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Glancing beyond or being confined to routines: Labour ward midwives' responses to change as a result of action research
Midwifery 29 (2013) 573–578
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Glancing beyond or being confined to routines: Labour ward midwives' responses to change as a result of action research Viola Nyman, MNSc, RN, RM (Clinical Midwife, Postgraduate Research Student)a,b,n, Terese Bondas, PhD, MNSc, RN, PHN (Professor in Nursing Science)c,d, Soo Downe, PhD, MSc, RM (Professor of Midwifery Studies)e, Marie Berg, PhD, MNSc, MPH, RNM (Professor in Health and Care Sciences specialising in Reproductive and Perinatal Health and Midwifery Science)b a
NÄL-Hospital, Larketorpsvagen 5, 461 85 Trollhattan, Sweden Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden University of Nordland, Norway d University of Eastern Finland, Finland e Research in Childbirth and Health (ReaCH) Group, University of Central Lancashire, Preston, England, UK b c
art ic l e i nf o
a b s t r a c t
Article history: Received 25 May 2012 Received in revised form 23 September 2012 Accepted 21 February 2013
Objective: to examine midwives' responses to a changed approach in the initial encounters with women and their partners in the labour ward. Design: as part of a local project to improve hospital based childbirth care, Action Research (AR) was undertaken with midwives. To establish their beliefs, practices, and responses to change during the first cycle, 37 out of 57 midwives were interviewed. Data analysis was guided by interpretative description. Setting: a labour ward in western Sweden. Findings: two themes emerged: ‘Glancing beyond routines’ describes how the changed care approach enabled ‘valuing the idea’ and ‘acquiring extended space to create a lingering presence’. The theme ‘being confined to inherent routines’ expresses ‘resistance to the need for change’ and a ‘feeling of pressure to change’. Key conclusions: the AR study design enabled the midwives to reflect on their routines and to transform tacit use-in-action to reflection-in-action. Midwives who persisted in being confined to inherent routines felt pressured by the change process. Others felt that the AR process granted them official licence to create chronological and emotional space in which they could ‘be’ and not just ‘do’. Implications for practice: to a greater or lesser extent, midwives in this setting had integrated relatively impersonal system-wide technocratic norms of childbirth into their belief systems and behaviours. The data suggest that a whole-system shift is necessary to enable caring, behaviours based on the formation of positive relationships to become the key driver of the first encounter on the labour ward. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Action research Interpretive description Labour ward Midwives
Introduction The basis for a caring approach in clinical practice is relationship. This is enacted in the encounter between the person who needs care and the person who provides it. Health-care provision can be purely technical and highly effective. However, therapeutic health-care delivery requires an engagement with the notion of ‘caritas’—altruistic love (Eriksson, 2002). This includes responsibility for the Other, or in the words of Levinas ‘not letting the Other alone’ (Lavoie et al., 2006). It involves respect for the dignity
n Corresponding author at: NÄL-Hospital, Larketorpsvagen 5, 461 85 Trollhattan, Sweden. E-mail address: [email protected] (V. Nyman).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.02.010
of the human being, the desire to show genuine interest, and the intention to work in partnership with the woman so that their expressed needs are authentically taken into account (Eriksson, 2002). Essential in a humanistic care approach in childbirth is the caring relationship (Hunter et al., 2008; Kirkham, 2010) which also has been identified as including the following central dimensions: availability, mediation of trust, mutuality, confirmation, support of uniqueness and of meaningfulness (Lundgren and Berg, 2007). Research has also demonstrated that if such care is established early and provided as part of a structured care pathway, fewer women were disappointed with the amount of attention received from staff than those allocated to usual care (Hodnett et al., 2008). For women and their partners, the care approach at the first meeting with maternity care professionals on a labour ward is
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crucial (Nyman et al., 2011). Earlier studies in Sweden and Norway have indicated that parents' first arrival in a labour ward is characterised by waiting for permission to enter and to stay (Eri et al., 2009; Nyman et al., 2011). Many women are in the latent phase of labour when seeking care for the first time and these women are often advised to return home (Malone et al., 1996; O'Driscoll et al., 2003) as admittance to hospital before active labour is associated with higher rates of obstetric interventions including caesarean section (Holmes et al., 2001; Jackson et al., 2003; Bailit et al., 2005; Gharoro and Enabudoso, 2006), and to prolonged total length of labour (Malone et al., 1996; Jackson et al., 2003; Bailit et al., 2005). However, to be sent home can lead to feelings of confusion and concern (Baxter, 2007), as many women who arrive in a labour ward do so because they feel a strong need for support, and, in some cases, a definite desire to hand over responsibility for the labour and for the well-being of their infant (Carlsson et al., 2009). As part of a programme to improve institutional labour and childbirth care, an Action Research (AR) project was undertaken. The chosen focus was the way women were greeted and treated when they first arrived in the labour ward. This paper is one part of the first cycle of the AR process and is aimed at examining midwives' responses to the collaboratively agreed changes made for the initial encounters with women and their partners in the labour ward.
Methodology The democratic process of AR aims at developing practical knowing and bringing together action and reflection, theory and practice, in participation with others (Hart, 1995). Within the AR process, the purpose is not only to describe, understand and explain the world, but also to change it: a move towards praxis. The epistemological assumption in AR is that sharing knowledge production with the researched is powerful (Reason and Torbert, 2001). The AR study starts initially with the definition of context and purpose, followed by cycles with four phases: diagnosing (naming the issue), planning action, action and evaluation. In the final phase of a cycle participants evaluate and reflect on the action (Coghlan and Brannick, 2009). The aim of the overall AR study is to encourage collaborative reflection and practice change in relation to the arrival of women in labour and their partners to a hospital based labour ward in Sweden. The aim of the study reported in this paper was to examine midwives' responses and views during the first cycle of the agreed changed approach. Data were analysed through interpretative description. This approach guides the systematic generation of thematic patterns, and provides theoretical scaffolding within qualitative data sets (Thorne, 2008).
Ethical considerations The research protocol was assessed by the Regional Ethics Board (Dnr 590-11) which gave an advisory assessment based on the conclusion that the study did not fall under the Swedish ethical legislation based on the Helsinki declaration. The team were advised to ensure that the midwives were not pressured to participate in the interviews, considering the fact that the interviewing midwife was employed at the same labour ward. Context and purpose The setting for the study was a hospital located in western Sweden. Prior to the AR study, the usual care process at women's
and their partners' arrival to the labour ward included a number of routines. Before arrival, the woman was supposed to call the labour ward and talk to a coordinating midwife whose job was to assess if and when a woman actually needed labour ward admission. On arrival, the woman and her partner were met by the midwife coordinator or the allocated midwife or sometimes by a health-care assistant, and shown into a waiting room, an examination room, or directly to a labour room. Then the coordinating midwife or the allocated midwife made the assessment of the woman's labour phase and situation. This included starting fetal heart monitoring with a cardiotocograph (CTG) for about 30 minutes, and asking questions about when the contractions started, if the water had broken, and if there was any bleeding per vaginum. The midwife mostly stayed a short time and then, leaving the CTG running, she left the room to read notes, document performed activities in the woman's medical record, and to do other miscellaneous tasks. The CTG monitoring could be seen on monitors in the midwives' office and the CTG could be running unnecessarily for more than 30 minutes if the midwife became busy, leaving the woman/couple unaware of what was happening, or what was due to happen. With the aim of improving practice for women in normal labour, a project group was established in 2010 comprising of five midwives and two health-care assistants working in the labour ward. Staff who voluntarily wanted to participate in the project were invited by the head of the division and the AR was linked to this project. In the first phase of the AR cycle, the diagnosis was made that the first encounter needed to be addressed. The project group had 11 meetings to diagnose and plan the ideas. The first author (VN) participated in the project group and acted as an insider researcher in the AR project following the principles described by Coghlan and Brannick (2009). In the second, planning phase, the first issue to be addressed was the approach to women and partners seeking entry to the labour ward. Information about the work process and development of the action was regularly discussed in staff meetings once a month. In addition, during the whole process the first author (VN) had spontaneous discussions with colleagues about the action and research in the regular clinical work place (approximately 2–3 days per week). Opinions about the key focus were considered from the whole staff, which contributed to the credibility of the changes (Koch, 1994). Following all the debates, an action plan (the third, action phase of the AR cycle) was implemented in February 2011, including the following key principles:
meet the parents' needs of being cared for without unnecessary delay;
strive to establish a reciprocal relationship; make women and partners feel as confident as possible in the new context;
give information based on individual needs; strive to stay with the woman/couple while the CTG was ongoing.
Face to face interviews The fourth phase of the first AR cycle was an evaluation of participating midwives reflections. During the first five months after the action plan was launched (February 2011–June 2011), midwives were interviewed face to face by the first author (VN) in a private room at the labour ward on occasions when they were free to talk. Midwives were informed about the purpose of the study verbally, and in a written information sheet, which included details of what would be required of them if they agreed to take part. They were asked to sign a consent form if they were happy to
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proceed. They were told that they could freely withdraw consent at any time. The consent form included permission to use individual quotes, and assurances that their identity would be protected by confidential handling of the data. For this study, midwives were the only professional group included, as they are responsible for the first meeting. All 57 midwives in the study site labour ward were eligible to take part in the interviews. Interviews took place as and when a midwife had time to take part. After 37 interviews were completed, it was agreed in the research team that theoretical saturation had been reached, and so no more data were collected. All interviews were audio taped. The age range of the whole population was 30–63 years (mean: 49.5, median: 51) and the age of the participants was 34–62 years (mean: 49, median: 52). The mean years of working experience as a midwife for the whole population was 19 (median: 20) and for the participants was 19 (median: 14), with the mean length of time they had worked on the labour ward being 12 years (median: 14). The interviews were guided by a set of trigger questions: ‘How do you perceive the changed approach in care for women and their partners at their arrival to labour ward? What does the change mean to you?’ Clarifying questions were asked such as ‘can you explain what you mean?’, ‘can you please extend further?’ The interviews lasted 15–20 minutes. Data analysis All interviews were transcribed word for word. Using interpretive descriptive methodology the analysis aimed at the generation of thematic patterns among and between the individual midwives (Thorne, 2008). First, the transcripts were read, reflected on and analysed by three of the authors (VN, TB, MB). An English version of the findings at this stage was then written and the fourth author (SD) provided analytic input. In an iterative process of reflection, critical examination, and informed questioning, data were divided into blocks expressing meanings. In further readings these meanings were synthesised and tied together into themes consisting of essential meanings that answered the overall research question, how midwives viewed and felt about the change process, with a particular focus on the initial encounters with women and their partners. Reflexive note From personal experiences as midwives and nurses, all four authors strongly believe that the first encounter is a highly significant moment for the midwife and the couple, which has the potential to turn their anxiety and uncertainty about the coming labour into confidence and hope. It also has the potential to reinforce fear and anxiety, and to set the tone for a potentially difficult labour. Apart from this pre-understanding no predetermined hypothesises or theories or interpretive sources were decided on beforehand. Findings The analysis of midwives' views and feelings about the change in the initial encounters with women and their partners arriving to the labour ward identified an overall thematic pattern with two poles: glancing beyond routines and being confined to inherent routines. The concept ‘routines’ here implies the midwifery, obstetric and behavioural routines in the studied context. Glancing beyond routines describes how, for some midwives, the changed care approach provided increased potential for them to support each woman and partner, by focusing on their individual needs in
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a holistic sense. Two elements underpin this theme: ‘valuing the idea’ and ‘acquiring extended space to create a lingering presence’. The other theme, being confined to inherent routines, expresses the experience of midwives who were still committed to pre-existing local cultural norms, which over other activities prioritised routine surveillance of the mother and her fetus. In this case, the underpinning elements are ‘resistance to the need for change’ and ‘feeling the pressure to change’. The analysis shows that, to a greater or lesser extent, all participants expressed elements of the identified phenomena during the five months that the interviews took place. In the next section, the thematic patterns are described in more detail. Quotes from participants are identified as M 1–37 (M ¼midwife). Glancing beyond routines Valuing the idea The element ‘valuing the idea’ mirrors midwives' appreciations that an establishment of an authentic relationship is a prerequisite for continuing caring through labour and birth: Sometimes I have wondered what it is that makes that some think that it is tough to take a new patient and I can feel the same that it is demanding with a new patient. I think I have cracked the code, it's about new relations. It's always difficult with new relations. When I have been in to the couple and faced them and had the first meeting then it isn't that tough anymore because I know who they are and what I got in front of me. M19 The opportunity to be there already from the beginning was valued as an outcome of the change process. This enabled staff to be open to the parents' feelings, including their anxieties. This was a relational space which, previously, was overwhelmed by the focus on electronic surveillance. The desire to be empathic was emphasised as necessary to create a welcoming feeling for the woman and her partner: Respondent: In the beginning I thought, isn't it what we are doing (having an admission dialogue) but now when I have tried it, thought about it, I understand it better not to run out after (starting) CTG but to stay with the patient. So, before I didn't quite understand because then I thought, what is this? Interviewer: What is it that you have understood? Respondent: That it is important to be there and allow yourself to be there. Because the few minutes we have met earlier, running in and out again, has not been good. Through this new routine I became more interested in her and him. What they think and who they are. Then it's not just a fetus and CTG and contractions but who it is that is behind. M8 Acquiring extended space to create a lingering presence Another element of the glancing beyond the routines was that the new approach extended space; it was invigorating. It challenged established norms and behaviours, and this gave space for and enabled the change to be established. The concept of ‘space’ includes both physical and mental space, and time. To work undisturbed in the first encounter gave space to be ‘truly present’ physically and mentally with the woman and her partner. For some participants, this legitimised what they had always done, or wanted to do. This engendered a sense of being allowed to ‘be’, and a respite from having to ‘do’, especially when deciding to sit down beside the woman and partner: You get that moment with the patient you don't have to think that it is not permitted (for me) to be there. Then you don't have to rush forth and back all the time, this is much better. I've
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always tried to do like that … I have done the notes there (in the room) and checked the CTG and talked and asked about their expectations and all that. So there is not that much new, but now it is in some way that you do it (do it differently). M20 This ‘official’ permission, to be present and lingering from the very beginning of the encounter with a couple, was mediated to an extent by how far colleagues on shift that day also accepted the new way of working. Enabling midwives to feel that they could be with a newly arrived woman and her partner depended on colleagues' good intentions to take on the daily ward duties that would otherwise not be done: You just hope that you are given the opportunity, that it is respected by all the others when you get a patient, that you are allowed to take the time M10//I think it is really good because I feel calmer with this (new approach) that I'm allowed to be in there. M37 Appreciating the extended space included taking the time and staying until the parents settled down properly. The midwives felt that this engendered in the woman and her partner a feeling of being seen and listened to, and of feeling comfortable in the institutional setting. These midwives were convinced that the creation in the woman and her partner of a firm feeling of midwifery support, established already from the beginning, would persist when the midwife left the room for a while. A ‘lingering presence’ was established. When the couple got a feeling of having their own space, and an established relationship of mutual trust, this brought reciprocal benefits for both the woman and the midwife: You want the confirmation that it feels good and that it's working, if you get that feedback it feels good.—If I get those (women and partners) with me who are worried and maybe wondering about what's happening and those who don't quite understand their own body reactions the pain and anxiousness, that you get them with you calmly and safely I think they are feeling well, then you get a calm and safe patient who might have the strength to be able to take a walk for a while or that she might tackle her own pain or worry. M14 Being confined to inherent routines Resistance to the need for change The other part of the overall thematic pattern, ‘being confined to own routines’, included the element being ‘resistant to the need for change’, capturing a belief that inherent routines were already optimal in the first encounter in the labour ward. This was, in some midwives, manifested as resistance to changing ways of thinking. On the continuum of perceptions of change the feeling of ‘imposition’ demonstrated resistance to the changes, in a reaction to what was seen as a critique of the current practice: It is a bit imposed, I've been working as a midwife for 15 years, and I feel that I have always had an admission dialogue with the patient, but maybe I haven't stayed there the first 30 minutes with the patient, instead I've been coming and going or I consider from case to case where I need to put my effort.M31 To be ‘resistant to the need for change’ also includes a sense that the changed care approach was nothing new, and that it did not add to the quality of the first reception of the woman and her partner. It could include having a pragmatic desire to continue with established routines that permitted midwives to handle high workloads, as if there was someone or something dictating a work pressure in a certain way or speed, a spectre of haste that haunted the labour ward system:
But it is just that I have several patients that I run between so there is no such time, that's my reality and there is nothing I can do about that. M33 Another part of being ‘resistant to the need for change’ is rooted in the need to know the medical and obstetric history of the arriving woman and not to miss important information that the woman might want the midwife to be aware of before the encounter. The midwife's need to transmit to the woman the reassurance that her records were about to be consulted was given as an argument for the need to go out and do this (if it was not done previous to the woman's arrival) and not to stay the 15–20 minutes suggested by the new routines: I greet the patient and make a contact and put the CTG on and say now I'm going out to read your medical report and that I'll be back. M1 Embedded in this element is also a view that the first encounter is primarily an assessment situation, an inventory for the midwife to identify where in labour the woman is, and to decide further actions by vaginal examination and other clinical information. The importance of assessing the overall needs of the woman and her partner, which was part of the new approach, did not feature in some accounts: You ask how frequent the contractions are, if there is any bleeding or water and where the pain is…what they think they want or not want to have. I usually do like this that I examine vaginally and then you know more and we can make a plan from there about how to proceed. So after that we can decide together, when I know, because the vaginal examination reveals everything we are about to do. M29 Feeling the pressure to change ‘Being confined to routines’ also includes the element ‘feeling the pressure to change’ the ways of doing tasks, especially the routine of starting the CTG and letting it run while the midwife leaves the room. The main argument for not being able to adopt the new approach was time constraints, including other CTG traces that had to be watched simultaneously: When you sit and talk with the (newly arrived) patient and ask how it's going, you maybe have another patient in labour and then you look at the computer to check the (the other woman's) CTG, what it looks like and how it's going and so on. That's not really good either, you're not focused. M32 In a busy labour ward it is difficult to talk or act differently because it could increase workloads for other midwives and cause irritation. ‘Feeling the pressure to change’ expresses the extra strain imposed by new ways of working that might cause this kind of irritation to colleagues if a midwife lingered in a room too long on a busy day: Fifteen minutes, I think, is a minimal change out on the ward, because that's what we use today, but maybe in another way, but if you talk for 30–35 minutes (at admission) you don't actually know how to have a dialogue… then it is rather wrong to do like that, … in that case I think it could cause irritation because then you are absent when we are this few (midwives on duty). M24 To ‘feel the pressure to change’ was rooted in the need to get out of the room to finish other tasks while the CTG was running and to take a break, to mentally and physically reload and to inform other staff about future actions needed for the coordination of the daily work. Some participants felt that this practice of leaving the couple and updating was accepted and appreciated by colleagues,
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in contrast to staying in the room, which was not valued or encouraged in the same way: You just hope that you are given the opportunity, that it is respected by all the others when you get a patient that you are allowed to take the time. M10 ‘Feeling the pressure to change’ was a reflection of the belief that the new approach disturbed the routine of recording a CTG trace among the first things undertaken during the encounter. This was felt to be an important driver in keeping to the standard ways of doing things, because of the organisational belief that the CTG trace was an essential tool in identifying if there was any imminent or actual pathology in the fetal heart pattern. This risk assessment was mandated for midwives working in the research site. Without wider system change, the move away from using CTG was seen as not doable: Nobody dares to react (back off) somehow we do a lot of CTG traces and then you think that you maybe could wait and just listen (to the baby's heart) intermittently. M21
Discussion The focus of this study was to understand the ways in which midwives experienced and reflected on a changed care approach at the first encounter with women and their partners on their arrival to a labour ward. The new content and tasks proposed and actioned by the collaborative AR group were, in theory, ways of working that most of the respondents felt they should already be enacting, in an ideal work setting. However, the AR study design enabled them to reflect on their existing routines and to articulate the challenges they experienced during the process. It further demonstrated existing cultural norms, which were more focused on the expectations and needs of colleagues than those of women and partners. These collegiate norms were in turn based on technocratic beliefs that saturated usual practice (O'Connell and Downe, 2009), and that interrupted the creation of positive relationships between midwives and labouring women and partners. The overall thematic pattern ‘glancing beyond routines’ and ‘being confined to inherent routines’ describes the miscellaneous ways midwives related to the creation of a caring relationship. A caring approach in the establishment of a therapeutic alliance includes ‘not letting the Other alone’ (Lavoie et al., 2006). The value of reflecting and glancing beyond routines facilitated some of the midwives to build a lingering presence in the labour room, and to develop an extended space in which to ‘be’ and not just ‘do’. For midwives who were able to glance beyond the routines the changed approach helped them to see beyond the ruling norms of medico-technical surveillance and management. This also allowed them to legitimately display the more subtle values of caring, including dimensions of availability, mediation of trust, mutuality, confirmation and support of uniqueness, all central concepts in midwifery caring (Lundgren and Berg, 2007). Furthermore the change gave them extended space to create a positive birthing atmosphere, a central aspect identified in a recent midwifery model of childbirth care (Berg et al., 2012). The midwives in this study expressed behaviours that suggested that they were truly present from the beginning of the arrival of the woman and her partner to the labour ward. For us as a research team the data suggested that genuine, non-mechanical and non-routinised attention paved the way for lingering (Parse, 1998) enduring presence (Berg and Dahlberg, 2001). The change was complicated when the midwives persisted in being confined to inherent routines. Some seemed to be reluctant
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to respond to the AR process; they demonstrated confusion and a feeling of being pressured to change. Midwives experiences of hospital practice in publicly funded settings with shortage of staff and lack of time have been expressed as ‘getting through the work’, and to be compliant to technocratic norms and standardised care (O'Connell and Downe, 2009), the ‘dark side’ of midwifery (Kirkham, 2010) and this was also apparent in the data in this study. The norm was to initially focus on practical undertakings like starting the CTG, and then to leave to read the medical report. This kind of response has been interpreted as a way of resisting changes that undermine personal expertise and understandings (Carroll and Quijada, 2004). The data reveal a profound uneasiness in some midwives about just sitting with the woman and partner, rather than doing specific tasks, especially if the woman was not in the active phase of labour. This suggests that midwives needed to ‘pause’ a moment, to renew emotional, physical, mental and spiritual energy (Ghaye, 2007) for the new commitment to this specific labouring woman, after which they were more able to wholeheartedly enter into the relationship. However, this meant that women and partners had to wait for emotional, mental and spiritual support until they had achieved the ‘legitimate’ stage of active labour. Other data from this research project (Nyman et al., 2011) have indicated that the women and partners experience midwives as being uninterested and uncaring when they leave the room soon after meeting. For other participants, resistance to change seemed to be based on an intractable belief that the primary imperative during the first encounter with the labouring woman was to undertake a clinical assessment and to start the CTG. This belief persisted despite their awareness that the baseline electronic fetal monitoring test does not improve well-being for mother or infant, and, indeed, might be linked with adverse outcomes (Blix, 2006; Devane et al., 2012). The step to go away from using CTG was at the start of the AR far from doable at this suite. Midwives were imprisoned in a hegemonies ‘CTG faith’ that is internalised in a way that it appears to be taken for granted (Foucault and Sheridan, 1979). Study limitations Data for this study were collected through interviews with most of the midwives in the study site. Some interviews were short. However, they were very focused on one specific element of the workload, so rich data could be collected on this precise aspect in a short period of time. Rapid engagement was also enabled as the researcher was known to the interviewees, limiting the need to form effective conversational relationships at the beginning of the interviews. To do AR in one's own organisation is a complex process. At the same time as AR is a collaborative work, the raising of specific questions and judgments makes it political, making it a threat to existing norms. To handle interpretations or outcomes that could be perceived negatively by the organisation could become a sensitive matter. This means that the researcher who is a member of the organisation must effectively balance the organisational membership role with the role of a researcher with the function of inquiring in ways that might be challenging for colleagues who, later, one must work with. This may have influenced some of the accounts given in the participants' interviews.
Conclusion The AR design enabled midwives to reflect on their routines, to articulate the challenges they experienced during the AR process, and to start to move from tacit knowing-in-action to reflection-inaction. There were those who could not accept the need for the
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change, and who saw presence and listening as incompatible with existing values and the social system and norms in the labour ward. Even those who grasped the opportunity to change were aware of the negative impact on colleagues, and of tacit disapproval from some. Despite a general acceptance of the benefits of genuine caring in labour through the set-up of a good midwife– woman/partner relationship in the first encounter, in this first cycle of the AR process, individual and system-wide norms interfered with enacting the agreed changes. The AR process is collaboratively ongoing to illuminate and develop the system's values, to address this continuing barrier.
Conflict of interest No conflict of interest has been declared by the authors.
Acknowledgements The authors are grateful to all participating clinical midwives in the labour ward and Lena Tylegård for transcription of interviews, and NU-Hospital Organisation, Trollhattan and Uddevalla for financial support of this research. References Bailit, J.L., Dierker, L., Blanchard, M.H., Mercer, B.M., 2005. Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstetrics & Gynecology 105, 77–79. Baxter, J., 2007. Care during the latent phase of labour: supporting normal birth. British Journal of Midwifery 15, 765–767. Berg, M., Asta Olafsdottir, O., Lundgren, I., 2012. A midwifery model of womancentred childbirth care—In Swedish and Icelandic settings. Sexual & Reproductive Healthcare 3, 79–87. Berg, M., Dahlberg, K., 2001. Swedish midwives' care of women who are at high obstetric risk or who have obstetric complications. Midwifery 17, 259–266. Blix, E., 2006. Innkomst-CTG: en vurdering av testens prediktive verdier, reliabilitet og effekt: betydning for jordmødre i deres daglige arbeid. (English Labor Admission Test: an Assessment of the Test's Predictive Value, Reliability and Effect: the Meaning for the Midwives in their Daily Work.) Dissertation. Carlsson, I.M., Hallberg, L.R., Odberg Pettersson, K., 2009. Swedish women's experiences of seeking care and being admitted during the latent phase of labour: a grounded theory study. Midwifery 25, 172–180. Carroll, J.S., Quijada, M.A., 2004. Redirecting traditional professional values to support safety: changing organisational culture in health care. Quality and Safety in Health Care 13, ii16–ii21.
Coghlan, D., Brannick, T., 2009. Doing Action Research in Your Own Organization. Sage, London. Devane, D., Lalor, J.G., Daly, S., McGuire, W., Smith, V., 2012. Cardiotocography versus Intermittent Auscultation of Fetal Heart on Admission to Labour Ward for Assessment of Fetal Wellbeing. Cochrane Database of Systematic Reviews. Eri, T.S., Blystad, A., Gjengedal, E., Blaaka, G., 2010. Negotiating credibility: first-time mothers' experiences of contact with the labour ward before hospitalisation. Midwifery 26, e25–e30. Eriksson, K., 2002. Caring science in a new key. Nursing Science Quarterly 15, 61–65. Foucault, M., Sheridan, A., 1979. Discipline and Punish: the Birth of the Prison. Vintage Books, New York. Gharoro, E.P., Enabudoso, E.J., 2006. Labour management: an appraisal of the role of false labour and latent phase on the delivery mode. Journal of Obstetrics and Gynaecology 26, 534–537. Ghaye, T., 2007. Building the Reflective Healthcare Organisation. Blackwell, Oxford. Hart, E., 1995. Action Research for Health and Social Care: a Guide to Practice. Open University Press, Buckingham. Hodnett, E.D., Stremler, R., Willan, A.R., et al., 2008. Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial. BMJ: British Medical Journal (International Edition) 337, 618–622. Holmes, P., Oppenheimer, L.W., Wen, S.W., 2001. The relationship between cervical dilatation at initial presentation in labour and subsequent intervention. BJOG: an International Journal of Obstetrics and Gynaecology 108, 1120–1124. Hunter, B., Berg, M., Lundgren, I., Ólafsdóttir, Ó.Á., Kirkham, M., 2008. Relationships: the hidden threads in the tapestry of maternity care. Midwifery 24, 132–137. Jackson, D.J., Lang, J.M., Ecker, J., Swartz, W.H., Heeren, T., 2003. Impact of collaborative management and early admission in labor on method of delivery. Journal of Obstetric, Gynecologic and Neonatal Nursing 32, 147–157. (discussion 158–160). Kirkham, M., 2010. The Midwife–Mother Relationship. Palgrave Macmillan, Basingstoke. Koch, T., 1994. Establishing rigour in qualitative research: the decision trail. Journal of Advanced Nursing 19, 976–986. Lavoie, M., De Koninck, T., Blondeau, D., 2006. The nature of care in light of Emmanuel Levinas. Nursing Philosophy 7, 225–234. Lundgren, I., Berg, M., 2007. Central concepts in the midwife–woman relationship. Scandinavian Journal of Caring Sciences 21, 220–228. Malone, F.D., Geary, M., Chelmow, D., Stronge, J., Boylan, P., D'Alton, M.E., 1996. Prolonged labor in nulliparas: lessons from the active management of labor. Obstetrics & Gynecology 88, 211–215. Nyman, V., Downe, S., Berg, M., 2011. Waiting for permission to enter the labour ward world: first time parents' experiences of the first encounter on a labour ward. Sexual & Reproductive Healthcare 2, 129–134. O'Connell, R., Downe, S., 2009. A metasynthesis of midwives' experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (London) 13, 589–609. O'Driscoll, K., Meagher, D., Robson, M., 2003. Active Management of Labour: the Dublin Experience. Mosby, Edinburgh. Parse, R.R., 1998. The Human Becoming School of Thought: a Perspective for Nurses and Other Health Professionals. Sage Publications, Thousand Oaks, California. Reason, P., Torbert., W.R., 2001. The action turn: Toward a transformational social science. Concepts and Transformation 6, 1–37. Thorne, S. E., 2008. Interpretive Description. Left Coast Press, Walnut Creek, CA.
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Midwifery journal homepage: www.elsevier.com/midw
Glancing beyond or being confined to routines: Labour ward midwives' responses to change as a result of action research Viola Nyman, MNSc, RN, RM (Clinical Midwife, Postgraduate Research Student)a,b,n, Terese Bondas, PhD, MNSc, RN, PHN (Professor in Nursing Science)c,d, Soo Downe, PhD, MSc, RM (Professor of Midwifery Studies)e, Marie Berg, PhD, MNSc, MPH, RNM (Professor in Health and Care Sciences specialising in Reproductive and Perinatal Health and Midwifery Science)b a
NÄL-Hospital, Larketorpsvagen 5, 461 85 Trollhattan, Sweden Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden University of Nordland, Norway d University of Eastern Finland, Finland e Research in Childbirth and Health (ReaCH) Group, University of Central Lancashire, Preston, England, UK b c
art ic l e i nf o
a b s t r a c t
Article history: Received 25 May 2012 Received in revised form 23 September 2012 Accepted 21 February 2013
Objective: to examine midwives' responses to a changed approach in the initial encounters with women and their partners in the labour ward. Design: as part of a local project to improve hospital based childbirth care, Action Research (AR) was undertaken with midwives. To establish their beliefs, practices, and responses to change during the first cycle, 37 out of 57 midwives were interviewed. Data analysis was guided by interpretative description. Setting: a labour ward in western Sweden. Findings: two themes emerged: ‘Glancing beyond routines’ describes how the changed care approach enabled ‘valuing the idea’ and ‘acquiring extended space to create a lingering presence’. The theme ‘being confined to inherent routines’ expresses ‘resistance to the need for change’ and a ‘feeling of pressure to change’. Key conclusions: the AR study design enabled the midwives to reflect on their routines and to transform tacit use-in-action to reflection-in-action. Midwives who persisted in being confined to inherent routines felt pressured by the change process. Others felt that the AR process granted them official licence to create chronological and emotional space in which they could ‘be’ and not just ‘do’. Implications for practice: to a greater or lesser extent, midwives in this setting had integrated relatively impersonal system-wide technocratic norms of childbirth into their belief systems and behaviours. The data suggest that a whole-system shift is necessary to enable caring, behaviours based on the formation of positive relationships to become the key driver of the first encounter on the labour ward. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Action research Interpretive description Labour ward Midwives
Introduction The basis for a caring approach in clinical practice is relationship. This is enacted in the encounter between the person who needs care and the person who provides it. Health-care provision can be purely technical and highly effective. However, therapeutic health-care delivery requires an engagement with the notion of ‘caritas’—altruistic love (Eriksson, 2002). This includes responsibility for the Other, or in the words of Levinas ‘not letting the Other alone’ (Lavoie et al., 2006). It involves respect for the dignity
n Corresponding author at: NÄL-Hospital, Larketorpsvagen 5, 461 85 Trollhattan, Sweden. E-mail address: [email protected] (V. Nyman).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.02.010
of the human being, the desire to show genuine interest, and the intention to work in partnership with the woman so that their expressed needs are authentically taken into account (Eriksson, 2002). Essential in a humanistic care approach in childbirth is the caring relationship (Hunter et al., 2008; Kirkham, 2010) which also has been identified as including the following central dimensions: availability, mediation of trust, mutuality, confirmation, support of uniqueness and of meaningfulness (Lundgren and Berg, 2007). Research has also demonstrated that if such care is established early and provided as part of a structured care pathway, fewer women were disappointed with the amount of attention received from staff than those allocated to usual care (Hodnett et al., 2008). For women and their partners, the care approach at the first meeting with maternity care professionals on a labour ward is
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crucial (Nyman et al., 2011). Earlier studies in Sweden and Norway have indicated that parents' first arrival in a labour ward is characterised by waiting for permission to enter and to stay (Eri et al., 2009; Nyman et al., 2011). Many women are in the latent phase of labour when seeking care for the first time and these women are often advised to return home (Malone et al., 1996; O'Driscoll et al., 2003) as admittance to hospital before active labour is associated with higher rates of obstetric interventions including caesarean section (Holmes et al., 2001; Jackson et al., 2003; Bailit et al., 2005; Gharoro and Enabudoso, 2006), and to prolonged total length of labour (Malone et al., 1996; Jackson et al., 2003; Bailit et al., 2005). However, to be sent home can lead to feelings of confusion and concern (Baxter, 2007), as many women who arrive in a labour ward do so because they feel a strong need for support, and, in some cases, a definite desire to hand over responsibility for the labour and for the well-being of their infant (Carlsson et al., 2009). As part of a programme to improve institutional labour and childbirth care, an Action Research (AR) project was undertaken. The chosen focus was the way women were greeted and treated when they first arrived in the labour ward. This paper is one part of the first cycle of the AR process and is aimed at examining midwives' responses to the collaboratively agreed changes made for the initial encounters with women and their partners in the labour ward.
Methodology The democratic process of AR aims at developing practical knowing and bringing together action and reflection, theory and practice, in participation with others (Hart, 1995). Within the AR process, the purpose is not only to describe, understand and explain the world, but also to change it: a move towards praxis. The epistemological assumption in AR is that sharing knowledge production with the researched is powerful (Reason and Torbert, 2001). The AR study starts initially with the definition of context and purpose, followed by cycles with four phases: diagnosing (naming the issue), planning action, action and evaluation. In the final phase of a cycle participants evaluate and reflect on the action (Coghlan and Brannick, 2009). The aim of the overall AR study is to encourage collaborative reflection and practice change in relation to the arrival of women in labour and their partners to a hospital based labour ward in Sweden. The aim of the study reported in this paper was to examine midwives' responses and views during the first cycle of the agreed changed approach. Data were analysed through interpretative description. This approach guides the systematic generation of thematic patterns, and provides theoretical scaffolding within qualitative data sets (Thorne, 2008).
Ethical considerations The research protocol was assessed by the Regional Ethics Board (Dnr 590-11) which gave an advisory assessment based on the conclusion that the study did not fall under the Swedish ethical legislation based on the Helsinki declaration. The team were advised to ensure that the midwives were not pressured to participate in the interviews, considering the fact that the interviewing midwife was employed at the same labour ward. Context and purpose The setting for the study was a hospital located in western Sweden. Prior to the AR study, the usual care process at women's
and their partners' arrival to the labour ward included a number of routines. Before arrival, the woman was supposed to call the labour ward and talk to a coordinating midwife whose job was to assess if and when a woman actually needed labour ward admission. On arrival, the woman and her partner were met by the midwife coordinator or the allocated midwife or sometimes by a health-care assistant, and shown into a waiting room, an examination room, or directly to a labour room. Then the coordinating midwife or the allocated midwife made the assessment of the woman's labour phase and situation. This included starting fetal heart monitoring with a cardiotocograph (CTG) for about 30 minutes, and asking questions about when the contractions started, if the water had broken, and if there was any bleeding per vaginum. The midwife mostly stayed a short time and then, leaving the CTG running, she left the room to read notes, document performed activities in the woman's medical record, and to do other miscellaneous tasks. The CTG monitoring could be seen on monitors in the midwives' office and the CTG could be running unnecessarily for more than 30 minutes if the midwife became busy, leaving the woman/couple unaware of what was happening, or what was due to happen. With the aim of improving practice for women in normal labour, a project group was established in 2010 comprising of five midwives and two health-care assistants working in the labour ward. Staff who voluntarily wanted to participate in the project were invited by the head of the division and the AR was linked to this project. In the first phase of the AR cycle, the diagnosis was made that the first encounter needed to be addressed. The project group had 11 meetings to diagnose and plan the ideas. The first author (VN) participated in the project group and acted as an insider researcher in the AR project following the principles described by Coghlan and Brannick (2009). In the second, planning phase, the first issue to be addressed was the approach to women and partners seeking entry to the labour ward. Information about the work process and development of the action was regularly discussed in staff meetings once a month. In addition, during the whole process the first author (VN) had spontaneous discussions with colleagues about the action and research in the regular clinical work place (approximately 2–3 days per week). Opinions about the key focus were considered from the whole staff, which contributed to the credibility of the changes (Koch, 1994). Following all the debates, an action plan (the third, action phase of the AR cycle) was implemented in February 2011, including the following key principles:
meet the parents' needs of being cared for without unnecessary delay;
strive to establish a reciprocal relationship; make women and partners feel as confident as possible in the new context;
give information based on individual needs; strive to stay with the woman/couple while the CTG was ongoing.
Face to face interviews The fourth phase of the first AR cycle was an evaluation of participating midwives reflections. During the first five months after the action plan was launched (February 2011–June 2011), midwives were interviewed face to face by the first author (VN) in a private room at the labour ward on occasions when they were free to talk. Midwives were informed about the purpose of the study verbally, and in a written information sheet, which included details of what would be required of them if they agreed to take part. They were asked to sign a consent form if they were happy to
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proceed. They were told that they could freely withdraw consent at any time. The consent form included permission to use individual quotes, and assurances that their identity would be protected by confidential handling of the data. For this study, midwives were the only professional group included, as they are responsible for the first meeting. All 57 midwives in the study site labour ward were eligible to take part in the interviews. Interviews took place as and when a midwife had time to take part. After 37 interviews were completed, it was agreed in the research team that theoretical saturation had been reached, and so no more data were collected. All interviews were audio taped. The age range of the whole population was 30–63 years (mean: 49.5, median: 51) and the age of the participants was 34–62 years (mean: 49, median: 52). The mean years of working experience as a midwife for the whole population was 19 (median: 20) and for the participants was 19 (median: 14), with the mean length of time they had worked on the labour ward being 12 years (median: 14). The interviews were guided by a set of trigger questions: ‘How do you perceive the changed approach in care for women and their partners at their arrival to labour ward? What does the change mean to you?’ Clarifying questions were asked such as ‘can you explain what you mean?’, ‘can you please extend further?’ The interviews lasted 15–20 minutes. Data analysis All interviews were transcribed word for word. Using interpretive descriptive methodology the analysis aimed at the generation of thematic patterns among and between the individual midwives (Thorne, 2008). First, the transcripts were read, reflected on and analysed by three of the authors (VN, TB, MB). An English version of the findings at this stage was then written and the fourth author (SD) provided analytic input. In an iterative process of reflection, critical examination, and informed questioning, data were divided into blocks expressing meanings. In further readings these meanings were synthesised and tied together into themes consisting of essential meanings that answered the overall research question, how midwives viewed and felt about the change process, with a particular focus on the initial encounters with women and their partners. Reflexive note From personal experiences as midwives and nurses, all four authors strongly believe that the first encounter is a highly significant moment for the midwife and the couple, which has the potential to turn their anxiety and uncertainty about the coming labour into confidence and hope. It also has the potential to reinforce fear and anxiety, and to set the tone for a potentially difficult labour. Apart from this pre-understanding no predetermined hypothesises or theories or interpretive sources were decided on beforehand. Findings The analysis of midwives' views and feelings about the change in the initial encounters with women and their partners arriving to the labour ward identified an overall thematic pattern with two poles: glancing beyond routines and being confined to inherent routines. The concept ‘routines’ here implies the midwifery, obstetric and behavioural routines in the studied context. Glancing beyond routines describes how, for some midwives, the changed care approach provided increased potential for them to support each woman and partner, by focusing on their individual needs in
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a holistic sense. Two elements underpin this theme: ‘valuing the idea’ and ‘acquiring extended space to create a lingering presence’. The other theme, being confined to inherent routines, expresses the experience of midwives who were still committed to pre-existing local cultural norms, which over other activities prioritised routine surveillance of the mother and her fetus. In this case, the underpinning elements are ‘resistance to the need for change’ and ‘feeling the pressure to change’. The analysis shows that, to a greater or lesser extent, all participants expressed elements of the identified phenomena during the five months that the interviews took place. In the next section, the thematic patterns are described in more detail. Quotes from participants are identified as M 1–37 (M ¼midwife). Glancing beyond routines Valuing the idea The element ‘valuing the idea’ mirrors midwives' appreciations that an establishment of an authentic relationship is a prerequisite for continuing caring through labour and birth: Sometimes I have wondered what it is that makes that some think that it is tough to take a new patient and I can feel the same that it is demanding with a new patient. I think I have cracked the code, it's about new relations. It's always difficult with new relations. When I have been in to the couple and faced them and had the first meeting then it isn't that tough anymore because I know who they are and what I got in front of me. M19 The opportunity to be there already from the beginning was valued as an outcome of the change process. This enabled staff to be open to the parents' feelings, including their anxieties. This was a relational space which, previously, was overwhelmed by the focus on electronic surveillance. The desire to be empathic was emphasised as necessary to create a welcoming feeling for the woman and her partner: Respondent: In the beginning I thought, isn't it what we are doing (having an admission dialogue) but now when I have tried it, thought about it, I understand it better not to run out after (starting) CTG but to stay with the patient. So, before I didn't quite understand because then I thought, what is this? Interviewer: What is it that you have understood? Respondent: That it is important to be there and allow yourself to be there. Because the few minutes we have met earlier, running in and out again, has not been good. Through this new routine I became more interested in her and him. What they think and who they are. Then it's not just a fetus and CTG and contractions but who it is that is behind. M8 Acquiring extended space to create a lingering presence Another element of the glancing beyond the routines was that the new approach extended space; it was invigorating. It challenged established norms and behaviours, and this gave space for and enabled the change to be established. The concept of ‘space’ includes both physical and mental space, and time. To work undisturbed in the first encounter gave space to be ‘truly present’ physically and mentally with the woman and her partner. For some participants, this legitimised what they had always done, or wanted to do. This engendered a sense of being allowed to ‘be’, and a respite from having to ‘do’, especially when deciding to sit down beside the woman and partner: You get that moment with the patient you don't have to think that it is not permitted (for me) to be there. Then you don't have to rush forth and back all the time, this is much better. I've
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always tried to do like that … I have done the notes there (in the room) and checked the CTG and talked and asked about their expectations and all that. So there is not that much new, but now it is in some way that you do it (do it differently). M20 This ‘official’ permission, to be present and lingering from the very beginning of the encounter with a couple, was mediated to an extent by how far colleagues on shift that day also accepted the new way of working. Enabling midwives to feel that they could be with a newly arrived woman and her partner depended on colleagues' good intentions to take on the daily ward duties that would otherwise not be done: You just hope that you are given the opportunity, that it is respected by all the others when you get a patient, that you are allowed to take the time M10//I think it is really good because I feel calmer with this (new approach) that I'm allowed to be in there. M37 Appreciating the extended space included taking the time and staying until the parents settled down properly. The midwives felt that this engendered in the woman and her partner a feeling of being seen and listened to, and of feeling comfortable in the institutional setting. These midwives were convinced that the creation in the woman and her partner of a firm feeling of midwifery support, established already from the beginning, would persist when the midwife left the room for a while. A ‘lingering presence’ was established. When the couple got a feeling of having their own space, and an established relationship of mutual trust, this brought reciprocal benefits for both the woman and the midwife: You want the confirmation that it feels good and that it's working, if you get that feedback it feels good.—If I get those (women and partners) with me who are worried and maybe wondering about what's happening and those who don't quite understand their own body reactions the pain and anxiousness, that you get them with you calmly and safely I think they are feeling well, then you get a calm and safe patient who might have the strength to be able to take a walk for a while or that she might tackle her own pain or worry. M14 Being confined to inherent routines Resistance to the need for change The other part of the overall thematic pattern, ‘being confined to own routines’, included the element being ‘resistant to the need for change’, capturing a belief that inherent routines were already optimal in the first encounter in the labour ward. This was, in some midwives, manifested as resistance to changing ways of thinking. On the continuum of perceptions of change the feeling of ‘imposition’ demonstrated resistance to the changes, in a reaction to what was seen as a critique of the current practice: It is a bit imposed, I've been working as a midwife for 15 years, and I feel that I have always had an admission dialogue with the patient, but maybe I haven't stayed there the first 30 minutes with the patient, instead I've been coming and going or I consider from case to case where I need to put my effort.M31 To be ‘resistant to the need for change’ also includes a sense that the changed care approach was nothing new, and that it did not add to the quality of the first reception of the woman and her partner. It could include having a pragmatic desire to continue with established routines that permitted midwives to handle high workloads, as if there was someone or something dictating a work pressure in a certain way or speed, a spectre of haste that haunted the labour ward system:
But it is just that I have several patients that I run between so there is no such time, that's my reality and there is nothing I can do about that. M33 Another part of being ‘resistant to the need for change’ is rooted in the need to know the medical and obstetric history of the arriving woman and not to miss important information that the woman might want the midwife to be aware of before the encounter. The midwife's need to transmit to the woman the reassurance that her records were about to be consulted was given as an argument for the need to go out and do this (if it was not done previous to the woman's arrival) and not to stay the 15–20 minutes suggested by the new routines: I greet the patient and make a contact and put the CTG on and say now I'm going out to read your medical report and that I'll be back. M1 Embedded in this element is also a view that the first encounter is primarily an assessment situation, an inventory for the midwife to identify where in labour the woman is, and to decide further actions by vaginal examination and other clinical information. The importance of assessing the overall needs of the woman and her partner, which was part of the new approach, did not feature in some accounts: You ask how frequent the contractions are, if there is any bleeding or water and where the pain is…what they think they want or not want to have. I usually do like this that I examine vaginally and then you know more and we can make a plan from there about how to proceed. So after that we can decide together, when I know, because the vaginal examination reveals everything we are about to do. M29 Feeling the pressure to change ‘Being confined to routines’ also includes the element ‘feeling the pressure to change’ the ways of doing tasks, especially the routine of starting the CTG and letting it run while the midwife leaves the room. The main argument for not being able to adopt the new approach was time constraints, including other CTG traces that had to be watched simultaneously: When you sit and talk with the (newly arrived) patient and ask how it's going, you maybe have another patient in labour and then you look at the computer to check the (the other woman's) CTG, what it looks like and how it's going and so on. That's not really good either, you're not focused. M32 In a busy labour ward it is difficult to talk or act differently because it could increase workloads for other midwives and cause irritation. ‘Feeling the pressure to change’ expresses the extra strain imposed by new ways of working that might cause this kind of irritation to colleagues if a midwife lingered in a room too long on a busy day: Fifteen minutes, I think, is a minimal change out on the ward, because that's what we use today, but maybe in another way, but if you talk for 30–35 minutes (at admission) you don't actually know how to have a dialogue… then it is rather wrong to do like that, … in that case I think it could cause irritation because then you are absent when we are this few (midwives on duty). M24 To ‘feel the pressure to change’ was rooted in the need to get out of the room to finish other tasks while the CTG was running and to take a break, to mentally and physically reload and to inform other staff about future actions needed for the coordination of the daily work. Some participants felt that this practice of leaving the couple and updating was accepted and appreciated by colleagues,
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in contrast to staying in the room, which was not valued or encouraged in the same way: You just hope that you are given the opportunity, that it is respected by all the others when you get a patient that you are allowed to take the time. M10 ‘Feeling the pressure to change’ was a reflection of the belief that the new approach disturbed the routine of recording a CTG trace among the first things undertaken during the encounter. This was felt to be an important driver in keeping to the standard ways of doing things, because of the organisational belief that the CTG trace was an essential tool in identifying if there was any imminent or actual pathology in the fetal heart pattern. This risk assessment was mandated for midwives working in the research site. Without wider system change, the move away from using CTG was seen as not doable: Nobody dares to react (back off) somehow we do a lot of CTG traces and then you think that you maybe could wait and just listen (to the baby's heart) intermittently. M21
Discussion The focus of this study was to understand the ways in which midwives experienced and reflected on a changed care approach at the first encounter with women and their partners on their arrival to a labour ward. The new content and tasks proposed and actioned by the collaborative AR group were, in theory, ways of working that most of the respondents felt they should already be enacting, in an ideal work setting. However, the AR study design enabled them to reflect on their existing routines and to articulate the challenges they experienced during the process. It further demonstrated existing cultural norms, which were more focused on the expectations and needs of colleagues than those of women and partners. These collegiate norms were in turn based on technocratic beliefs that saturated usual practice (O'Connell and Downe, 2009), and that interrupted the creation of positive relationships between midwives and labouring women and partners. The overall thematic pattern ‘glancing beyond routines’ and ‘being confined to inherent routines’ describes the miscellaneous ways midwives related to the creation of a caring relationship. A caring approach in the establishment of a therapeutic alliance includes ‘not letting the Other alone’ (Lavoie et al., 2006). The value of reflecting and glancing beyond routines facilitated some of the midwives to build a lingering presence in the labour room, and to develop an extended space in which to ‘be’ and not just ‘do’. For midwives who were able to glance beyond the routines the changed approach helped them to see beyond the ruling norms of medico-technical surveillance and management. This also allowed them to legitimately display the more subtle values of caring, including dimensions of availability, mediation of trust, mutuality, confirmation and support of uniqueness, all central concepts in midwifery caring (Lundgren and Berg, 2007). Furthermore the change gave them extended space to create a positive birthing atmosphere, a central aspect identified in a recent midwifery model of childbirth care (Berg et al., 2012). The midwives in this study expressed behaviours that suggested that they were truly present from the beginning of the arrival of the woman and her partner to the labour ward. For us as a research team the data suggested that genuine, non-mechanical and non-routinised attention paved the way for lingering (Parse, 1998) enduring presence (Berg and Dahlberg, 2001). The change was complicated when the midwives persisted in being confined to inherent routines. Some seemed to be reluctant
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to respond to the AR process; they demonstrated confusion and a feeling of being pressured to change. Midwives experiences of hospital practice in publicly funded settings with shortage of staff and lack of time have been expressed as ‘getting through the work’, and to be compliant to technocratic norms and standardised care (O'Connell and Downe, 2009), the ‘dark side’ of midwifery (Kirkham, 2010) and this was also apparent in the data in this study. The norm was to initially focus on practical undertakings like starting the CTG, and then to leave to read the medical report. This kind of response has been interpreted as a way of resisting changes that undermine personal expertise and understandings (Carroll and Quijada, 2004). The data reveal a profound uneasiness in some midwives about just sitting with the woman and partner, rather than doing specific tasks, especially if the woman was not in the active phase of labour. This suggests that midwives needed to ‘pause’ a moment, to renew emotional, physical, mental and spiritual energy (Ghaye, 2007) for the new commitment to this specific labouring woman, after which they were more able to wholeheartedly enter into the relationship. However, this meant that women and partners had to wait for emotional, mental and spiritual support until they had achieved the ‘legitimate’ stage of active labour. Other data from this research project (Nyman et al., 2011) have indicated that the women and partners experience midwives as being uninterested and uncaring when they leave the room soon after meeting. For other participants, resistance to change seemed to be based on an intractable belief that the primary imperative during the first encounter with the labouring woman was to undertake a clinical assessment and to start the CTG. This belief persisted despite their awareness that the baseline electronic fetal monitoring test does not improve well-being for mother or infant, and, indeed, might be linked with adverse outcomes (Blix, 2006; Devane et al., 2012). The step to go away from using CTG was at the start of the AR far from doable at this suite. Midwives were imprisoned in a hegemonies ‘CTG faith’ that is internalised in a way that it appears to be taken for granted (Foucault and Sheridan, 1979). Study limitations Data for this study were collected through interviews with most of the midwives in the study site. Some interviews were short. However, they were very focused on one specific element of the workload, so rich data could be collected on this precise aspect in a short period of time. Rapid engagement was also enabled as the researcher was known to the interviewees, limiting the need to form effective conversational relationships at the beginning of the interviews. To do AR in one's own organisation is a complex process. At the same time as AR is a collaborative work, the raising of specific questions and judgments makes it political, making it a threat to existing norms. To handle interpretations or outcomes that could be perceived negatively by the organisation could become a sensitive matter. This means that the researcher who is a member of the organisation must effectively balance the organisational membership role with the role of a researcher with the function of inquiring in ways that might be challenging for colleagues who, later, one must work with. This may have influenced some of the accounts given in the participants' interviews.
Conclusion The AR design enabled midwives to reflect on their routines, to articulate the challenges they experienced during the AR process, and to start to move from tacit knowing-in-action to reflection-inaction. There were those who could not accept the need for the
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change, and who saw presence and listening as incompatible with existing values and the social system and norms in the labour ward. Even those who grasped the opportunity to change were aware of the negative impact on colleagues, and of tacit disapproval from some. Despite a general acceptance of the benefits of genuine caring in labour through the set-up of a good midwife– woman/partner relationship in the first encounter, in this first cycle of the AR process, individual and system-wide norms interfered with enacting the agreed changes. The AR process is collaboratively ongoing to illuminate and develop the system's values, to address this continuing barrier.
Conflict of interest No conflict of interest has been declared by the authors.
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