed with information seeming overwhelming or irrelevant.1,12,14,15,16 Opportunities to teach or reinforce parenting skills are limited.17 A study undertaken in Dublin estimated that midwives spent 8 h during a 24-h period on non-midwifery duties.15 It has been asserted that postnatal care has become task-orientated rather than, holistic and individual, with a focus on economics rather than meeting the specific needs of the woman and her family.13,18,19,20 The reduction of time available to midwives during the hospital postnatal stay suggests there is a need to review postnatal care. New and innovative strategies are required which give attention to identifying specific family needs and assisting the transition to parenthood considering the issues facing contemporary midwifery practice.1,18,21,22,23,24 Nevertheless, new ideas and change are not always readily accepted in midwifery practice. This phenomenon became evident while undertaking a research project to enhance the provision of postnatal education. This paper seeks to provide a discussion on the possibility that the provision of hospital postnatal care has been influenced by a negative culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care. To provide background to this notion, a concise overview
of the study PREPARE: Parents’ Reflections on Education Postpartum: An Action Research Enquiry is provided, followed by a discussion on the findings regarding midwives’ responses to change in this study.
Methodology The study adopted an action research methodology and follows the action research cycle of planning, action, observation and reflection.25 Action research was selected for this study because it provided a democratic, collaborative and dynamic framework for the research enquiry.26 The fundamental aim of action research is to improve practice and involve the people that a change in practice will affect.25 Specifically, action research provided a forum for parents and midwives to address the diverse issues regarding the preparation of people for parenthood. An ethics proposal was submitted to the participating hospital and the University of South Australia Human Research Ethics Committees and ethics approval was obtained. Further to this, communication with the Postnatal Unit Head (PUH) and midwifery staff outlining the purpose of the research, gained support for the study. The issues of rigour in this study have been addressed through a number of means to including triangulation of data collection methods, peer debriefing and member checking reviewing the reviewing the findings with parents.27,28,29 The initial planning phase explored the experiences of mothers and fathers by conducting anonymous self-report questionnaires. Two questionnaires were purpose designed for mothers and fathers respectively. The questionnaires provided the parents with an opportunity to reflect on their own experience, with particular emphasis given to the provision of education and support during the early postnatal period. Eighty-five parents returned completed questionnaires within six weeks of the birth of their baby. Numeric data from the questionnaire was analysed as simple descriptive statistics using the software package SPSS. 12 and thematic analysis was employed to process the written data. The findings from the questionnaire, combined with a review of current literature informed an Action Research Group (ARG).30 The ARG consisted of six midwives from the postnatal ward, the Fatherhood Support Worker (FSW), who provided an antenatal class for fathers, and an Infant and Perinatal Mental Health Nurse. Specifically, the ARG provided midwives an opportunity to respond to the needs of parents identified through the questionnaires and address some of the problems they perceived in their work environment. Several key themes emerged from the ARG discussions including the lack of time available for midwives to provide education to prepare parents for parenthood during the postnatal period. Also, the midwives and FSW recognised the need to individualise the education and support offered to both mothers and fathers as a means of enhancing the readiness of each family to embrace life at home with a new baby and
114 as a means of utilising the time available in hospital more effectively. Through the process of four ARG discussions a number of actions to enhance the preparation of parents for parenthood were proposed including a postnatal planner booklet, ‘‘Coming Ready or Not!’’, a brochure for mothers, ‘‘Congratulations . . . You’re a Mother!’’ and informational postcards for fathers, ‘‘My Dad . . .’’. The actions were developed with further input from parents through focus group discussion and telephone interviews. A focus group for fathers was facilitated at the participating hospital to discuss the findings from the questionnaire and contribute to the development of the postcards and booklet. Nine fathers and the fatherhood support worker attended this focus group and contributed suggestions to improve the booklet and further assist in meeting the needs of fathers. A draft copy of the booklet was reviewed further by parents and ward midwives. Midwives on the postnatal ward were provided a copy of the booklet and asked to document comments and feedback. Eleven parents were provided a copy of the booklet to review and feedback was provided through phone interviews. Five mothers and only one father participated in the phone interviews. Some of the mothers, however, had detailed comments provided by their partner about the booklet. Through the collaborative process, coordinated through the planning phase, actions were proposed, developed and refined. Each action was implemented on the postnatal ward following several training sessions with the ward midwives to explain the purpose of the resources and how they could be used during the postnatal period. The actions were evaluated by parents through self-report questionnaires similar in design to the initial questionnaires but with specific questions regarding each action. One hundred and twenty-two parents completed and returned the second questionnaire. The findings from the questionnaires indicated that, from the perspective of parents, the actions developed and trialled offer positive enhancements in the provision of postnatal education. These findings have been documented in other articles.30,31 Midwives working on the postnatal ward at the time of implementation were also invited to provide feedback regarding the actions through a focus group discussion. Further, the midwives involved in the ARG process reviewed the actions through a final ARG. The following section will document and discuss the perspective of the postnatal ward midwives and the ARG participants regarding the actions.
L. McKellar et al. The researcher began the discussion by reviewing the purpose of the study and distributing the brochure, postcards and booklet. The midwives were asked if they had used any of the resources to assist them in providing education to parents. Many of the midwives commented that they had seen the resources but had not used them. Responses included, ‘‘I’ve seen it (the brochure) in parent’s bundles, but I’ve never seen anybody read it.’’ ‘‘I’ve looked at the pictures.’’ ‘‘I’ve not read it myself.’’ The midwives were asked to comment on each specific action. The following is an example of discussion regarding the postcards. The postcards contained father-specific information on the back side of a black and white picture. Comments were as follows: ‘‘I’ve never read them.’’ ‘‘There is something on the back? Oh, I never saw that. I thought it was just the pictures.’’ (The group laughs). ‘‘I have never read the back’’ (spoken with an amazed tone). (The group laughs). ‘‘Oh, I see. More comprehensive than I thought.’’ It became apparent throughout the discussion, that the midwives had not used the resources as had been intended. In general, they assessed the resources negatively and there appeared to be consensus that the resources were not overly beneficial in providing education to parents. One midwife even commented that, ‘‘I think they have been a waste of money - a complete waste of money!’’ Further, the midwives were asked if they had specifically used the resources with mothers or fathers as a teaching tool. Once again, the response was negative, with comments such as,
Findings
‘‘There is so much to tell them (mothers).’’
Focus group discussion with ward midwives
‘‘We go through all of this, but not specifically with the brochure, bit by bit.’’
The focus group discussion with ward midwives was conducted as part of a routine postnatal ward staff meeting. Eleven midwives attended the staff meeting. One midwife had been part of the ARG otherwise the group exclusively represented midwives working on the postnatal ward. Written consent was gained from all midwives present with permission to tape the discussion. The discussion continued for 20 min, at which point the PUH asked the researcher to conclude to allow a formal staff meeting to commence. The researcher left the meeting at the end of the discussion.
‘‘They don’t want this sort of stuff.’’ ‘‘Don’t want a piece of paper.’’ During the discussion the researcher reiterated that the resources had been designed to be used by midwives in hospital to support education and facilitate individual discussion with parents. The midwives acknowledged that, most often, the resources were not given directly to parents but
Encountering the culture of midwifery practice on the postnatal ward left for parents to discover during their stay in hospital or at home. It was evident that while the researcher believed the process for implementing the actions had been explained during the initial training sessions, this training may not have been sufficient. The midwives did not understand how the resources were to be used and had not embraced them as potentially beneficial strategies to enhance postnatal care. Interestingly, as the discussion progressed, the midwives became less defensive and began entering into the discussion more positively. It became clear that, given the opportunity and time, the ward midwives may have become more supportive. It is possible that some of the difficulties with implementation may have been overcome if a broader cohort of midwives had been directly involved in the study from the planning phase. While this had been the original intent of this study, the degree of involvement anticipated had not been achieved. In conclusion of the discussion the midwives were asked to provide further general feedback. A number of positive comments were made. Discussion was as follows: (Researcher) ‘‘So, you have actually shown the fathers?’’ ‘‘Yes and they have been thrilled with them. Something for the men.’’ (Group member offer agreement in the background). ‘‘Looks like it (the brochure) is easy to read.’’ ‘‘I think it is great and I make a point of telling people it is in there.’’ ‘‘Yeah.’’ (Researcher) ‘‘Have you used it with the mother?’’ ‘‘I say ‘look at this.’ Otherwise it’s just another thing they get given and shoved in the folder.’’ (Researcher) ‘‘So you actually handed it to the mother?’’ ‘‘Yes.’’
Final ARG An ARG discussion was organised to review the results of the questionnaire and discuss the comments from the midwifery focus group. Only three ARG midwives were able to attend. One of the ARG midwives had also been present at the midwives discussion group. The FSW was unable to be present but the researcher provided a detailed account of input she had received from the FSW via phone conversations and emails. The feedback from the FSW regarding the postcards was positive and included comments such as ‘‘congratulations on the postcards.’’ The FSW stated that he believed the postcards were ‘‘a great outcome for dads in SA (South Australia).’’ According to the FSW, the postcards would be valuable beyond the local context in which they were developed. The FSW stated, ‘‘I would love to get more printed ( postcards) so that dads attending other hospitals will get the benefit from the postcards.’’ Following this, 20,000
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postcards were reprinted and distributed throughout South Australia. The session commenced with personal conversations regarding one of the ARG midwives and the previous PUH, who were absent due to various reasons including a change in position. The midwives commented on the difficulties experienced implementing the strategies in practice, particularly without the previous PUH, who had been particularly supportive of the project. The midwives indicated that the support of the previous PUH had positively influenced their experience and motivation with regards to change. They believed that it was important for the PUH to be involved and committed to the process of change. The findings from the parents’ evaluation questionnaire were presented and each midwife was given a summary of the results. The comments included, ‘‘this is great’’ and ‘‘excellent.’’ The midwife present at the ward midwives focus group recounted some of the comments from the discussion, explaining to the other midwives that the resources had not been implemented as intended. Both midwives responded by commenting that they had used the resources and found them helpful. Further discussion continued regarding the attitude of the ward midwives to the strategies. It was acknowledged that the staff appeared negative and at times hostile towards new ideas. The ARG midwives agreed that many midwives did not appear to be open to change, particularly those working on their ward. The researcher asked why they believed this was so. One midwife suggested that this was influenced, at least in part, by the changes in length of hospital stay. She stated, ‘‘I think it is due to having less time to do everything with parents. You used to have five days, now you only have two. I think they resent this and feel like they have too much to do.’’ This idea was explored further. It was suggested that midwives providing postnatal care felt angry and resentful about the reduced hospital stay for parents. It was proposed that this may influence the way in which the midwives respond to further changes and new ideas. Midwives may feel confronted and overwhelmed when presented with innovations, such as those initiated in the study, because they already feel unable to keep up with the demands on their time. Changes in practice may be perceived simply as further intrusions on their limited time and energy.
Discussion The negativity of the ward midwives regarding the innovations implemented in the study, contrasted strikingly with the more positive responses from both parents and the ARG midwives. The ward midwives asserted that the actions were not beneficial for midwifery practice and did not meet the needs of parents. Superficially, this finding was simply disappointing. Nevertheless, when reflecting on why the midwives were initially so negative, it is possible to uncover key issues in the provision of hospital postnatal care that remain unaddressed. These issues can be identified as two central themes emerging from the sessions with the ward midwives and the ARG, notably, lack of ownership and the problematic nature of the current culture of the postnatalcare environment.
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Lack of ownership Many of the midwives on the postnatal ward clearly did not feel any sense of ownership of the actions implemented in the study. Rather, they saw them as an imposition. As noted, a number of midwives were not familiar with the content and purpose of the resources and most had not used them to assist in the provision of education to parents. It is likely that the training provided for the ward midwives regarding implementing the actions was ineffective because the midwives had not recognised the potential benefit of the actions for their practice. Lack of ownership has been identified as a factor inhibiting the introduction of changes in practice.32 Greenwood states that it is important for health-care providers to own an action in order for it to be implemented effectively.33 Reed rightly identifies that encouraging ownership is not simple.32 Ownership may require participants to admit responsibility or embrace changes they are not ready for. In contrast to the ward midwives, the ARG midwives demonstrated a sense of ownership and enthusiastically promoted the actions in practice. Importantly, the ARG midwives had been involved in generating and refining the actions and understood the rationale underpinning the innovations. Unfortunately, as a small group within the midwives working on the ward, the ARG midwives were unable to successfully communicate their understanding or enthusiasm to enough of their colleagues. Additionally, the lack of ownership by the PUH at the time of implementation did not facilitate change. It is important that the value of leadership with in midwifery practice is recognised. Leaders that support and actively engage in the process of change may influence the final outcomes.
Negativity towards change It might be argued that the negativity of the ward midwives regarding the actions reflects an underlying culture which continues to pervade postnatal midwifery practice. It also seems reasonable, to assert that the negative nature of postnatal culture contributed significantly to the midwives’ inability to take ownership of the actions. In discussion with the ARG midwives, it was suggested that the practice of early discharge has contributed significantly to creating a negative culture in the hospital postnatal-care environment. It is important to reflect further on the way in which early discharge has impacted on the practice and morale of midwives. As previously documented, early discharge has been wellexamined in light of the mortality and morbidity outcomes for mothers and babies. Minimal attention has been given, however, to the impact of early discharge on midwives.1,34 Changes in the structure of maternity care provided in hospital have, arguably, been detrimental to the motivation of midwives.35,36 Reducing the time allocated to provide postnatal care should have been accompanied by a comprehensive review of the purpose and management of postnatal care, however, many organisations have simply tried to incorporate the same routines in less time. This has resulted in frustrated and exhausted midwives.1,35 Midwives claim that the reduction in time has forced the provision of postnatal care to become standardised rather than individualised, increasingly task-oriented and delivered in a manner
L. McKellar et al. that often appears brusque. Furthermore, the stress associated with working within such pressured time constraints has created anxiety, irritation and a loss of fulfilment for midwives.24,35,36,37,38 While some midwives are able to embrace an evolving system with flexibility and creative solutions, many pragmatically resolve to simply do what they can without seeking to problem-solve or lift the culture of their profession.38,39 The words ‘grief’ and ‘disappointment’ have been used to describe the emotional response of midwives to organisational change.35,39,40 In this study, the midwives were described as ‘angry’ and ‘resentful’. Interestingly, these emotions are often identified as part of the continuum experienced by individuals encountering loss and grief. It is valuable to reflect on how organisational changes have confronted many midwives with a loss of the capacity to practice according to the ideals of their profession. Furthermore, when exploring the issue of early discharge with midwives in Sweden, Lindeberg et al. identified that negative feelings can lead to hesitancy in taking risks and resistance to change.35 It should not be surprising then, to be confronted by the kind of emotive response and lack of preparedness to embrace innovation, evident in the ward midwives’ response to the actions in this study. It has been suggested that grief may be one of the foundational components contributing to the development of this negative culture.35 In order to adequately address the complexities of providing innovative postnatal care, there is a need to more thoroughly explore the possibility of a ‘grief-stricken’ postnatal culture within midwifery practice in Australia.
Grief-stricken postnatal culture Grief, as a result of organisational change within a profession, has been examined by a number of scholars.41,42,43 It has been cited as a major factor in a lack of responsiveness to innovation and progression by those impacted by change.42 Change requires people to let go of traditional and familiar ways and to move forward and embrace new and unfamiliar concepts. This process of ‘letting go’ represents loss for many individuals, especially if the changes do not appear to fit within their paradigm of best practice. Stein (p. 204) aptly describes this as a ‘‘triad of change-loss-grief.’’43 Undeniably, midwifery practice has experienced change over recent decades. While many changes represent positive steps forward and should be regarded as gain, some changes represent loss.44 Of particular relevance to this study, is the organisational change to the postnatal hospital stay resulting from the implementation of early discharge. Introducing a model of early discharge reduced the time available for midwives to fulfil the scope of midwifery practice during the early postnatal period. This change represented a loss for midwives who felt unable to provide optimal care and education to parents in such limited time. Tension has occurred as midwives have endeavoured to practice within the constraints of institutional policy and medicalised routines. Describing the response of midwives to the implementation of early discharge as grief, provides an explanation for the behaviour and attitudes expressed by some midwives during this study. Understanding the process of grief may give direction for further research and guide the way in which ongoing changes can be implemented successfully.
Encountering the culture of midwifery practice on the postnatal ward Perlman and Takacs describe ten steps in the grieving process resulting from organisational change.45 These steps are defined as equilibrium, denial, anger, bargaining, chaos, depression, resignation, openness, readiness and re-emergence. Schoolfield and Orduna adopted the framework proposed by Perlman and Takacs to understand the responses of staff nurses to change within a large oncology unit in America.42 In their study, denial was commonly associated with verbalising perceived impossibilities associated with the change. Anger was evident in the form of resistance, as nurses assumed that change would increase their workload. Bargaining was noted as nurses tried to reduce the impact of the change, by attempting to show that the changes introduced were ineffective. Chaos resulted as staff realised that the change was permanent and a resultant sense of powerlessness gave rise to depression and resignation. During these stages, nurses recounted stories of ‘how it used to be’ as they passively accepted the change, allowing resistance to subside. The subsequent stages of openness and readiness were characterised by nurses who were more energetic and willing to embrace the change, as they began to identify possible benefits. Finally, re-emergence occurred in which there was resolution. The change became acceptable within the paradigm of individual nurses, enabling them to work effectively within the new system and move on. Notably, some nurses did not move through this process completely and remained in an earlier stage of grief, creating difficulty for those who were able to progress.42 Similar responses have been noted from midwives to institutional changes, particularly regarding the model of early discharge.35,39,40,44 Midwives have responded with frustration and anger towards reduced time available to provide postnatal care. There has been chaos as midwives have tried to fit previous routines and methods into condensed timeframes. Stories of ‘how it used to be’ suggest that some midwives may be resigning themselves to the permanency of change. It is possible, that recognition of loss and acknowledgment of grief may enable midwives to move forward and let go of past ideals.41,43 It is important that policy makers and instigators of organisational change acknowledge the occurrence of grief and understand progressive adaptation to change within work environments.41 This may facilitate more successful transitional processes for both the institutions and the individuals who work within them. Without adequate recognition of the change process on the part of the organisation, practitioners dealing with every-day implications of change may not find the necessary support to move through the process. This may result in a lack of trust in the organisation, leaving individuals to simply ‘‘go through the motions’’ or leave (p. 7).41 Stein asserts that if individuals are not given the opportunity and support to acknowledge their loss and grieve, it is possible that the entire organisation will find difficulty moving forward.43 It is important that loss associated with change in midwifery practice is openly acknowledged and that midwives are given an opportunity to grieve. Enabling midwives to move through the process of grief will enable an acceptance of change. With acceptance may come the capacity for new vision and a commitment to embrace innovative solutions within current models of midwifery care, such as early discharge.
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Conclusion Undoubtedly, early discharge is here to stay. As a consequence, the difficulties early discharge presents for midwives working within the hospital environment must be resolved creatively. There is an ideological conflict evident in some studies, where midwives acknowledge benefits associated with parents going home early but also find it a barrier to providing care.36,38 Whether due to midwives’ inability to move forward and embrace new strategies or whether due to institutional routines still enforced during the postnatal period, midwives need to be brought through their own process of transition. There is a need to reflect, analyse and plan to meet the needs of midwives in the changing arena of maternity care provision.36,39 It is imperative that organisations review postnatal protocols and that more midwives are included in developing strategies to assist them to provide optimal care.40,46 There is a need to actively generate a midwifery culture that is supportive, acknowledges the difficulties and is willing to find solutions together.39,40 It would be beneficial to more fully explore this concept of grief associated with organisational change, and the ongoing implication for midwifery practice in Australia. Acknowledging the limitations of this study, particularly in regards to small sample size and the inability to generalise the findings, it would be valuable to undertake further research to validate whether the responses of midwives in this, and other studies, represent the broader community of midwives providing postnatal care in Australia. Further research investigating the attitudes and emotions of midwives regarding organisational and practice changes is undoubtedly warranted. In addition to research regarding grief and organisational change it would be useful to undertake research examining the extent of influence imposed by hospital institutions on midwifery practice during the postnatal period. It may be necessary to review the focus of care provided during the hospital stay, in light of the impact of early discharge, to determine whether the aims of care provided during this time reflect the needs of modern families in western society.
Acknowledgements Sources of funding: PhD scholarship APA. Bayer pharmaceuticals–—‘Bepanthum nappy cream’ provided funding for printing of the postcards developed for fathers. Ethical statement: An ethics proposal for this research was submitted to the participating hospital and the University of South Australia Human Research Ethics Committees and ethics approval was obtained.
References 1. Brown S, Bruinsma F, Darcy M, Small R, Lumley J. Early discharge: no evidence of adverse outcome in three populationbased Australian surveys of recent mothers, conducted in 1989, 1994, and 2000. Paediatric and Perinatal Epidemiology 2004; 18(3):202—13. 2. Forster D, Rayner S, McLachlan H, Rayner J, Yelland J, Gold L. Alternative approaches to early postnatal care: exploring women’s views. Melbourne: Mother and Child Health Research and the School of Nursing and Midwifery, La Trobe University; 2007 .
118 3. Chan A, Scott J, Nguyen A, Sage L. Pregnancy outcomes in South Australia 2005. Adelaide, Pregnancy Outcome Unit, Department of Health of South Australia; 2006. 4. Morse C, Durkin S, Buist A, Milgrom J. Improving the postnatal outcomes of new mothers. Journal of Advanced Nursing 2004; 45(5):465—74. 5. Petrou S, Boulvain M, Simon J, Maricot P, Borst F, Perneger T, et al. Home-based care after a shortened hospital stay versus hospital-based care postpartum: an economic evaluation. British Journal of Obstetrics and Gynaecology 2004;111(8):800—6. 6. Boulvain M, Perneger T, Othenin-Girard V, Petrou S, Berner M, Irion O. Home-based versus hospital-based postnatal care: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 2004;111(8):807—13. 7. Cooke M, Barclay L. Are we providing adequate postnatal services? Australian and New Zealand Journal of Public Health 1999;23(2):210—1. 8. Ockenden J. After the birth is over . . . rest and support for new mothers. The Practising Midwife 2000;3(11):10—3. 9. Singh D, Newburn M. Postnatal care in the month after birth. The Practising Midwife 2001;4(5):22—5. 10. Hanna B, Edgecombe G, Jackson C, Newman S. The importance of first-time parent groups for new parents. Nursing and Health Sciences 2002;4(4):209—14. 11. Stamp G, Crowther C. Women’s views of their postnatal care by midwives at an Adelaide women’s hospital. Midwifery 1994;10(3): 148—56. 12. Sanford S, Lamb C. Nurse partners: going beyond the delivery room. Mother Baby Journal 1997;2(6):8—12. 13. Gilmour C, Twining S. Postnatal care in hospitals: ritual routine or individualised. Australian College of Midwives Incorporated 2002;15(2):11—5. 14. Cooke M. Postnatal care: what do women want? Nursing Review 2000;15(3). 15. McKenna H, Hasson F, Smith M. A Delphi survey of midwives and midwifery students to identify non-midwifery duties. Midwifery 2002;18(3):314—22. 16. Persson E, Dykes A. Parents’ experience of early discharge from hospital after birth in Sweden. Midwifery 2002;18(1):53—60. 17. Maloni J. The content and sources of knowledge about the infant. MCN The American Journal of Maternal/Child Nursing 1994;22(4):110—20. 18. MacArthur C, Winter H, Bick D, Knowles H, Lilford R, Henderson C, et al. Effects of redesigned community postnatal care on women’s health 4 months after birth: a cluster randomised controlled trial. The Lancet 2002;359(9302):378—86. 19. Mitchell M, Doyle M. Evaluating a new course in postnatal care. British Journal of Midwifery 2002;10(12):746—50. 20. Holtslander L. Clinical application of the 15-minute family interview: addressing the needs of postpartum families. Journal of Family Nursing 2005;11(1):5—18. 21. Keppler A, Roudebush J. Postpartum follow-up care in a hospitalbased clinic: an update on an expanded program. Journal of Perinatal and Neonatal Nursing 1999;13(1):1—14. 22. Ruchala P. Teaching new mothers: priorities of midwives and postpartum women. JOGNN 2000;29(3):265—73. 23. Fredriksson G, Hogberg U, Lundman B. Postpartum care should provide alternatives to meet parents’ need for safety, active participation, and ‘bonding’. Midwifery 2003;19(3):267—76. 24. Cattrel R, Lavender T, Wallymahmed A, Kingdom C, Riley J. Postnatal care: what matters to midwives. British Journal of Midwifery 2005;13(4):206—13.
L. McKellar et al. 25. Kemmis S, McTaggart R. The action research planner. Victoria: Deakin University Press; 1982. 26. Waterman H, Tillen D, Dickson R. Action research: a systematic review and guidance for assessment. Health Technology Assessment 2001;5(23):1—166. 27. Polit D, Hungler B. Nursing research principles and methods. 5th ed. Philadelphia: Lippincott; 1995. 28. Lincoln Y, Guba E. Naturalistic inquiry. California: Sage Publications; 1985. 29. Sandelowski M. ‘To be of use’: enhancing the utility of qualitative research. Nursing Outlook 1997;45(3):125—32. 30. McKellar L, Pincombe J, Henderson A. Insights from Australian parents into educational experiences in the early postnatal period. Midwifery 2006;22(4):356—64. 31. McKellar L, Pincombe J, Henderson A. Enhancing fathers educational experiences during the early postnatal period. The Journal of Perinatal Education 2008;17(4):12—20. 32. Reed J. Using action research in nursing practice with older people: democratising knowledge. Journal of Clinical Nursing 2005;14(5):594—600. 33. Greenwood J. Action Research: a few details, a caution and something new. Journal of Advanced Nursing 1994;20(1):13—8. 34. Brown S, Davey M, Bruinsma F. Women’s views and experiences of postnatal hospital care in the Victorian survey of recent mothers 2000. Midwifery 2005;21(2):109—26. 35. Lindberg I, Christensson K, Ohrling K. Midwives’ experience of organisational and professional change. Midwifery 2005;21(4): 355—64. 36. Rayner J, Forster D, McLachlan H, Yelland J, Davey M. A statewide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives. Midwifery 2008;24(3): 310—20. 37. McKellar L, Pincombe J, Henderson A. Congratulations–—you’re a mother: a strategy for enhancing postnatal education for firsttime mothers investigated through an action research cycle. Adelaide: University of South Australia; 2002. 38. Hunter B. Conflicting ideologies as a source of emotion work in midwifery. Midwifery 2004;20(3):261—72. 39. Kirkham S, Stapleton H. Midwives’ support needs as childbirth changes. Journal of Advanced Nursing 2000;32(2):465—72. 40. Hughes D, Deery R, Lovatt A. A critical ethnographic approach to facilitating cultural shift in midwifery. Midwifery 2002;18(1): 43—52. 41. Taylor P. Loss and grief: issues for organisational change and development. HERDSA Annual International Conference. 1999. 42. Schoolfield M, Orduna A. Understanding staff nurse responses to change: utilisation of a grief-change framework to facilitate innovation. Clinical Nurse Specialist 2001;15(5):224—9. 43. Stein H. Letting go of who we were: the triad of change-loss-grief on organisational and wider cultural life: a case study and its broader implications. Organisational and Social Dynamics: An International Journal of Psychoanalytic Systemic and Group Relations Perspective 2006;6(2):204—23. 44. Kirkham S. The culture of midwifery in the National Health Service in England. Journal of Advanced Nursing 1999;30(3): 732—9. 45. Perlman D, Takacs G. The 10 stages of change. Nursing Management 1990;21(4):33—8. 46. McLachlan H, Forster D, Yelland J, Rayner J, Lumley J. Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victorian, Australia. Midwifery 2008;24(3):358—70.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/wombi
Encountering the culture of midwifery practice on the postnatal ward during Action Research: An impediment to change Lois McKellar a,b,*, Jan Pincombe b, Ann Henderson c a
School of Population Health and Clinical Practice, The University of Adelaide, Australia School of Nursing and Midwifery, University of South Australia, Australia c Centre for Continuing Education, Children, Youth & Women’s Health Service, Australia b
Received 22 December 2008; received in revised form 12 February 2009; accepted 12 February 2009
KEYWORDS Midwifery; Postnatal care; Action research; Institutional change; Midwifery culture
Summary Background: The reduction of time available to midwives during the hospital postnatal stay suggests that there is a need to review postnatal care. Innovative strategies are required which give attention to specific family needs and assist in the transition to parenthood. Nevertheless, new ideas and changes are not always readily accepted in midwifery practice. Aim: To enhance the provision of postnatal care to parents in the early postnatal period given time constraints for parents’ hospital stay. Methods: Action research was employed to explore the educational experiences of parents in the postnatal period. An action research group (ARG) was established, comprising predominantly of midwives. Based on data collected from parents through questionnaires, focus groups and interviews, three actions were developed and implemented on a postnatal ward. Results: The actions were evaluated by 122 parents through self-report questionnaires. Midwives working on the postnatal ward and midwives involved in the ARG provided feedback regarding the actions through separate focus group discussions. The parents who participated in the study and, the midwives involved in the ARG, were positive about the actions and perceived them to be beneficial in preparing parents for parenthood. Many of the ward midwives, however, were negative about the actions and questioned their benefit for midwifery practice. Discussion: The negativity of the ward midwives regarding the innovations implemented in the study contrasted strikingly with the positive responses from both parents and the action research midwives. Two themes emerged which may explain the response of midwives to the actions, notably, a lack of ownership of the actions and the problematic nature of the current culture of the postnatal-care environment.
* Corresponding author at: Discipline of Nursing, School of Population Health and Clinical Practice, Level 3, Eleanor Harrald Building, The University of Adelaide, SA 5000, Australia. Tel.: +61 8 8303 3866; fax: +61 8 8303 3594. E-mail address: [email protected] (L. McKellar). 1871-5192/$ — see front matter # 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.wombi.2009.02.003
Encountering the culture of midwifery practice on the postnatal ward
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Conclusion: It appears that the provision of hospital postnatal care has been influenced by an underlying culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care. # 2009 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Background The length of postnatal hospital stay within contemporary western society has declined significantly in the last twenty years.1 In Australia, the majority of women continue to give birth in hospital and are discharged within two to three days unless complications exist.2,3 Most of these mothers will receive a visit from a midwife within several days of discharge.1,4 This change in practice, known as early discharge, is largely due to efforts to control rising health-care costs and as a countering response to the medicalisation of childbirth.5 A number of studies have been conducted to determine the benefits and risks associated with early discharge. The findings suggest that there is no increase in maternal and infant morbidity and recommend that early discharge should be ‘‘considered as an acceptable alternative to a longer duration of care in hospital’’ (5 pp., 807).1,4,5,6 Nevertheless, the policy remains controversial and early discharge presents a number of challenges to the provision of postnatal care in hospital. Specifically, the delivery of education and support are acknowledged as areas considerably affected by shorter hospital stays.7,8,9 Once discharged from hospital, many parents do not have adequate experience or help available to them and find themselves at home unprepared for the dayto-day realities of parenthood.4,10 Traditionally, hospital midwives have been relied upon as a major source of information and support. Many midwives claim that the reduction of time available during the postnatal hospital stay impedes their ability to provide this type of care.11,12,13 It appears that medically based routines and non-midwifery duties challenge the use of time, resulting in education being offered to parents in a manner that is rushed with information seeming overwhelming or irrelevant.1,12,14,15,16 Opportunities to teach or reinforce parenting skills are limited.17 A study undertaken in Dublin estimated that midwives spent 8 h during a 24-h period on non-midwifery duties.15 It has been asserted that postnatal care has become task-orientated rather than, holistic and individual, with a focus on economics rather than meeting the specific needs of the woman and her family.13,18,19,20 The reduction of time available to midwives during the hospital postnatal stay suggests there is a need to review postnatal care. New and innovative strategies are required which give attention to identifying specific family needs and assisting the transition to parenthood considering the issues facing contemporary midwifery practice.1,18,21,22,23,24 Nevertheless, new ideas and change are not always readily accepted in midwifery practice. This phenomenon became evident while undertaking a research project to enhance the provision of postnatal education. This paper seeks to provide a discussion on the possibility that the provision of hospital postnatal care has been influenced by a negative culture in midwifery practice, which in turn, has impeded the change required to enhance postnatal care. To provide background to this notion, a concise overview
of the study PREPARE: Parents’ Reflections on Education Postpartum: An Action Research Enquiry is provided, followed by a discussion on the findings regarding midwives’ responses to change in this study.
Methodology The study adopted an action research methodology and follows the action research cycle of planning, action, observation and reflection.25 Action research was selected for this study because it provided a democratic, collaborative and dynamic framework for the research enquiry.26 The fundamental aim of action research is to improve practice and involve the people that a change in practice will affect.25 Specifically, action research provided a forum for parents and midwives to address the diverse issues regarding the preparation of people for parenthood. An ethics proposal was submitted to the participating hospital and the University of South Australia Human Research Ethics Committees and ethics approval was obtained. Further to this, communication with the Postnatal Unit Head (PUH) and midwifery staff outlining the purpose of the research, gained support for the study. The issues of rigour in this study have been addressed through a number of means to including triangulation of data collection methods, peer debriefing and member checking reviewing the reviewing the findings with parents.27,28,29 The initial planning phase explored the experiences of mothers and fathers by conducting anonymous self-report questionnaires. Two questionnaires were purpose designed for mothers and fathers respectively. The questionnaires provided the parents with an opportunity to reflect on their own experience, with particular emphasis given to the provision of education and support during the early postnatal period. Eighty-five parents returned completed questionnaires within six weeks of the birth of their baby. Numeric data from the questionnaire was analysed as simple descriptive statistics using the software package SPSS. 12 and thematic analysis was employed to process the written data. The findings from the questionnaire, combined with a review of current literature informed an Action Research Group (ARG).30 The ARG consisted of six midwives from the postnatal ward, the Fatherhood Support Worker (FSW), who provided an antenatal class for fathers, and an Infant and Perinatal Mental Health Nurse. Specifically, the ARG provided midwives an opportunity to respond to the needs of parents identified through the questionnaires and address some of the problems they perceived in their work environment. Several key themes emerged from the ARG discussions including the lack of time available for midwives to provide education to prepare parents for parenthood during the postnatal period. Also, the midwives and FSW recognised the need to individualise the education and support offered to both mothers and fathers as a means of enhancing the readiness of each family to embrace life at home with a new baby and
114 as a means of utilising the time available in hospital more effectively. Through the process of four ARG discussions a number of actions to enhance the preparation of parents for parenthood were proposed including a postnatal planner booklet, ‘‘Coming Ready or Not!’’, a brochure for mothers, ‘‘Congratulations . . . You’re a Mother!’’ and informational postcards for fathers, ‘‘My Dad . . .’’. The actions were developed with further input from parents through focus group discussion and telephone interviews. A focus group for fathers was facilitated at the participating hospital to discuss the findings from the questionnaire and contribute to the development of the postcards and booklet. Nine fathers and the fatherhood support worker attended this focus group and contributed suggestions to improve the booklet and further assist in meeting the needs of fathers. A draft copy of the booklet was reviewed further by parents and ward midwives. Midwives on the postnatal ward were provided a copy of the booklet and asked to document comments and feedback. Eleven parents were provided a copy of the booklet to review and feedback was provided through phone interviews. Five mothers and only one father participated in the phone interviews. Some of the mothers, however, had detailed comments provided by their partner about the booklet. Through the collaborative process, coordinated through the planning phase, actions were proposed, developed and refined. Each action was implemented on the postnatal ward following several training sessions with the ward midwives to explain the purpose of the resources and how they could be used during the postnatal period. The actions were evaluated by parents through self-report questionnaires similar in design to the initial questionnaires but with specific questions regarding each action. One hundred and twenty-two parents completed and returned the second questionnaire. The findings from the questionnaires indicated that, from the perspective of parents, the actions developed and trialled offer positive enhancements in the provision of postnatal education. These findings have been documented in other articles.30,31 Midwives working on the postnatal ward at the time of implementation were also invited to provide feedback regarding the actions through a focus group discussion. Further, the midwives involved in the ARG process reviewed the actions through a final ARG. The following section will document and discuss the perspective of the postnatal ward midwives and the ARG participants regarding the actions.
L. McKellar et al. The researcher began the discussion by reviewing the purpose of the study and distributing the brochure, postcards and booklet. The midwives were asked if they had used any of the resources to assist them in providing education to parents. Many of the midwives commented that they had seen the resources but had not used them. Responses included, ‘‘I’ve seen it (the brochure) in parent’s bundles, but I’ve never seen anybody read it.’’ ‘‘I’ve looked at the pictures.’’ ‘‘I’ve not read it myself.’’ The midwives were asked to comment on each specific action. The following is an example of discussion regarding the postcards. The postcards contained father-specific information on the back side of a black and white picture. Comments were as follows: ‘‘I’ve never read them.’’ ‘‘There is something on the back? Oh, I never saw that. I thought it was just the pictures.’’ (The group laughs). ‘‘I have never read the back’’ (spoken with an amazed tone). (The group laughs). ‘‘Oh, I see. More comprehensive than I thought.’’ It became apparent throughout the discussion, that the midwives had not used the resources as had been intended. In general, they assessed the resources negatively and there appeared to be consensus that the resources were not overly beneficial in providing education to parents. One midwife even commented that, ‘‘I think they have been a waste of money - a complete waste of money!’’ Further, the midwives were asked if they had specifically used the resources with mothers or fathers as a teaching tool. Once again, the response was negative, with comments such as,
Findings
‘‘There is so much to tell them (mothers).’’
Focus group discussion with ward midwives
‘‘We go through all of this, but not specifically with the brochure, bit by bit.’’
The focus group discussion with ward midwives was conducted as part of a routine postnatal ward staff meeting. Eleven midwives attended the staff meeting. One midwife had been part of the ARG otherwise the group exclusively represented midwives working on the postnatal ward. Written consent was gained from all midwives present with permission to tape the discussion. The discussion continued for 20 min, at which point the PUH asked the researcher to conclude to allow a formal staff meeting to commence. The researcher left the meeting at the end of the discussion.
‘‘They don’t want this sort of stuff.’’ ‘‘Don’t want a piece of paper.’’ During the discussion the researcher reiterated that the resources had been designed to be used by midwives in hospital to support education and facilitate individual discussion with parents. The midwives acknowledged that, most often, the resources were not given directly to parents but
Encountering the culture of midwifery practice on the postnatal ward left for parents to discover during their stay in hospital or at home. It was evident that while the researcher believed the process for implementing the actions had been explained during the initial training sessions, this training may not have been sufficient. The midwives did not understand how the resources were to be used and had not embraced them as potentially beneficial strategies to enhance postnatal care. Interestingly, as the discussion progressed, the midwives became less defensive and began entering into the discussion more positively. It became clear that, given the opportunity and time, the ward midwives may have become more supportive. It is possible that some of the difficulties with implementation may have been overcome if a broader cohort of midwives had been directly involved in the study from the planning phase. While this had been the original intent of this study, the degree of involvement anticipated had not been achieved. In conclusion of the discussion the midwives were asked to provide further general feedback. A number of positive comments were made. Discussion was as follows: (Researcher) ‘‘So, you have actually shown the fathers?’’ ‘‘Yes and they have been thrilled with them. Something for the men.’’ (Group member offer agreement in the background). ‘‘Looks like it (the brochure) is easy to read.’’ ‘‘I think it is great and I make a point of telling people it is in there.’’ ‘‘Yeah.’’ (Researcher) ‘‘Have you used it with the mother?’’ ‘‘I say ‘look at this.’ Otherwise it’s just another thing they get given and shoved in the folder.’’ (Researcher) ‘‘So you actually handed it to the mother?’’ ‘‘Yes.’’
Final ARG An ARG discussion was organised to review the results of the questionnaire and discuss the comments from the midwifery focus group. Only three ARG midwives were able to attend. One of the ARG midwives had also been present at the midwives discussion group. The FSW was unable to be present but the researcher provided a detailed account of input she had received from the FSW via phone conversations and emails. The feedback from the FSW regarding the postcards was positive and included comments such as ‘‘congratulations on the postcards.’’ The FSW stated that he believed the postcards were ‘‘a great outcome for dads in SA (South Australia).’’ According to the FSW, the postcards would be valuable beyond the local context in which they were developed. The FSW stated, ‘‘I would love to get more printed ( postcards) so that dads attending other hospitals will get the benefit from the postcards.’’ Following this, 20,000
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postcards were reprinted and distributed throughout South Australia. The session commenced with personal conversations regarding one of the ARG midwives and the previous PUH, who were absent due to various reasons including a change in position. The midwives commented on the difficulties experienced implementing the strategies in practice, particularly without the previous PUH, who had been particularly supportive of the project. The midwives indicated that the support of the previous PUH had positively influenced their experience and motivation with regards to change. They believed that it was important for the PUH to be involved and committed to the process of change. The findings from the parents’ evaluation questionnaire were presented and each midwife was given a summary of the results. The comments included, ‘‘this is great’’ and ‘‘excellent.’’ The midwife present at the ward midwives focus group recounted some of the comments from the discussion, explaining to the other midwives that the resources had not been implemented as intended. Both midwives responded by commenting that they had used the resources and found them helpful. Further discussion continued regarding the attitude of the ward midwives to the strategies. It was acknowledged that the staff appeared negative and at times hostile towards new ideas. The ARG midwives agreed that many midwives did not appear to be open to change, particularly those working on their ward. The researcher asked why they believed this was so. One midwife suggested that this was influenced, at least in part, by the changes in length of hospital stay. She stated, ‘‘I think it is due to having less time to do everything with parents. You used to have five days, now you only have two. I think they resent this and feel like they have too much to do.’’ This idea was explored further. It was suggested that midwives providing postnatal care felt angry and resentful about the reduced hospital stay for parents. It was proposed that this may influence the way in which the midwives respond to further changes and new ideas. Midwives may feel confronted and overwhelmed when presented with innovations, such as those initiated in the study, because they already feel unable to keep up with the demands on their time. Changes in practice may be perceived simply as further intrusions on their limited time and energy.
Discussion The negativity of the ward midwives regarding the innovations implemented in the study, contrasted strikingly with the more positive responses from both parents and the ARG midwives. The ward midwives asserted that the actions were not beneficial for midwifery practice and did not meet the needs of parents. Superficially, this finding was simply disappointing. Nevertheless, when reflecting on why the midwives were initially so negative, it is possible to uncover key issues in the provision of hospital postnatal care that remain unaddressed. These issues can be identified as two central themes emerging from the sessions with the ward midwives and the ARG, notably, lack of ownership and the problematic nature of the current culture of the postnatalcare environment.
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Lack of ownership Many of the midwives on the postnatal ward clearly did not feel any sense of ownership of the actions implemented in the study. Rather, they saw them as an imposition. As noted, a number of midwives were not familiar with the content and purpose of the resources and most had not used them to assist in the provision of education to parents. It is likely that the training provided for the ward midwives regarding implementing the actions was ineffective because the midwives had not recognised the potential benefit of the actions for their practice. Lack of ownership has been identified as a factor inhibiting the introduction of changes in practice.32 Greenwood states that it is important for health-care providers to own an action in order for it to be implemented effectively.33 Reed rightly identifies that encouraging ownership is not simple.32 Ownership may require participants to admit responsibility or embrace changes they are not ready for. In contrast to the ward midwives, the ARG midwives demonstrated a sense of ownership and enthusiastically promoted the actions in practice. Importantly, the ARG midwives had been involved in generating and refining the actions and understood the rationale underpinning the innovations. Unfortunately, as a small group within the midwives working on the ward, the ARG midwives were unable to successfully communicate their understanding or enthusiasm to enough of their colleagues. Additionally, the lack of ownership by the PUH at the time of implementation did not facilitate change. It is important that the value of leadership with in midwifery practice is recognised. Leaders that support and actively engage in the process of change may influence the final outcomes.
Negativity towards change It might be argued that the negativity of the ward midwives regarding the actions reflects an underlying culture which continues to pervade postnatal midwifery practice. It also seems reasonable, to assert that the negative nature of postnatal culture contributed significantly to the midwives’ inability to take ownership of the actions. In discussion with the ARG midwives, it was suggested that the practice of early discharge has contributed significantly to creating a negative culture in the hospital postnatal-care environment. It is important to reflect further on the way in which early discharge has impacted on the practice and morale of midwives. As previously documented, early discharge has been wellexamined in light of the mortality and morbidity outcomes for mothers and babies. Minimal attention has been given, however, to the impact of early discharge on midwives.1,34 Changes in the structure of maternity care provided in hospital have, arguably, been detrimental to the motivation of midwives.35,36 Reducing the time allocated to provide postnatal care should have been accompanied by a comprehensive review of the purpose and management of postnatal care, however, many organisations have simply tried to incorporate the same routines in less time. This has resulted in frustrated and exhausted midwives.1,35 Midwives claim that the reduction in time has forced the provision of postnatal care to become standardised rather than individualised, increasingly task-oriented and delivered in a manner
L. McKellar et al. that often appears brusque. Furthermore, the stress associated with working within such pressured time constraints has created anxiety, irritation and a loss of fulfilment for midwives.24,35,36,37,38 While some midwives are able to embrace an evolving system with flexibility and creative solutions, many pragmatically resolve to simply do what they can without seeking to problem-solve or lift the culture of their profession.38,39 The words ‘grief’ and ‘disappointment’ have been used to describe the emotional response of midwives to organisational change.35,39,40 In this study, the midwives were described as ‘angry’ and ‘resentful’. Interestingly, these emotions are often identified as part of the continuum experienced by individuals encountering loss and grief. It is valuable to reflect on how organisational changes have confronted many midwives with a loss of the capacity to practice according to the ideals of their profession. Furthermore, when exploring the issue of early discharge with midwives in Sweden, Lindeberg et al. identified that negative feelings can lead to hesitancy in taking risks and resistance to change.35 It should not be surprising then, to be confronted by the kind of emotive response and lack of preparedness to embrace innovation, evident in the ward midwives’ response to the actions in this study. It has been suggested that grief may be one of the foundational components contributing to the development of this negative culture.35 In order to adequately address the complexities of providing innovative postnatal care, there is a need to more thoroughly explore the possibility of a ‘grief-stricken’ postnatal culture within midwifery practice in Australia.
Grief-stricken postnatal culture Grief, as a result of organisational change within a profession, has been examined by a number of scholars.41,42,43 It has been cited as a major factor in a lack of responsiveness to innovation and progression by those impacted by change.42 Change requires people to let go of traditional and familiar ways and to move forward and embrace new and unfamiliar concepts. This process of ‘letting go’ represents loss for many individuals, especially if the changes do not appear to fit within their paradigm of best practice. Stein (p. 204) aptly describes this as a ‘‘triad of change-loss-grief.’’43 Undeniably, midwifery practice has experienced change over recent decades. While many changes represent positive steps forward and should be regarded as gain, some changes represent loss.44 Of particular relevance to this study, is the organisational change to the postnatal hospital stay resulting from the implementation of early discharge. Introducing a model of early discharge reduced the time available for midwives to fulfil the scope of midwifery practice during the early postnatal period. This change represented a loss for midwives who felt unable to provide optimal care and education to parents in such limited time. Tension has occurred as midwives have endeavoured to practice within the constraints of institutional policy and medicalised routines. Describing the response of midwives to the implementation of early discharge as grief, provides an explanation for the behaviour and attitudes expressed by some midwives during this study. Understanding the process of grief may give direction for further research and guide the way in which ongoing changes can be implemented successfully.
Encountering the culture of midwifery practice on the postnatal ward Perlman and Takacs describe ten steps in the grieving process resulting from organisational change.45 These steps are defined as equilibrium, denial, anger, bargaining, chaos, depression, resignation, openness, readiness and re-emergence. Schoolfield and Orduna adopted the framework proposed by Perlman and Takacs to understand the responses of staff nurses to change within a large oncology unit in America.42 In their study, denial was commonly associated with verbalising perceived impossibilities associated with the change. Anger was evident in the form of resistance, as nurses assumed that change would increase their workload. Bargaining was noted as nurses tried to reduce the impact of the change, by attempting to show that the changes introduced were ineffective. Chaos resulted as staff realised that the change was permanent and a resultant sense of powerlessness gave rise to depression and resignation. During these stages, nurses recounted stories of ‘how it used to be’ as they passively accepted the change, allowing resistance to subside. The subsequent stages of openness and readiness were characterised by nurses who were more energetic and willing to embrace the change, as they began to identify possible benefits. Finally, re-emergence occurred in which there was resolution. The change became acceptable within the paradigm of individual nurses, enabling them to work effectively within the new system and move on. Notably, some nurses did not move through this process completely and remained in an earlier stage of grief, creating difficulty for those who were able to progress.42 Similar responses have been noted from midwives to institutional changes, particularly regarding the model of early discharge.35,39,40,44 Midwives have responded with frustration and anger towards reduced time available to provide postnatal care. There has been chaos as midwives have tried to fit previous routines and methods into condensed timeframes. Stories of ‘how it used to be’ suggest that some midwives may be resigning themselves to the permanency of change. It is possible, that recognition of loss and acknowledgment of grief may enable midwives to move forward and let go of past ideals.41,43 It is important that policy makers and instigators of organisational change acknowledge the occurrence of grief and understand progressive adaptation to change within work environments.41 This may facilitate more successful transitional processes for both the institutions and the individuals who work within them. Without adequate recognition of the change process on the part of the organisation, practitioners dealing with every-day implications of change may not find the necessary support to move through the process. This may result in a lack of trust in the organisation, leaving individuals to simply ‘‘go through the motions’’ or leave (p. 7).41 Stein asserts that if individuals are not given the opportunity and support to acknowledge their loss and grieve, it is possible that the entire organisation will find difficulty moving forward.43 It is important that loss associated with change in midwifery practice is openly acknowledged and that midwives are given an opportunity to grieve. Enabling midwives to move through the process of grief will enable an acceptance of change. With acceptance may come the capacity for new vision and a commitment to embrace innovative solutions within current models of midwifery care, such as early discharge.
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Conclusion Undoubtedly, early discharge is here to stay. As a consequence, the difficulties early discharge presents for midwives working within the hospital environment must be resolved creatively. There is an ideological conflict evident in some studies, where midwives acknowledge benefits associated with parents going home early but also find it a barrier to providing care.36,38 Whether due to midwives’ inability to move forward and embrace new strategies or whether due to institutional routines still enforced during the postnatal period, midwives need to be brought through their own process of transition. There is a need to reflect, analyse and plan to meet the needs of midwives in the changing arena of maternity care provision.36,39 It is imperative that organisations review postnatal protocols and that more midwives are included in developing strategies to assist them to provide optimal care.40,46 There is a need to actively generate a midwifery culture that is supportive, acknowledges the difficulties and is willing to find solutions together.39,40 It would be beneficial to more fully explore this concept of grief associated with organisational change, and the ongoing implication for midwifery practice in Australia. Acknowledging the limitations of this study, particularly in regards to small sample size and the inability to generalise the findings, it would be valuable to undertake further research to validate whether the responses of midwives in this, and other studies, represent the broader community of midwives providing postnatal care in Australia. Further research investigating the attitudes and emotions of midwives regarding organisational and practice changes is undoubtedly warranted. In addition to research regarding grief and organisational change it would be useful to undertake research examining the extent of influence imposed by hospital institutions on midwifery practice during the postnatal period. It may be necessary to review the focus of care provided during the hospital stay, in light of the impact of early discharge, to determine whether the aims of care provided during this time reflect the needs of modern families in western society.
Acknowledgements Sources of funding: PhD scholarship APA. Bayer pharmaceuticals–—‘Bepanthum nappy cream’ provided funding for printing of the postcards developed for fathers. Ethical statement: An ethics proposal for this research was submitted to the participating hospital and the University of South Australia Human Research Ethics Committees and ethics approval was obtained.
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