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Chinese midwives’ experience of providing continuity of care to labouring women
Midwifery 27 (2011) 243–249
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Chinese midwives’ experience of providing continuity of care to labouring women Chunyi Gu, RNM, BScN (Clinical Midwifery Supervisor)a,, Zheng Zhang, RNM (Head Midwife)a, Yan Ding, RN, MScN (Director and Research Supervisor)b a b
Labour Unit, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China Nursing Department, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
a r t i c l e in fo
abstract
Article history: Received 28 March 2009 Received in revised form 8 June 2009 Accepted 14 June 2009
Objective: to explore and describe Chinese midwives’ experience of providing one-to-one continuity of care to labouring women. Design: a qualitative study using a phenomenological approach. Data were collected using open-ended, tape-recorded interviews. The analysis of the transcribed texts included searching for themes sorted into clusters for a final expression of the essential structure of the phenomenon. Setting: Obstetrics and gynaecology hospital of Fudan University, Shanghai, China. Participants: 12 midwives, providing one-to-one continuity of care to labouring women. Findings: two main categories were identified: (1) midwives’ feelings on providing continuity of care, and (2) impact of on-call system on midwives providing continuity of care. Key themes emerged from each main category: (1) ‘playing important roles in labour care’, ‘gaining a sense of self-achievement’, ‘falling into exhaustion and frustration’ and ‘coping with caring work’; and (2) ‘on-call syndrome’, ‘affecting personal lives’ and ‘managing on-call shift’. The midwives experienced mixed feelings of being with women and expressed their adaptation to being on-call, which was the essence of this study. They played important roles in caring for women, gained a sense of self-achievement and developed suitable coping strategies. However, they also indicated the impact of the on-call system upon them in the process of providing continuity of care. Conclusion and implications for practice: midwives have gained both positive and negative experiences when providing continuity of care to labouring women. The positive aspects may facilitate other professional midwives working in a similar role, whereas the negative aspects may inform them of learning to live with this situation, and may also have implications for managers to develop new approaches to the organisation and provision of continuity of care to support midwives’ practice, and to fully utilise ‘flexibility’ under an on-call system. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Midwives One-to-one midwifery Continuity of care On-call system Phenomenology
Introduction Childbirth is a complex life event characterised by rapid biological, social and emotional transitions (Blaaka and Eri, 2008). Caring for birthing women as a unique life event is the core of the midwifery profession. Policy in the United Kingdom has recommended the establishment of models of care that provide continuity of care (Department of Health Expert Maternity Group, 1993). Concurrently, women’s experience of continuity of care has been studied in various countries. To our knowledge, only a limited number of studies have focused on midwives’ views, perceptions and experience in terms of continuity of care. This
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E-mail address: [email protected] (C. Gu). 0266-6138/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2009.06.007
study explores and describes midwives’ experience of providing continuity of care to labouring women in the Chinese context.
Literature review One-to-one midwifery and continuity of care In order to provide woman- and family-centred care, one-toone midwifery practice was developed as a demonstration project to put the principles of ‘Changing Childbirth’ into practice (Page et al., 1998). The term ‘one-to-one’ illustrated the concept of continuity of caregiver (Page et al., 1998). Continuity of care and carer are important determinants of a positive experience (Page et al., 2000). The definition and scope of continuity of care differ in various research and settings. Some have interpreted it as a shared
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philosophy of care (continuity of caring), whilst others view it as the provision of care by a known carer or a small team of midwives throughout the childbirth experience (continuity of carer) (Hundley et al., 1995). There have been different models of continuity of care implemented in midwifery practice. The midwives in such schemes provide the majority of care for women in their caseload, throughout the entire pregnancy, labour, birth and postpartum period, which can achieve a high degree of continuity of care (Page et al., 1999; Homer et al., 2002). The midwives are on-call to provide care during labour. ‘Being on-call’ is regarded as ‘being ready to go to work’ or ‘being available for work if needed’ (Wiegers, 2007). This present article focuses on a new model of continuity of care, which refers to continuous support and care by an on-call midwife from the onset of labour to two hours post partum. Different ways of providing continuity of care can have their pros and cons. Continuous support during labour facilitates birth, enhances the mother’s memory of the experience, reduces many forms of medical intervention (Pascali-Bonaro and Kroeger, 2004), and helps women to form a relationship with their midwives (Farquhar et al., 2000). Women who had continuous intrapartum support were likely to have a slightly shorter labour and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences (Hodnett et al., 2007). Midwives providing continuity of care will also build a better support system (Kirkham, 2000). However, according to Morgan et al. (1998) and Freeman (2006), continuity of carer is not a clear predictor of women’s satisfaction, and women do not focus on the model of care provided, but on the content of the care provided. Meanwhile, providing continuity of care affects on-call midwives in various ways (Todd et al., 1998; Fereday and Oster, 2009).
Midwives’ experience of continuity of care Midwives have long been responsible for care during pregnancy and during and after childbirth for healthy women with normal pregnancies (Swedish Midwives Association, 1995). Most midwives providing one-to-one continuity of care find that the on-call shifts are more flexible and appropriate than working standard shifts (Page, 2003). However, Sandall (1997) noted that both frequency and length of on-call are major causes of occupational stress. Although midwives providing continuity of care are reported as experiencing increased autonomy and job satisfaction (Walker et al., 2004), this also causes problem for the midwives overcommitting and exhausting themselves (Todd et al., 1998), and often comes at a cost to their personal lives (Sandall, 1995, 1997; Stevens and McCourt, 2002), due to either needing to be continuously available or providing long on-call cover (Todd et al., 1998). The studies of Shallow (2001) and Sandall (1997) demonstrated that stress and frustration were acknowledged by midwives and attributed to their inability to develop meaningful relationships with the women for whom they cared. A major source of satisfaction for midwives comes from their relationships with women (Stevens and McCourt, 2002). However, the increased workload with higher demands, more stressful working environment, and lack of time and human resources all contribute to less job satisfaction and little energy to engage in caring, which makes the work more serious and less enjoyable compared with when the midwives worked more closely together. Therefore, there is a need to develop systems of care that will protect against burnout of care providers (Weaver et al., 2005), and a need for shared governance to allow midwives to meet both organisational and professional goals (Walker et al., 2004).
Maternity health care is an obstetrician-led model in China. Cheung (2009) noted that the demise of Chinese midwifery resulted from the belief that obstetricians were better trained and safer practitioners than midwives. The only midwives employed are those who work in labour and delivery rooms in hospitals, most of whom are nurses learning on the job (Cheung et al., 2009). A Chinese midwife usually provides one-to-one care during labour (Cheung et al., 2005), while obstetricians are involved in pregnancy. Hence, the model of one-to-one continuity of care provided by midwives in our study commenced from the onset of labour until two hours post partum. This gives rise to questions about how Chinese midwives provide midwifery care to women, and we consider it important to understand and describe midwives’ experiences of carrying out continuity of care of labouring women in the Chinese context. Aim The aim of this study was to explore and describe midwives’ experiences of providing continuity of care to labouring women in the city of Shanghai in China.
Methods This study is qualitative with a phenomenological approach. Phenomenology is a philosophy and a method, which stresses the importance of describing and understanding human experience as it is lived, before theorising (Husserl, 1970). The object of research based on Husserl’s ideas is the ‘phenomenon’ or the ‘experience of a phenomenon’ (Paley, 1997). The emphasis is on how individuals make sense of their own world, how these definitions are shared, and how actors create that world. Crucial in lifeworld research is openness (Husserl, 1970). It includes the researcher’s true willingness to listen, see and understand, and involves respect and humility, as well as sensibility and flexibility towards the phenomena. The pivotal move in Husserl’s philosophy is the phenomenological reduction, a procedure associated with ‘bracketing’ (Paley, 1997), which means an initial ‘suspension of belief’ in the ‘outer world’ (Koch, 1995). The researcher should be conscious about their pre-understanding in order to restrain it during the whole research process, from data collection to formulation of findings. The primary interest in lifeworld research is not the persons as informants, but the phenomena itself (Dahlberg et al., 2001). In China, there is a dearth of research using the phenomenological method. Hence, our study used the Husserlian phenomenological approach to describe and understand Chinese midwives’ experiences of providing continuity of care to labouring women. Setting This study was carried out in the labour unit of Fudan University Obstetrics and Gynaecology Hospital, Shanghai, China. The hospital is a specialised teaching hospital in China. There are 12 wards with 370 beds, including departments of gynaecology, obstetrics, family planning, traditional Chinese medicine combined with Western medicine and neonatology. The number of births is about 6000 per year. The midwives usually work in the labour and delivery rooms and their roles are to provide labour care and to conduct normal spontaneous births. In an attempt to improve women’s experience of care during labour and childbirth, we have implemented a model of one-toone continuity of care, which refers to continuous care and
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support by an on-call midwife from the onset of labour to two hours post partum. ‘One-to-one care’ here means that each midwife cares for one woman in labour. When the woman’s cervix is two centimetres dilated, with contractions occurring five to six minutes apart, we describe it as the onset of labour. Each woman has a chance of getting continuity of care by midwives. The midwives’ flexible working pattern or on-call system is quite different from eight-hour shifts. When the duty rota is made up by the head midwife, some midwives are assigned to flexible work and others to shifts. The two jobs are interchangeable so that on-call midwives are on eight-hour shifts and shift midwives are on-call every three months. A midwife working the normal shift pattern works 40 hours per week and 176 hours per month, whereas an on-call midwife works irregularly and flexibly, and her working hours depend on the workload. If she works more than 176 hours per month, the additional work time will be her extra days off. If less than 176 hours, she will have to work more or have her relevant days off deducted. In addition, the on-call midwife who performs well in providing midwifery care and gets most votes can be given the title of ‘Star Midwife’ and receives a bonus, which aims to increase midwives’ job satisfaction. Ethical considerations and access Ethical approval was obtained by the Research Committee of the Obstetrics and Gynaecology Hospital, Fudan University. Access to undertake the study was given by the Head of the Labour Unit from which the participants were to be recruited. All potential participants were given an information sheet explaining the purpose of the study. They were informed that they had the right to decline to participate, and that if they agreed to participate, they could subsequently withdraw from the study. All those agreeing to participate were asked to sign a form agreeing to take part.
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researchers need to make inferences from the data at all stages: the formulation of meanings, the devising of categories, and the proposal of an essential structure. First, the field notes and the participants’ transcripts were read to acquire an overall feeling for their ideas in order to understand them. Second, each transcript was re-read looking for meaningful themes. The next step included organisation of the themes into clusters by relating them to each other and looking for the common constituents. In order to maintain the openness to the phenomenon as a whole, and to gain a valid description, the researchers went back again and again to the original text. The clusters were summarised in a structure that consisted of an essence described through constituents and validated by quotations. Finally, the researchers returned to the participants for a validation of the findings. Each participant was encouraged to give feedback on whether the description of the data was accurate. All participants responded that the data did describe their experiences as reported. The findings were translated into English by an independent bilingual researcher. The translations were then proofread by another bilingual researcher and were finally validated by a professor whose native language was English.
Findings In this study, the interviewees were all women aged between 24 and 32 years. Their experience as midwives ranged from three to eight years. Four of them were junior midwives and eight of them were senior midwives. Their education varied from junior college to university education. The findings were described using two main categories: midwives’ feelings on providing continuity of care; and the impact of the on-call system on midwives providing continuity of care. Participants’ quotations were used to illustrate the text and codes were used to maintain anonymity. The quotations were translated into English for the purpose of publication.
Sample Midwives’ feelings on providing continuity of care Purposive sampling was undertaken to ensure the recruitment of a wide range of midwives of diverse ages, with different levels of experience and education. Participation in the study were voluntary. We recruited 15 midwives and the final sample size was 12. As data redundancy was occurring and no new information was forthcoming after the twelfth interview, data saturation was achieved and there was no need to recruit more midwives. Data collection Open-ended interviews were conducted with the 12 midwives. The interviews were tape-recorded and began with an open question: ‘Can you describe your experience of providing continuity of care to labouring women?’ Probing questions, such as ‘Can you tell me more? What do you mean?’ were used. Participants’ expressions and emotions were also noted by the interviewer. The length of the interviews varied between 50 and 70 minutes. The interviews were conducted in Mandarin. Field notes were taken to facilitate the analysis. Data analysis Each interview was transcribed verbatim. Field notes and transcribed data from interviews were analysed by the interviewers, using phenomenological analysis based on principles described by Dahlberg et al. (2001). According to Paley (1997), the
In this section, we describe what midwives did and how they felt and coped with the situation in which they provided continuity of care. Playing important roles in labour care Unlike the shift midwife providing discontinuous and ‘onemidwife-to-many-women’ care, the on-call midwife provided one-to-one care for women from the onset of labour to two hours post partum, which is the process of being with women. During this process, the midwife became an important person who was accessible and of great help to the woman. She played the role as a labour coach providing continuous encouragement: yI often teach woman how to use breathing techniques to relieve their pain during different labour stages. As their labour coach, I am responsible for encouraging them continuously. After all, they need me so much at that time. (Midwife 7) Also the midwife acted as a friend of the labouring woman. She was always ready to listen to the woman’s feelings and complaints, and then inform and explain to the woman and her partner about the labour progress, and developed a close rapport with her clients: ythe woman could not tolerate the labour pain and wanted to have a caesarean section. I told her that she should have more
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patience, and that everything was going well. Then she calmed down slowly and finally had a natural birthy. And now her baby girl is three years old and we still have contact with each other. (Midwife 5) Gaining a sense of self-achievement The midwives spent much more time caring for individual mothers when they provided continuity of care. They gained a sense of self-achievement during the caring process of being with the mother. Their commitment to midwifery care enabled them to form a strong sense of responsibility: as a professional midwife, I just become more and more cautious. It is my duty to be a good caregiver to the mother and I should give her the best care. (Midwife 10)
I had been with her for 10 hours when she was eight centimetres dilated and the doctor ordered a caesarean section due to her baby’s malposition. Then the partner complained, ‘we would have chosen a caesarean section if I had known this. Now my wife has suffered from much more pain’. yHearing this, I felt misunderstood and so downheartened. (Midwife 10) The midwives also reported their feelings of frustration and stress when the women and their partners had a distrust of them: Sometimes they do not trust you. Thinking of you as a little nurse-midwife, they prefer to search for the doctor’s advicey they regard him/her as a person of authority. Then I feel that my efforts are in vain, only with an exhausted body left. (Midwife 6) Coping with caring work
Participants reported that women achieving a normal birth and their words of gratitude were factors that might influence the midwives’ working enthusiasm and motivation. As one midwife identified: when the woman eventually delivered a healthy baby after suffering intense contractions, I felt very excited, pleased and full of successy. (Midwife 3) The midwives reported feelings of achievement and honour after being chosen as the ‘Star Midwife’:
The midwives could run into a variety of problems and difficulties as they provided continuity of care. They described feelings of exhaustion or burnout in their working process of being with women. However, they had actively developed a series of coping strategies to relieve their stress. They searched for support from their husbands, parents, sisters, friends and colleagues. Having a good rest, taking a walk, listening to music and going travelling are ways of relaxation for them to achieve a balance between life and work:
I got the most votes on one occasion and was elected as ‘Star Midwife’, from which I gained more self-confidence. (Midwife 8)
After returning home from work, I always go to bed for a good rest. Sometimes I have a chat with my friends. Sometimes I like to go travelling in my leisure time. (Midwife 1)
The midwives indicated that they had greatly improved some midwifery skills when being with the women, such as theoretical and practical knowledge, midwifery techniques and communication skills:
Good collaboration is quite essential among the midwives providing continuity of care during the ‘on-call’ month. As one midwife stated:
although the work is demanding and laborious, I have really learned many thingsy For instance, I just become more and more experienced in communicating with the woman and her partner. The job is very challenging. (Midwife 12)
If one of us cannot arrive at the hospital on time, another one will come instead of her. And we co-operate well and keep in good order, I think. (Midwife 6)
Falling into exhaustion and frustration The midwives providing continuity of care did not have fixed working hours and all participants had experience of working continuously for 16 hours or so. They described their feelings of fatigue and lack of sleep when being with women. The woman did have poor contractions and made slow progressy. I accompanied her for nearly 14 hours without any rest or sleep. At that time, I just felt like a working machine.... (Midwife 9) Participants emphasised that shift work and heavy workloads also caused their exhaustion, but they had to guarantee the quality of care for the women they accompanied: yyou must be together with the woman. You need to talk to her, comfort her, examine cervical dilation and observe the total labour stagey and sometimes you have to provide care to labouring women one after another. The work is quite demanding and tiring, especially during these baby boom years. (Midwife 5) When being with women, some midwives encountered those who made only a little progress, or those who finally gave birth by caesarean section. Some of these women or their partners misunderstood or complained about their midwife:
Impact of on-call system upon midwives providing continuity of care In this section, we describe the impact of the on-call system upon midwives, and the strategies that midwives have developed to acclimatise themselves to being on-call. ‘On-call syndrome’ The midwives had to be available for on-call work for one month, which, to some extent, led to their ‘on-call syndrome’. They had various emotions or sentiments caused by the on-call hours during the ‘special month’. Some of the participants displayed their ‘normal’ or ‘calm’ feelings when their head midwife made the duty rota of providing continuity of care: yI think this is a routine work and my profession. I have already got used to it. (Midwife 12) Others had emotional fluctuations such as passiveness or complaining. As one of them indicated: usually I am rostered to the on-call shift every three months, and I know when it is my turn. But each time I just wish it would never come to my turny the work is really demanding. (Midwife 5)
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Participants also emphasised their feelings of anxiety, uncertainty and anticipation when being on-call. They did not know when they would be called into work, and were unable to switch off their mobile phones at night. They described the wish of not being called late at night: It is possible to be called at any time. When I know I will be the next one to go to work, I can hardly fall asleepy if only there was no on-call shift late at night. (Midwife 11) yI could easily have choice and control over my working life when I used to work eight-hour shiftsy But now, it is difficult for me to arrange anything beforehand when on-call. (Midwife 5) Affecting personal lives The midwives’ on-call work and flexible working hours depended on women’s uncertain labour onset and individual differences, which had a significant impact on their personal and family lives and social activities. For example, the work affected their chances of receiving continuing education: I attend correspondence courses twice a week, but often miss them when being called into work. After getting home, I just feel too tired to concentrate on my studyy. (Midwife 9) The midwives also described their family members as the oncall shift-related victims: yMy husband is always worried about me, especially when I get to work at night. Sometimes he just takes me to my workplace, which actually affects his own life and worky Very often, when we are sleeping at mid night, a sudden ringing of the telephone wakes up all the kids, my poor victims. (Midwife 4) The midwives’ social activities were greatly limited during the on-call month. As one of them said: ysometimes I have a date with my friends but have to cancel it and go to work once the hospital phones me. When going shopping outside, I repeatedly check my mobile phone in case I have missed a call. (Midwife 2) Managing on-call shift The midwives reported that working flexible hours and on-call differed greatly from working eight-hour shifts. They also indicated that adapting themselves to on-call work was the premise of providing continuity of care, and they were able to develop several ways to achieve a work–life balance: at first, I felt anxious when being on-call. Later on, I just made self-adjustments and considered it routine worky, then I got used to it and reached a balance between work and life. (Midwife 4) The midwives emphasised the importance of trying to utilise the on-call shift to make it more flexible: the thing is you should get ready for the job. Once you manage it properly, you will find it less awful than you have imaginedy. After that, you can adapt yourselves to the whole process of work. Actually it can be flexible for both you and the woman you are with if you have good time management. (Midwife 2)
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Discussion A limitation of the study was the lack of midwives’ contact with women in pregnancy, which was due to the maternity care model in China and lack of midwifery resources. Any generalisation of the study findings should be handled with caution. However, the findings are richly described to allow the reader to determine the transferability of this phenomenon to other contexts. They may be relevant for other units with a similar way of interpreting and practising continuity of care. The findings do reflect the voices of the participants. It is considered important to study the midwives’ experience of providing continuity of care and the impact of an on-call system on them. The findings are discussed using the two main categories: midwives’ feelings on providing continuity of care; and the impact of the on-call system on midwives. The midwives’ experience of providing continuity of care can be interpreted as feelings of being with women and adaptation to being on-call, which is the essence of this study.
Midwives’ feelings on providing continuity of care The midwives in this study described providing continuity of care as a process of being with women, consisting of continuous presence, reassurance, encouragement and praise, in agreement with Blaaka and Eri (2008). On the one hand, during this process, the midwives spent much time with women, playing important roles in supporting and coaching, obtaining a sense of selfachievement in midwifery skills, and forming a strong sense of responsibility. The midwives also developed a close rapport with the women through positive interactions. These findings are supported by other studies and show that midwives gain confidence, interaction with women, and job satisfaction when providing one-to-one continuity of care (Flint and Poulengeris, 1987; Watson et al., 1999; Page, 2003; Walker et al., 2004). On the other hand, exhaustion was mentioned by midwives in this study as one of the negative aspects of being with women. This might be caused by the long length of labour, the uncertainty of labour stage, demanding workload, and an inability to develop meaningful relationships with the woman and the doctor. This is in agreement with Blaaka and Eris (2008) statement that being with women in the birth situation demands presence, continuity and time, and requires dealing with certainty and uncertainty, which can influence the attitudes of the midwives. In addition, the midwives spent quite a long time with labouring women, and described feelings of fatigue and lack of sleep. They also expressed stress and frustration during the process of continuity of care, as reported by Sandall (1997). As Janssen and Nachreiner (2004) note in their study, high variability of working hours is associated with increased impairments in health and well-being, and the flexible hours should be controlled to reduce the adverse effects on employees. In this study, misunderstanding and distrust from the women and their partners caused the midwives stress and frustration. Larsson et al. (2009) also mentioned that lack of trust in the normal birth process among women affected midwives. The fact that the Chinese maternity care system is an obstetrician-led model and midwifery is historically regarded as a second-class occupation (Cheung, 2009) might be the root cause. It can possibly explain the reason why doctors in China provide antenatal examinations to women, whilst midwives only work in labour rooms as nurse–midwives, and why the model of continuity of care is restricted to the labour and childbirth period. Therefore, it is important for managers to build up a better support system for midwives to enhance their positive feelings of being with women. As Hood et al. (2009) state, strong clinical midwifery leadership is
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needed to support midwives’ practice and to foster midwifery-led decision making.
Impact of on-call system upon midwives In this study, the midwives’ work requires rotating shifts, on-call, continuous presence and commitment. They indicated feelings of anxiety, anticipation and uncertainty when being on-call, which is supported by other research studies (Sandall, 1997; Fereday and Oster, 2009). As Page (2003) states, the provision of true continuity of carer is difficult to achieve in maternity services, where most midwives have become accustomed to working shifts. Midwives in this study expressed their wish not to be called at night, as providing continuity of care under an on-call system, especially night calls, impacted upon them. Other research has also demonstrated that midwives dislike the long on-call shifts and unsociable hours (Todd et al., 1998), and that midwives need to know that they are not on-call so they can relax and enjoy themselves (Fereday and Oster, 2009). Despite the impact of the on-call system upon midwives, the participants were capable of developing different kinds of coping strategies to manage the on-call system and flexible working hours.
Coping and adaptation to being on-call Adaptation to being on-call has been described by midwives as the premise of being with women and providing high-quality care, which is the essence of this study. The study identified that individual adjustment, family, social and occupational support, and team collaborations are various ways in which midwives can enable themselves to cope with stress, and acclimatise to the on-call system. These points support the work of other researchers (Caelli et al., 2003; Smith et al., 2006; Fereday and Oster, 2009). The participants reported that the on-call system has, to some extent, limited their choice and control over their life compared with the eight-hour standard shifts. Having choice and control over one’s working life is one way in which midwives and nurses can better achieve a work–life balance (Gray, 2004; Pryce et al., 2006). Midwives and nurses are also reportedly experiencing stress and burnout as a result of difficulties balancing their working and personal lives (Smith et al., 2006; Pryjmachuk and Richards, 2007). Therefore, it is essential to develop ‘flexibility’ under the on-call system, not only for the women who receive individualised continuity of care, but also for the midwives to arrange working hours to suit their family and other social activities (Fereday and Oster, 2009). Also it appears that occupational support from managers can better facilitate the management of the on-call system and flexible working patterns, thus meeting the needs of both labouring women and the midwives, and improving the work–life balance as well. Support and structure within the team environment are further elements of occupational support that facilitate the effective management of flexibility and time on-call (Fereday and Oster, 2009). The support may include re-arrangement of the duty rota according to the midwives’ individual requirements, allowing them to be more involved in the planning of shifts and the on-call system; and also the establishment of an incentive mechanism such as electing a ‘Star Midwife’ who provides high-quality care to labouring women. This modality of motivation aims to reduce midwives’ stress and burnout, and to increase their job satisfaction. Accordingly, the midwives can better adapt themselves to the on-call system and flexible working hours.
Conclusion and implications for practice This study used a qualitative research method to explore in depth the Chinese midwives’ experience of providing continuity of care to labouring women. Midwives expressed mixed feelings of being with women, and described their adaptive strategies to the on-call system, which is the most important finding of this study. There is great value in the process of providing continuity of care, both for the women who receive the care and for the midwives who provide the care. It may also facilitate other professional midwives working in a similar situation. Meanwhile, the findings indicate that the midwife participants in this study presented with ‘on-call syndrome’ and some negative perceptions of exhaustion and stress when working the on-call system and providing continuous care. Therefore, leadership is needed to support midwives’ practice and it may be necessary for managers to develop new approaches to the organisation and provision of continuity of care, and to fully utilise ‘flexibility’ under the on-call system, which is worthy of further study.
Acknowledgement This study was funded by grants from the Nursing School of Fudan University, Shanghai, China. Thanks to all those midwives who took part in the interviews. The authors would sincerely like to acknowledge the help of Professor Ingalill Rahm Hallberg, Director of the Swedish Institute for Health Care Sciences, and Ann M. Thomson, Professor of Midwifery, University of Manchester. References Blaaka, G., Eri, T.S., 2008. Doing midwifery between different belief systems. Midwifery 24, 344–352. Caelli, K., Downie, J., Letendre, A., 2003. Parents’ experiences of midwife-managed care following the loss of a baby in a previous pregnancy. Journal of Advanced Nursing 39, 127–136. Cheung, N.F., Mander, R., Cheng, L., 2005. The ‘doula-midwives’ in Shanghai. Evidence Based Midwifery 3, 73–79. Cheung, N.F., 2009. Chinese midwifery: the history and modernity. Midwifery 25, 228–241. Cheung, N.F., Mander, R., Wang, X.L., et al., 2009. Chinese midwives’ views on a proposed midwife-led normal birth unit. Midwifery, doi:10.1016/ j.midw.2008.01.009. (accessed 14 March 2008). Dahlberg, K., Drew, N., Nystro¨m, M., 2001. Reflective Lifeworld Research. Studentlitteratur, Lund, 259pp. Department of Health Expert Maternity Group, 1993. Changing Childbirth. Department of Health HMSO, London. Farquhar, M., Camilleri-Ferrante, C., Todd, C., 2000. Continuity of care in maternity services: women’s views of one team midwifery scheme. Midwifery 16, 35–47. Fereday, J., Oster, C., 2009. Managing a work–life balance: the experiences of midwives working in a group practice setting. Midwifery, doi:10.1016/ j.midw.2008.06.004. (accessed 23 August 2008). Flint, C., Poulengeris, P., 1987. The ‘Know Your Midwife’ Report. South West Thames Regional Health Authority and the Wellington Foundation, London. Freeman, L.M., 2006. Continuity of carer and partnership: a review of the literature. Women and Birth 19, 39–44. Gray, J., 2004. The answer is out there. Nursing Standard 18, 3. Hodnett, E.D., Gates, S., Hofmeyr, G.J., et al. 2007. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews CD003766. doi:10.1002/14651858.CD003766.pub2. Homer, C.S.E., Davis, G.K., Cooke, M., et al., 2002. Women’s experiences of continuity of midwifery car in a randomised controlled trial in Australia. Midwifery 18, 102–112. Hood, L., Fenwick, J., Butt, J., 2009. A story of scrutiny and fear: Australian midwives’ experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice. Midwifery, doi:10.1016/j.midw.2008.07.008. (accessed 19 September 2008). Hundley, V.A., Cruickshank, F.M., Glazener, C.M., et al., 1995. Satisfaction and continuity of care: staff views of care in a midwife managed delivery unit. Midwifery 11, 163–173. Husserl, E., 1970. The Crisis of the European Sciences and Transcendental Phenomenology. An Introduction to Phenomenological Philosophy, Translated by D. Carr. Northwestern University Press, Evanston, IL, 405pp. Janssen, D., Nachreiner, F., 2004. Health and psychosocial effects of flexible working hours. Rev Saude Publica 38, 11–18.
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Chinese midwives’ experience of providing continuity of care to labouring women Chunyi Gu, RNM, BScN (Clinical Midwifery Supervisor)a,, Zheng Zhang, RNM (Head Midwife)a, Yan Ding, RN, MScN (Director and Research Supervisor)b a b
Labour Unit, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China Nursing Department, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
a r t i c l e in fo
abstract
Article history: Received 28 March 2009 Received in revised form 8 June 2009 Accepted 14 June 2009
Objective: to explore and describe Chinese midwives’ experience of providing one-to-one continuity of care to labouring women. Design: a qualitative study using a phenomenological approach. Data were collected using open-ended, tape-recorded interviews. The analysis of the transcribed texts included searching for themes sorted into clusters for a final expression of the essential structure of the phenomenon. Setting: Obstetrics and gynaecology hospital of Fudan University, Shanghai, China. Participants: 12 midwives, providing one-to-one continuity of care to labouring women. Findings: two main categories were identified: (1) midwives’ feelings on providing continuity of care, and (2) impact of on-call system on midwives providing continuity of care. Key themes emerged from each main category: (1) ‘playing important roles in labour care’, ‘gaining a sense of self-achievement’, ‘falling into exhaustion and frustration’ and ‘coping with caring work’; and (2) ‘on-call syndrome’, ‘affecting personal lives’ and ‘managing on-call shift’. The midwives experienced mixed feelings of being with women and expressed their adaptation to being on-call, which was the essence of this study. They played important roles in caring for women, gained a sense of self-achievement and developed suitable coping strategies. However, they also indicated the impact of the on-call system upon them in the process of providing continuity of care. Conclusion and implications for practice: midwives have gained both positive and negative experiences when providing continuity of care to labouring women. The positive aspects may facilitate other professional midwives working in a similar role, whereas the negative aspects may inform them of learning to live with this situation, and may also have implications for managers to develop new approaches to the organisation and provision of continuity of care to support midwives’ practice, and to fully utilise ‘flexibility’ under an on-call system. & 2009 Elsevier Ltd. All rights reserved.
Keywords: Midwives One-to-one midwifery Continuity of care On-call system Phenomenology
Introduction Childbirth is a complex life event characterised by rapid biological, social and emotional transitions (Blaaka and Eri, 2008). Caring for birthing women as a unique life event is the core of the midwifery profession. Policy in the United Kingdom has recommended the establishment of models of care that provide continuity of care (Department of Health Expert Maternity Group, 1993). Concurrently, women’s experience of continuity of care has been studied in various countries. To our knowledge, only a limited number of studies have focused on midwives’ views, perceptions and experience in terms of continuity of care. This
Corresponding author.
E-mail address: [email protected] (C. Gu). 0266-6138/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2009.06.007
study explores and describes midwives’ experience of providing continuity of care to labouring women in the Chinese context.
Literature review One-to-one midwifery and continuity of care In order to provide woman- and family-centred care, one-toone midwifery practice was developed as a demonstration project to put the principles of ‘Changing Childbirth’ into practice (Page et al., 1998). The term ‘one-to-one’ illustrated the concept of continuity of caregiver (Page et al., 1998). Continuity of care and carer are important determinants of a positive experience (Page et al., 2000). The definition and scope of continuity of care differ in various research and settings. Some have interpreted it as a shared
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philosophy of care (continuity of caring), whilst others view it as the provision of care by a known carer or a small team of midwives throughout the childbirth experience (continuity of carer) (Hundley et al., 1995). There have been different models of continuity of care implemented in midwifery practice. The midwives in such schemes provide the majority of care for women in their caseload, throughout the entire pregnancy, labour, birth and postpartum period, which can achieve a high degree of continuity of care (Page et al., 1999; Homer et al., 2002). The midwives are on-call to provide care during labour. ‘Being on-call’ is regarded as ‘being ready to go to work’ or ‘being available for work if needed’ (Wiegers, 2007). This present article focuses on a new model of continuity of care, which refers to continuous support and care by an on-call midwife from the onset of labour to two hours post partum. Different ways of providing continuity of care can have their pros and cons. Continuous support during labour facilitates birth, enhances the mother’s memory of the experience, reduces many forms of medical intervention (Pascali-Bonaro and Kroeger, 2004), and helps women to form a relationship with their midwives (Farquhar et al., 2000). Women who had continuous intrapartum support were likely to have a slightly shorter labour and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences (Hodnett et al., 2007). Midwives providing continuity of care will also build a better support system (Kirkham, 2000). However, according to Morgan et al. (1998) and Freeman (2006), continuity of carer is not a clear predictor of women’s satisfaction, and women do not focus on the model of care provided, but on the content of the care provided. Meanwhile, providing continuity of care affects on-call midwives in various ways (Todd et al., 1998; Fereday and Oster, 2009).
Midwives’ experience of continuity of care Midwives have long been responsible for care during pregnancy and during and after childbirth for healthy women with normal pregnancies (Swedish Midwives Association, 1995). Most midwives providing one-to-one continuity of care find that the on-call shifts are more flexible and appropriate than working standard shifts (Page, 2003). However, Sandall (1997) noted that both frequency and length of on-call are major causes of occupational stress. Although midwives providing continuity of care are reported as experiencing increased autonomy and job satisfaction (Walker et al., 2004), this also causes problem for the midwives overcommitting and exhausting themselves (Todd et al., 1998), and often comes at a cost to their personal lives (Sandall, 1995, 1997; Stevens and McCourt, 2002), due to either needing to be continuously available or providing long on-call cover (Todd et al., 1998). The studies of Shallow (2001) and Sandall (1997) demonstrated that stress and frustration were acknowledged by midwives and attributed to their inability to develop meaningful relationships with the women for whom they cared. A major source of satisfaction for midwives comes from their relationships with women (Stevens and McCourt, 2002). However, the increased workload with higher demands, more stressful working environment, and lack of time and human resources all contribute to less job satisfaction and little energy to engage in caring, which makes the work more serious and less enjoyable compared with when the midwives worked more closely together. Therefore, there is a need to develop systems of care that will protect against burnout of care providers (Weaver et al., 2005), and a need for shared governance to allow midwives to meet both organisational and professional goals (Walker et al., 2004).
Maternity health care is an obstetrician-led model in China. Cheung (2009) noted that the demise of Chinese midwifery resulted from the belief that obstetricians were better trained and safer practitioners than midwives. The only midwives employed are those who work in labour and delivery rooms in hospitals, most of whom are nurses learning on the job (Cheung et al., 2009). A Chinese midwife usually provides one-to-one care during labour (Cheung et al., 2005), while obstetricians are involved in pregnancy. Hence, the model of one-to-one continuity of care provided by midwives in our study commenced from the onset of labour until two hours post partum. This gives rise to questions about how Chinese midwives provide midwifery care to women, and we consider it important to understand and describe midwives’ experiences of carrying out continuity of care of labouring women in the Chinese context. Aim The aim of this study was to explore and describe midwives’ experiences of providing continuity of care to labouring women in the city of Shanghai in China.
Methods This study is qualitative with a phenomenological approach. Phenomenology is a philosophy and a method, which stresses the importance of describing and understanding human experience as it is lived, before theorising (Husserl, 1970). The object of research based on Husserl’s ideas is the ‘phenomenon’ or the ‘experience of a phenomenon’ (Paley, 1997). The emphasis is on how individuals make sense of their own world, how these definitions are shared, and how actors create that world. Crucial in lifeworld research is openness (Husserl, 1970). It includes the researcher’s true willingness to listen, see and understand, and involves respect and humility, as well as sensibility and flexibility towards the phenomena. The pivotal move in Husserl’s philosophy is the phenomenological reduction, a procedure associated with ‘bracketing’ (Paley, 1997), which means an initial ‘suspension of belief’ in the ‘outer world’ (Koch, 1995). The researcher should be conscious about their pre-understanding in order to restrain it during the whole research process, from data collection to formulation of findings. The primary interest in lifeworld research is not the persons as informants, but the phenomena itself (Dahlberg et al., 2001). In China, there is a dearth of research using the phenomenological method. Hence, our study used the Husserlian phenomenological approach to describe and understand Chinese midwives’ experiences of providing continuity of care to labouring women. Setting This study was carried out in the labour unit of Fudan University Obstetrics and Gynaecology Hospital, Shanghai, China. The hospital is a specialised teaching hospital in China. There are 12 wards with 370 beds, including departments of gynaecology, obstetrics, family planning, traditional Chinese medicine combined with Western medicine and neonatology. The number of births is about 6000 per year. The midwives usually work in the labour and delivery rooms and their roles are to provide labour care and to conduct normal spontaneous births. In an attempt to improve women’s experience of care during labour and childbirth, we have implemented a model of one-toone continuity of care, which refers to continuous care and
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support by an on-call midwife from the onset of labour to two hours post partum. ‘One-to-one care’ here means that each midwife cares for one woman in labour. When the woman’s cervix is two centimetres dilated, with contractions occurring five to six minutes apart, we describe it as the onset of labour. Each woman has a chance of getting continuity of care by midwives. The midwives’ flexible working pattern or on-call system is quite different from eight-hour shifts. When the duty rota is made up by the head midwife, some midwives are assigned to flexible work and others to shifts. The two jobs are interchangeable so that on-call midwives are on eight-hour shifts and shift midwives are on-call every three months. A midwife working the normal shift pattern works 40 hours per week and 176 hours per month, whereas an on-call midwife works irregularly and flexibly, and her working hours depend on the workload. If she works more than 176 hours per month, the additional work time will be her extra days off. If less than 176 hours, she will have to work more or have her relevant days off deducted. In addition, the on-call midwife who performs well in providing midwifery care and gets most votes can be given the title of ‘Star Midwife’ and receives a bonus, which aims to increase midwives’ job satisfaction. Ethical considerations and access Ethical approval was obtained by the Research Committee of the Obstetrics and Gynaecology Hospital, Fudan University. Access to undertake the study was given by the Head of the Labour Unit from which the participants were to be recruited. All potential participants were given an information sheet explaining the purpose of the study. They were informed that they had the right to decline to participate, and that if they agreed to participate, they could subsequently withdraw from the study. All those agreeing to participate were asked to sign a form agreeing to take part.
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researchers need to make inferences from the data at all stages: the formulation of meanings, the devising of categories, and the proposal of an essential structure. First, the field notes and the participants’ transcripts were read to acquire an overall feeling for their ideas in order to understand them. Second, each transcript was re-read looking for meaningful themes. The next step included organisation of the themes into clusters by relating them to each other and looking for the common constituents. In order to maintain the openness to the phenomenon as a whole, and to gain a valid description, the researchers went back again and again to the original text. The clusters were summarised in a structure that consisted of an essence described through constituents and validated by quotations. Finally, the researchers returned to the participants for a validation of the findings. Each participant was encouraged to give feedback on whether the description of the data was accurate. All participants responded that the data did describe their experiences as reported. The findings were translated into English by an independent bilingual researcher. The translations were then proofread by another bilingual researcher and were finally validated by a professor whose native language was English.
Findings In this study, the interviewees were all women aged between 24 and 32 years. Their experience as midwives ranged from three to eight years. Four of them were junior midwives and eight of them were senior midwives. Their education varied from junior college to university education. The findings were described using two main categories: midwives’ feelings on providing continuity of care; and the impact of the on-call system on midwives providing continuity of care. Participants’ quotations were used to illustrate the text and codes were used to maintain anonymity. The quotations were translated into English for the purpose of publication.
Sample Midwives’ feelings on providing continuity of care Purposive sampling was undertaken to ensure the recruitment of a wide range of midwives of diverse ages, with different levels of experience and education. Participation in the study were voluntary. We recruited 15 midwives and the final sample size was 12. As data redundancy was occurring and no new information was forthcoming after the twelfth interview, data saturation was achieved and there was no need to recruit more midwives. Data collection Open-ended interviews were conducted with the 12 midwives. The interviews were tape-recorded and began with an open question: ‘Can you describe your experience of providing continuity of care to labouring women?’ Probing questions, such as ‘Can you tell me more? What do you mean?’ were used. Participants’ expressions and emotions were also noted by the interviewer. The length of the interviews varied between 50 and 70 minutes. The interviews were conducted in Mandarin. Field notes were taken to facilitate the analysis. Data analysis Each interview was transcribed verbatim. Field notes and transcribed data from interviews were analysed by the interviewers, using phenomenological analysis based on principles described by Dahlberg et al. (2001). According to Paley (1997), the
In this section, we describe what midwives did and how they felt and coped with the situation in which they provided continuity of care. Playing important roles in labour care Unlike the shift midwife providing discontinuous and ‘onemidwife-to-many-women’ care, the on-call midwife provided one-to-one care for women from the onset of labour to two hours post partum, which is the process of being with women. During this process, the midwife became an important person who was accessible and of great help to the woman. She played the role as a labour coach providing continuous encouragement: yI often teach woman how to use breathing techniques to relieve their pain during different labour stages. As their labour coach, I am responsible for encouraging them continuously. After all, they need me so much at that time. (Midwife 7) Also the midwife acted as a friend of the labouring woman. She was always ready to listen to the woman’s feelings and complaints, and then inform and explain to the woman and her partner about the labour progress, and developed a close rapport with her clients: ythe woman could not tolerate the labour pain and wanted to have a caesarean section. I told her that she should have more
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patience, and that everything was going well. Then she calmed down slowly and finally had a natural birthy. And now her baby girl is three years old and we still have contact with each other. (Midwife 5) Gaining a sense of self-achievement The midwives spent much more time caring for individual mothers when they provided continuity of care. They gained a sense of self-achievement during the caring process of being with the mother. Their commitment to midwifery care enabled them to form a strong sense of responsibility: as a professional midwife, I just become more and more cautious. It is my duty to be a good caregiver to the mother and I should give her the best care. (Midwife 10)
I had been with her for 10 hours when she was eight centimetres dilated and the doctor ordered a caesarean section due to her baby’s malposition. Then the partner complained, ‘we would have chosen a caesarean section if I had known this. Now my wife has suffered from much more pain’. yHearing this, I felt misunderstood and so downheartened. (Midwife 10) The midwives also reported their feelings of frustration and stress when the women and their partners had a distrust of them: Sometimes they do not trust you. Thinking of you as a little nurse-midwife, they prefer to search for the doctor’s advicey they regard him/her as a person of authority. Then I feel that my efforts are in vain, only with an exhausted body left. (Midwife 6) Coping with caring work
Participants reported that women achieving a normal birth and their words of gratitude were factors that might influence the midwives’ working enthusiasm and motivation. As one midwife identified: when the woman eventually delivered a healthy baby after suffering intense contractions, I felt very excited, pleased and full of successy. (Midwife 3) The midwives reported feelings of achievement and honour after being chosen as the ‘Star Midwife’:
The midwives could run into a variety of problems and difficulties as they provided continuity of care. They described feelings of exhaustion or burnout in their working process of being with women. However, they had actively developed a series of coping strategies to relieve their stress. They searched for support from their husbands, parents, sisters, friends and colleagues. Having a good rest, taking a walk, listening to music and going travelling are ways of relaxation for them to achieve a balance between life and work:
I got the most votes on one occasion and was elected as ‘Star Midwife’, from which I gained more self-confidence. (Midwife 8)
After returning home from work, I always go to bed for a good rest. Sometimes I have a chat with my friends. Sometimes I like to go travelling in my leisure time. (Midwife 1)
The midwives indicated that they had greatly improved some midwifery skills when being with the women, such as theoretical and practical knowledge, midwifery techniques and communication skills:
Good collaboration is quite essential among the midwives providing continuity of care during the ‘on-call’ month. As one midwife stated:
although the work is demanding and laborious, I have really learned many thingsy For instance, I just become more and more experienced in communicating with the woman and her partner. The job is very challenging. (Midwife 12)
If one of us cannot arrive at the hospital on time, another one will come instead of her. And we co-operate well and keep in good order, I think. (Midwife 6)
Falling into exhaustion and frustration The midwives providing continuity of care did not have fixed working hours and all participants had experience of working continuously for 16 hours or so. They described their feelings of fatigue and lack of sleep when being with women. The woman did have poor contractions and made slow progressy. I accompanied her for nearly 14 hours without any rest or sleep. At that time, I just felt like a working machine.... (Midwife 9) Participants emphasised that shift work and heavy workloads also caused their exhaustion, but they had to guarantee the quality of care for the women they accompanied: yyou must be together with the woman. You need to talk to her, comfort her, examine cervical dilation and observe the total labour stagey and sometimes you have to provide care to labouring women one after another. The work is quite demanding and tiring, especially during these baby boom years. (Midwife 5) When being with women, some midwives encountered those who made only a little progress, or those who finally gave birth by caesarean section. Some of these women or their partners misunderstood or complained about their midwife:
Impact of on-call system upon midwives providing continuity of care In this section, we describe the impact of the on-call system upon midwives, and the strategies that midwives have developed to acclimatise themselves to being on-call. ‘On-call syndrome’ The midwives had to be available for on-call work for one month, which, to some extent, led to their ‘on-call syndrome’. They had various emotions or sentiments caused by the on-call hours during the ‘special month’. Some of the participants displayed their ‘normal’ or ‘calm’ feelings when their head midwife made the duty rota of providing continuity of care: yI think this is a routine work and my profession. I have already got used to it. (Midwife 12) Others had emotional fluctuations such as passiveness or complaining. As one of them indicated: usually I am rostered to the on-call shift every three months, and I know when it is my turn. But each time I just wish it would never come to my turny the work is really demanding. (Midwife 5)
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Participants also emphasised their feelings of anxiety, uncertainty and anticipation when being on-call. They did not know when they would be called into work, and were unable to switch off their mobile phones at night. They described the wish of not being called late at night: It is possible to be called at any time. When I know I will be the next one to go to work, I can hardly fall asleepy if only there was no on-call shift late at night. (Midwife 11) yI could easily have choice and control over my working life when I used to work eight-hour shiftsy But now, it is difficult for me to arrange anything beforehand when on-call. (Midwife 5) Affecting personal lives The midwives’ on-call work and flexible working hours depended on women’s uncertain labour onset and individual differences, which had a significant impact on their personal and family lives and social activities. For example, the work affected their chances of receiving continuing education: I attend correspondence courses twice a week, but often miss them when being called into work. After getting home, I just feel too tired to concentrate on my studyy. (Midwife 9) The midwives also described their family members as the oncall shift-related victims: yMy husband is always worried about me, especially when I get to work at night. Sometimes he just takes me to my workplace, which actually affects his own life and worky Very often, when we are sleeping at mid night, a sudden ringing of the telephone wakes up all the kids, my poor victims. (Midwife 4) The midwives’ social activities were greatly limited during the on-call month. As one of them said: ysometimes I have a date with my friends but have to cancel it and go to work once the hospital phones me. When going shopping outside, I repeatedly check my mobile phone in case I have missed a call. (Midwife 2) Managing on-call shift The midwives reported that working flexible hours and on-call differed greatly from working eight-hour shifts. They also indicated that adapting themselves to on-call work was the premise of providing continuity of care, and they were able to develop several ways to achieve a work–life balance: at first, I felt anxious when being on-call. Later on, I just made self-adjustments and considered it routine worky, then I got used to it and reached a balance between work and life. (Midwife 4) The midwives emphasised the importance of trying to utilise the on-call shift to make it more flexible: the thing is you should get ready for the job. Once you manage it properly, you will find it less awful than you have imaginedy. After that, you can adapt yourselves to the whole process of work. Actually it can be flexible for both you and the woman you are with if you have good time management. (Midwife 2)
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Discussion A limitation of the study was the lack of midwives’ contact with women in pregnancy, which was due to the maternity care model in China and lack of midwifery resources. Any generalisation of the study findings should be handled with caution. However, the findings are richly described to allow the reader to determine the transferability of this phenomenon to other contexts. They may be relevant for other units with a similar way of interpreting and practising continuity of care. The findings do reflect the voices of the participants. It is considered important to study the midwives’ experience of providing continuity of care and the impact of an on-call system on them. The findings are discussed using the two main categories: midwives’ feelings on providing continuity of care; and the impact of the on-call system on midwives. The midwives’ experience of providing continuity of care can be interpreted as feelings of being with women and adaptation to being on-call, which is the essence of this study.
Midwives’ feelings on providing continuity of care The midwives in this study described providing continuity of care as a process of being with women, consisting of continuous presence, reassurance, encouragement and praise, in agreement with Blaaka and Eri (2008). On the one hand, during this process, the midwives spent much time with women, playing important roles in supporting and coaching, obtaining a sense of selfachievement in midwifery skills, and forming a strong sense of responsibility. The midwives also developed a close rapport with the women through positive interactions. These findings are supported by other studies and show that midwives gain confidence, interaction with women, and job satisfaction when providing one-to-one continuity of care (Flint and Poulengeris, 1987; Watson et al., 1999; Page, 2003; Walker et al., 2004). On the other hand, exhaustion was mentioned by midwives in this study as one of the negative aspects of being with women. This might be caused by the long length of labour, the uncertainty of labour stage, demanding workload, and an inability to develop meaningful relationships with the woman and the doctor. This is in agreement with Blaaka and Eris (2008) statement that being with women in the birth situation demands presence, continuity and time, and requires dealing with certainty and uncertainty, which can influence the attitudes of the midwives. In addition, the midwives spent quite a long time with labouring women, and described feelings of fatigue and lack of sleep. They also expressed stress and frustration during the process of continuity of care, as reported by Sandall (1997). As Janssen and Nachreiner (2004) note in their study, high variability of working hours is associated with increased impairments in health and well-being, and the flexible hours should be controlled to reduce the adverse effects on employees. In this study, misunderstanding and distrust from the women and their partners caused the midwives stress and frustration. Larsson et al. (2009) also mentioned that lack of trust in the normal birth process among women affected midwives. The fact that the Chinese maternity care system is an obstetrician-led model and midwifery is historically regarded as a second-class occupation (Cheung, 2009) might be the root cause. It can possibly explain the reason why doctors in China provide antenatal examinations to women, whilst midwives only work in labour rooms as nurse–midwives, and why the model of continuity of care is restricted to the labour and childbirth period. Therefore, it is important for managers to build up a better support system for midwives to enhance their positive feelings of being with women. As Hood et al. (2009) state, strong clinical midwifery leadership is
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needed to support midwives’ practice and to foster midwifery-led decision making.
Impact of on-call system upon midwives In this study, the midwives’ work requires rotating shifts, on-call, continuous presence and commitment. They indicated feelings of anxiety, anticipation and uncertainty when being on-call, which is supported by other research studies (Sandall, 1997; Fereday and Oster, 2009). As Page (2003) states, the provision of true continuity of carer is difficult to achieve in maternity services, where most midwives have become accustomed to working shifts. Midwives in this study expressed their wish not to be called at night, as providing continuity of care under an on-call system, especially night calls, impacted upon them. Other research has also demonstrated that midwives dislike the long on-call shifts and unsociable hours (Todd et al., 1998), and that midwives need to know that they are not on-call so they can relax and enjoy themselves (Fereday and Oster, 2009). Despite the impact of the on-call system upon midwives, the participants were capable of developing different kinds of coping strategies to manage the on-call system and flexible working hours.
Coping and adaptation to being on-call Adaptation to being on-call has been described by midwives as the premise of being with women and providing high-quality care, which is the essence of this study. The study identified that individual adjustment, family, social and occupational support, and team collaborations are various ways in which midwives can enable themselves to cope with stress, and acclimatise to the on-call system. These points support the work of other researchers (Caelli et al., 2003; Smith et al., 2006; Fereday and Oster, 2009). The participants reported that the on-call system has, to some extent, limited their choice and control over their life compared with the eight-hour standard shifts. Having choice and control over one’s working life is one way in which midwives and nurses can better achieve a work–life balance (Gray, 2004; Pryce et al., 2006). Midwives and nurses are also reportedly experiencing stress and burnout as a result of difficulties balancing their working and personal lives (Smith et al., 2006; Pryjmachuk and Richards, 2007). Therefore, it is essential to develop ‘flexibility’ under the on-call system, not only for the women who receive individualised continuity of care, but also for the midwives to arrange working hours to suit their family and other social activities (Fereday and Oster, 2009). Also it appears that occupational support from managers can better facilitate the management of the on-call system and flexible working patterns, thus meeting the needs of both labouring women and the midwives, and improving the work–life balance as well. Support and structure within the team environment are further elements of occupational support that facilitate the effective management of flexibility and time on-call (Fereday and Oster, 2009). The support may include re-arrangement of the duty rota according to the midwives’ individual requirements, allowing them to be more involved in the planning of shifts and the on-call system; and also the establishment of an incentive mechanism such as electing a ‘Star Midwife’ who provides high-quality care to labouring women. This modality of motivation aims to reduce midwives’ stress and burnout, and to increase their job satisfaction. Accordingly, the midwives can better adapt themselves to the on-call system and flexible working hours.
Conclusion and implications for practice This study used a qualitative research method to explore in depth the Chinese midwives’ experience of providing continuity of care to labouring women. Midwives expressed mixed feelings of being with women, and described their adaptive strategies to the on-call system, which is the most important finding of this study. There is great value in the process of providing continuity of care, both for the women who receive the care and for the midwives who provide the care. It may also facilitate other professional midwives working in a similar situation. Meanwhile, the findings indicate that the midwife participants in this study presented with ‘on-call syndrome’ and some negative perceptions of exhaustion and stress when working the on-call system and providing continuous care. Therefore, leadership is needed to support midwives’ practice and it may be necessary for managers to develop new approaches to the organisation and provision of continuity of care, and to fully utilise ‘flexibility’ under the on-call system, which is worthy of further study.
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