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Midwives' experiences of learning and teaching being ‘with woman’: A descriptive phenomenological study
Journal Pre-proof Midwives' experiences of learning and teaching being ‘with woman’: A descriptive phenomenological study Zoe Bradfield, Yvonne Hauck, Ravani Duggan, Michelle Kelly PII:
S1471-5953(19)30877-7
DOI:
https://doi.org/10.1016/j.nepr.2020.102699
Reference:
YNEPR 102699
To appear in:
Nurse Education in Practice
Received Date: 15 October 2019 Revised Date:
21 December 2019
Accepted Date: 13 January 2020
Please cite this article as: Bradfield, Z., Yvonne Hauck, , Duggan, R., Kelly, M., Midwives' experiences of learning and teaching being ‘with woman’: A descriptive phenomenological study, Nurse Education in Practice (2020), doi: https://doi.org/10.1016/j.nepr.2020.102699. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
CRediT Author Statement Dr Zoe Bradfield: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Project administration Prof Yvonne Hauck: Conceptualization, Methodology, Formal analysis, Writing - Review & Editing, Visualization A/ Prof Ravani Duggan: Conceptualization, Methodology, Formal analysis, Writing - Review & Editing A/ Prof Michelle Kelly : Conceptualization, Methodology, Formal analysis, Writing - Review & Editing
Title Midwives’ Experiences of Learning and Teaching Being ‘With Woman’: A Descriptive Phenomenological Study
Author’s Names Dr Zoe Bradfield 1, 2 Bentley, Western Australia 6845
Professor Yvonne Hauck 1, 2 Bentley, Western Australia 6845
Associate Professor Ravani Duggan 1 Bentley, Western Australia 6845
Associate Professor Michelle Kelly 1 Bentley, Western Australia 6845
Affiliations 1
Curtin University
Hayman Road Bentley, Western Australia 2
King Edward Memorial Hospital
Subiaco, Western Australia
Corresponding Author Dr Zoe Bradfield [email protected] +61 439 930 206 +61 8 9266 9484 51 Eglinton Crescent HAMERSLEY WA 6022
Acknowledgements The authorship team would like to thank the midwives who were interviewed for this study, for their time and for sharing their wisdom. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest None.
TITLE Midwives’ Experiences of Learning and Teaching Being ‘With Woman’: A Descriptive Phenomenological Study.
ABSTRACT Being ‘with woman’ is a fundamental concept of midwifery philosophy. Minimal evidence explicates ways this important construct is learned or taught. This paper reflects one part of a larger study and explored midwives’ experiences of learning and teaching related to the phenomenon of being ‘with woman’. Using a descriptive phenomenological approach, 31 midwives working in a variety of models in Western Australia were interviewed to explore the phenomenon of being ‘with woman’. Rich descriptions of how midwives learned and taught others to be ‘with woman’ were obtained. Descriptive phenomenology is useful in revealing features of the phenomenon through description of lived experiences of purposively sampled participants. Giorgi’s method was used to analyse data from the two main interview questions. The themes for learning to be ‘with woman’ were observing midwives; inspirational leaders; learning from the women; a variety of experiences enhances learning; and, develops over time. The themes for teaching being ‘with woman’ were, approaches for teaching; teaching is implicit; reliance on observation, comprehension and assimilation. Insights into the learning and teaching of practices supported by professional philosophy offer educators and leaders new knowledge and ways to enhance the transfer of knowledge and skills of being ‘with woman’. Highlights • • • •
Midwives learned to be ‘with woman’ by observing other midwives, women and leaders The ways in which midwives learned to be ‘with woman’ influenced their teaching Teaching was implicit and rarely intentionally taught Reliance on observation, comprehension and assimilation of practices inherent to being ‘with woman’
Keywords: learning, teaching, ‘with woman’, midwifery, philosophy
Background
Being ‘with woman’ is a central construct of the profession of midwifery. The importance of midwives being ‘with woman’, by providing woman centred care is written into the professional philosophy statements, codes
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of conduct and standards for practice of midwifery associations and regulators around the world (ACM, 2004, ICM, 2014, ACM, 2013, ACMN, 2012, Guilliland, 2010, NMBA, 2018, RCM, 2014). International midwifery leaders have emphasised the importance of the phenomenon in professional commentary, urging midwives to apply the philosophical guidance of being ‘with woman’, prioritising the development of a trusting relationship and partnership with the women they offer care to (Isherwood, 1992, Leap and Hunter, 2016, Tritten, 2000). Midwifery academics around the world have reinforced the necessity for midwifery curricula to be aligned with the midwifery philosophy of being ‘with woman’ by providing woman-centred care (Fahy, 1998, Crowther et al., 2019, Gilkison et al., 2015, Hunter, 2015). Despite its centrality, until recent times, there had been very little research conducted on the phenomenon of being ‘with woman’. This lack of empirical knowledge resulted in a reliance on an assumed common understanding about how midwives themselves identify the phenomenon and experience it in the context of clinical practice [reference removed for blinding]. Early research conducted in the United States (US), used a hermeneutic phenomenological approach to explore birth poetry written by ten midwives, which revealed that being ‘with woman’ is a specific and unique attribute of midwifery care (Hunter, 2003). Hunter’s research articulated a definition of being ‘with woman’ derived from a review of professional commentary and research that sought to understand the phenomenon from the perspective of women who had received exemplary care. “…being with woman, a midwifery concept, is defined as presence by midwifery/nursing professionals and social support … a willing and desired relationship between the midwife/nurse and the woman for which the care provider acts as a companion and guide” (Hunter, 2002). This early definition offered a genesis for the conceptualisation of being ‘with woman’. The recognised limitations are that the voice or understanding of practising midwives was not captured in the literature review or development of the definition, as published data were not available. A larger study conducted in Australia, of which this current research forms a part, included interviews from 31 midwives to explore midwives’ perceptions and experiences of being ‘with woman’ in the intrapartum period across a variety of clinical models. Midwives from all models conceptualised the phenomenon of being ‘with woman’ similarly. The findings confirmed that being ‘with woman’ is essential to the professional identity of being a midwife, underpins the partnership midwives form with women and is manifested through womancentred practice. In this research, midwives made clear that providing ‘woman centred’ care was the physical
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outworking; or the way a philosophical alignment to being ‘with woman’ was demonstrated in practise. Features that demonstrated woman-centred care were also provided including advocacy, facilitation of informed decision making, therapeutic presence, kindness and others [reference removed for blinding]. When working in continuity models, midwives described how this model consolidated the partnership between women and midwives enabling them to work with women in a way that aligned with their professional philosophy to provide woman-centred care [reference removed for blinding]. Midwives working in models where care was provided by an unknown midwife, described the essential skills of adaptive expertise and importance of developing a rapid rapport in order to be ‘with woman’ and align care that is centred on the woman’s agenda [reference removed for blinding]. Finally, within the private obstetric model, midwives referred to the importance of the collaborative relationship-triad between the midwife, woman and her contracted obstetrician to facilitate being ‘with woman’ [reference removed for blinding]. This recent Australian research in conjunction with the plethora of professional commentary from midwifery leaders around the globe reinforces the importance of midwives being ‘with woman’ to the identity, professional relationships and the practise of woman-centred midwifery care (Crowther et al., 2019, Dahlberg and Aune, 2013, Hunter et al., 2008, Lundgren and Berg, 2007, Page, 2003). Despite the centrality of the phenomenon to midwifery philosophy and practice, there is no available evidence that addresses how midwives themselves have learned to be ‘with woman’; or, how they teach it to midwifery students and new graduates. An explanation for this gap in knowledge based in evidence is offered by midwifery academic Suzan Ulrich who asserts that there has been minimal research focusing upon the essential features of midwifery practices as guided by philosophical principles (Ulrich, 2004). This identified gap in knowledge highlights a void between the assertions of the centrality of being ‘with woman’ to midwifery philosophy and the calls for inclusion in midwifery curricula despite no currently available empirical evidence about how the phenomenon is learned or taught by midwives. This research fills the current gap in knowledge by describing midwives’ experiences of learning and teaching being ‘with woman’.
Methods Descriptive phenomenology was selected for the study; the methodology has its genesis in the philosophy of phenomenology made popular by Edmund Husserl in the late 1800’s. Originally a mathematician, Husserl was
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interested in the functional and systematic exploration of the lived experience of participants in a way that reduced the influence of the researcher through the process of phenomenological reduction and produced essences representing the necessary and invariant features of a particular phenomenon (Finlay, 2013, Lopez and Willis, 2004). Descriptive phenomenology is known to expound poorly understood aspects of phenomena by uncovering the lived experience of participants (Giorgi, 1997, Moustakas, 1994). This methodology is useful for revealing constituents of a phenomenon in a way that “... neither adds nor subtracts from the invariant intentional object arrived at, but describes it precisely as it presents itself” (Giorgi, 2009). By ‘reducing’ any prior assumptions about being ‘with woman’, the researchers were freed to follow the descriptions of the phenomenon offered by the midwives, revealed in the accounts of their experiences. Owing to the previous dearth in evidence around how midwives themselves learned or continue to teach student midwives to be ‘with woman’, descriptive phenomenology was considered ideal to address our aim to describe midwives’ experiences of the phenomenon. This study was approved by XXX University Human Research Ethics Committee (HREC) (HREC 20XX – XXXX). Study Setting Midwives working in Western Australia (WA) who had provided care to women during labour and birth in the previous 12 months were invited to participate. Participants were recruited from each of the three main models of maternity care where labour and birth care is provided by (1) a known midwife (KM), (2) unknown midwife (UM), or; (3) an unknown midwife working with a known obstetrician (UMKO). These models and how they articulate with place of birth are further explicated in Figure 1. The study was initially advertised at a local midwifery conference with over 170 midwives in attendance, purposively sampled midwives who met the inclusion criteria and expressed an interest were contacted. Participants were recruited as they presented, irrespective of the model they practised in, no preference was given to recruiting one model before the other. Further recruitment occurred through snowball sampling where purposively sampled participants were able to connect the researcher to other midwives with lived experience of the phenomenon of being ‘with woman’, working in a variety of settings. Potential participants were contacted by email and provided an information letter. Written informed consent was obtained by the primary researcher prior to participation.
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Figure 1. Models of Midwifery Labour and Birth Care in Western Australia.
There is no prescribed method for determining the required sample size within qualitative studies. Scholars of descriptive phenomenological research offer differing assertions of ‘up to 20 participants’ (Cleary et al., 2014), and ‘between 3 and 30 participants’ (Cypress, 2018). Giorgi (2006) maintains that the number of participants is of less importance than the variation in the sampling which results in the necessary richness of description. We invited midwives working in all of the different models of care in WA. A cautious approach was taken with regard to recruitment, ensuring that differences in experiences described by participants would be captured, resulting in confirmability within the data (Sim et al., 2018). Recruitment continued until descriptions from within each of the models was complete and repetition of descriptions and concepts was confirmed. In total, 31 female midwives participated; their ages ranged from 35 to 62 years with a range of 3 to 35 years of midwifery experience. Ten midwives worked in standard public models where labour and birth care was provided by an unknown midwife; 11 were from private obstetric-led models where labour care was provided by an unknown midwife and known obstetrician; and a further ten worked in midwifery continuity models
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where care was provided by a known midwife. Nine participants had worked as midwives in countries outside Australia including 7 in England, 1 in Scotland and 1 in New Zealand. Participants had a range of midwifery education levels from different countries; and a total of 22 had previously worked in an alternate model of care; additional demographic data is presented in Table 1. Table 1. Participant Demographic Profile (N= 31)
The first author, a midwife academic with previous clinical experience in each of the three models described, conducted the interviews. The interviewer was known to two participants as past professional acquaintances, the potential for influence on participant responses was considered minimal as there had been a short (position-equivalent) working relationship with two midwives over five years ago. The remaining authors, all
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experienced qualitative researchers, were co-investigators and contributed in proposal development and data analysis. Data Collection Data were collected between December 2016 and July 2017. One to one, in-depth interviews were digitally recorded and transcribed verbatim by a professional transcription service which required the transcriber to provide written assurance of confidentiality. The interviews were conducted at a time and place convenient to the midwife participants who were on-call or shift workers. To facilitate inclusion of midwives working in rural and remote areas, four midwives were interviewed over the telephone which is an acceptable strategy in phenomenological research. This fulfilled the methodological requirement of prioritising potential variation in participant experiences. Data were collected concurrently from midwives working in each of the models. Central to the philosophy and practice of descriptive phenomenological research is the process of adopting a phenomenological attitude which requires the researcher to suspend prior conceptions of the phenomenon under study (Giorgi, 1997). Unique to descriptive phenomenology, this process of phenomenological reduction provokes a deliberate naïveté toward the phenomenon under study which facilitates the researcher to follow the accounts of the participants (Bevan, 2014). Interview questions advised by the philosophy of descriptive phenomenology are broad and open ended in order to allow full and rich descriptions of participant experiences of the phenomenon (Bevan, 2014, Giorgi, 1997). The initial question was ‘please would you describe your experiences of learning how to be ‘with woman’’? This was followed by, ‘thinking about your work with students and other midwives, please describe your experiences of teaching others to be ‘with woman’. The intentional adoption of a deliberate naïveté; with a mandate to describe the phenomenon as the participants experienced it, enabled the interviewer to follow the accounts of the participants adding prompts or questions only as required and if they offered the opportunity to further clarify the phenomenon. For many participants it was observed that there was an apparent ‘discovery’ about the importance of the phenomenon; reflecting on how they themselves learned; and, realising the implied nature that assumed other midwives or students would also learn the practice of being ‘with woman’ in the same way they had (Flood, 2010). Data Analysis
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Giorgi’s 4 step framework for phenomenological data analysis was used and was preceded by the process of phenomenological reduction previously described. Although the steps are presented in a linear fashion for convenience, the process was iterative and commenced at the point of data collection. The 4-step data analysis framework offered by Giorgi (1997) was applied: 1) data immersion, undertaking digital recording of the interviews enabled the primary researcher to be ‘fully present’ and focussed on participant descriptions during the interviews. Each audio interview was transcribed to facilitate review, listening back to the audio recordings ensured consistency and enhanced immersion in the data; 2) dividing the data into parts, individual meaning units or conceptualisations were extracted. Qualitative data analysis software Nvivo (v.12) facilitated management and grouping of the large amounts of data; 3) organisation and transformation of the data. Commonalities and divergence in descriptions of learning and teaching being ‘with woman’ were arranged and expressed to reveal essential features of the phenomenon; and 4) expressing constituents. In this final step, application of the ‘researchers’ disciplinary intuition’ was used to describe concepts which revealed the necessary and invariant constituents of the phenomenon. A key feature of the methodology, disciplinary intuition supports the conveyance of the constructs in the ‘language of the discipline’ from a phenomenological perspective. (Giorgi, 1997). The first author analysed all transcripts which were concurrently and independently analysed by at least one other member of the research team. Initial findings were presented at research team meetings and discussed where consensus was reached regarding themes arising from the two main interview questions which added rigor to the data analysis (Whitehead et al., 2016). The themes are presented in Figure 2.
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Figure 2. Themes for Learning and Teaching being ‘with woman’. The constructs of the phenomenon of learning and teaching being ‘with woman’ are supported by verbatim quotations from the participants. Participant quotes are italicised; and, to enhance clarity and brevity, nonessential words have been omitted and are indicated by an ellipsis (...). In addition, words added, with the intention of providing context are not italicised and have been indicated by square brackets [ ]. A unique
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th
identifier code indicates the participant and the model of care worked in, for example, (P6KM) indicates the 6 midwife interviewed who worked in the Known Midwife (KM) model. Results Analysis revealed descriptions in response to the two main interview questions (Fig 2). Descriptions of midwives’ experiences of learning to be ‘with woman’, revealed five main themes: observing midwives; inspirational leaders; learning from the women; variety of experiences and; develops over time. Midwives’
descriptions of teaching being ‘with woman’, revealed three main themes: approaches for teaching; teaching is implicit and; reliance on observation, comprehension and assimilation. Learning To Be ‘With Woman’ The themes from learning to be ‘with woman’ arose from midwives’ descriptions of the lived experiences of how they themselves learned to be ‘with woman’. Descriptions centred on the factors that influenced their learning of this important midwifery philosophy and practice embedded in woman-centred care. Observing Midwives Midwives described the process of learning to be ‘with woman’ by observing other midwives. This commenced while in the student role and followed through as a continuous professional process of learning through observation: I’ve watched as a student, learnt how to be with women ‘cause it is a learnt thing, you’ve got to see people do it well to learn how to do it well… you actually do learn from other midwives how to be with woman (P6KM). The process of observation then led to an incorporation in praxis: Watching others, watching how they do it. I think when I was a more junior midwife, very much I would watch others and more senior staff …watch what they do and try and model my practice on what they do (P7UM). Participants reflected on desirable and undesirable modelling in clinical practice: Observation of other midwives and how they practice I think has both positive and negatively influenced how I approached [being with woman] (P11UMKO). This strategy resulted in a posture of critical appraisal of characteristics and traits that were seen as either desirable or not in the process of learning to be ‘with woman’. …nearly every midwife you worked with did things differently so it was hard to nail down what the actual skill or information was that you needed to keep but it allowed you to see so many different ways of working and pull out, this is what I do want to be like, this is what I don’t want
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to be like…I loved seeing how different people did that. How did different people set up that relationship (P5UMKO). Inspirational Leaders Individuals identified as inspirational leaders influenced midwives’ conceptualisation and understanding of being with woman which impacted their learning. The importance of inspirational leaders was described as beneficial in facilitating a theoretical understanding of the importance of being ‘with woman’: I was amazingly lucky with the education I got with the lecturers I had when I was at uni [university]. At the time you didn’t realise how amazing it was but you know I had wonderful people like Nicky Leap and Pat Brodie and Hannah Dahlen and all these people were regular lecturers (P5KM). Other well-known international leaders were identified as being pivotal to developing an understanding of the importance of being ‘with woman’: I found out about these revolutionary midwives out there, like Ina May Gaskin (P2KM). Another participant offered: Michel Odent, you know, the knitting midwife … to be more like that (P5UMKO). Knowledge that was evidenced in applied midwifery practice also offered inspiration in the context of the clinical setting. One participant reflected on the strength and guidance provided by clinical mentors that influenced the development of woman-centred practices: my mentor, she was a very officious midwife. I had four midwives that really influenced me and they were all very strong women (P10UM). Another participant described the qualities of a midwife that had offered inspiration which influenced her own development of being ‘with woman’: When she went in the room everyone would just kind of exhale, like that really calming kind of presence I remember this midwife [being ‘with woman’] (P2UM). Learning from the Women Participants reflected on learning to be ‘with woman’ by observing and learning from women themselves. Midwives listened to women’s descriptions of elements of care that were valued, including what they liked or disliked about previous midwifery care: ...learning and talking to women. Of course you know talking to them about their past experiences and oh this amazing midwife or whatever (P7UM). Midwives working in continuity models described how the relationship developed in the context of this model of care provided an environment that fostered hearing and learning from the woman: when you already know a woman’s wishes before she arrives you can be, it’s easy to be with woman and do what she needs rather than try and to put
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something onto her that maybe she doesn’t necessarily want (P5KM). Another strategy to be ‘with woman’ was to listen and learn from the woman’s experience during debriefing opportunities: it’s really important that debrief [to receive] feedback to see how they felt about it [midwifery care] (P2UMKO). Other less formal methods such as taking the time to listen and being open to being led by women were seen equally as valuable ways for midwives to learn what is important to the individual woman, and, therefore, how to be with this woman: [women] do tell you their stories, you very much learn what not to do from that.... physically as well as emotionally, [women] will put your hands where they want them and without having to do anything will get you where they need you to be to support them (P5UMKO). Variety of Experiences Midwives who had the opportunity to work in a variety of clinical settings reported that this helped them to understand and learn various ways of being ‘with woman’ in different contexts: So I think having the variety of background and working in the public and then moving to the private, I think that’s helped ‘round me out’ ‘cause I know, I understand the both models (P3UMKO). Another midwife reflected on how learning to be ‘with woman’ in a different model influenced practices in the current model: I’m lucky in that I’ve had a good grounding and gained a good understanding of midwifery and being with women…because I’ve had what I’ve had previously I find it makes, for me it’s easier to be with the women and overlook some of the stuff that comes from the obstetric led care (P4UMKO). Others reflected on features inherent in the clinical context of previous employment that led them to become aware of factors that might impact on being ‘with woman’ …you were given rooms to look after not women. So I guess that tipped me to the other side [different model] as well, you can’t look after people properly if you’re not ‘with’ them (P3UM). Other participants described that the variety of experiences enabled them to learn that midwives can be ‘with woman’ in whichever circumstance they worked but identified features that facilitate being ‘with woman’ inherent to their current model: I’ve spent a bit of time working in standard models… for my first two years working at this hospital I did rotational [midwifery]. You can still do it [be ‘with woman’]. I mean it’s still wonderful [in fragmented models] but I feel like it’s a hundred times more wonderful when you’ve had the whole [continuity] experience (P5KM). Develops Over Time Participants described that learning to be ‘with woman’ is a continuous process that develops through experience: it [being ‘with woman’] comes with knowledge and experience P3 (UMKO). The accumulation of
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knowledge and understanding through experience reveals both the philosophical and practical elements of the phenomenon of being ‘with woman’. Midwives were emphatic that the knowledge and skills required to be ‘with woman’ could be learned: [being ‘with woman’] can be developed, it definitely can be learned or developed over time (P2UM). Another participant confirmed: It [being ‘with woman’] is something you develop all the time (P4KM). Others shared that in addition to experience, the process of learning to be ‘with woman’ was aided through critical reflection: that experience of doing it, every day you learn something new, how to do something better. So by being with woman you just learn, it’s a skill that I suppose by your experiences… “oh that went well, that didn’t go so well”, just putting together your tool kit (P7UM). Teaching Being ‘With Woman’ The themes describing midwives’ experiences of teaching midwifery students to be ‘with woman’ arose from responses to this related interview question. The themes highlighted the implicit nature of the transference of this central skill and described the approaches that midwives utilise to teach the practices of being ‘with woman’ to students. Approaches for Teaching Midwives shared the approach of modelling practice-behaviours that demonstrate the skill of being ‘with woman’: I guess you can teach it [being ‘with woman’] because it’s by leading by example. I’ve had feedback from students saying “I never thought by watching you that I could do the things that you’ve done” and it’s simple things. If a woman’s on a CTG, you’ve come in and you’re the afternoon shift she’s been on the CTG all morning and you know she’s got an epidural and you come in and ask what she wants and you’ve got your student and then the woman says “I wanted a vaginal birth but look this is what’s happened to me now. I wanted to be upright” and then I’ll say “let’s stand up next to the bed, let’s get a fit ball, let’s do these things” (P10UM) There was a reluctance among midwives to be ‘instructional’ about the ‘right way’ to be ‘with woman’ instead they encouraged students to develop practices unique to them: when I’m with students I’d always say “look this is my practice, then you have to shape your practice” (P7KM). Midwives reported being aware of balancing woman-centered care with teaching opportunities which added to the nuanced nature of clinical
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modelling as a teaching approach: … by modelling and teaching it [being ‘with woman’], if you get a chance you can step out of that situation and bring it up … you have to be very mindful of what’s actually happening in the room without making it a teaching concept (P8UMKO). Teaching is Implicit Midwives disclosed the implicit nature of the teaching of being ‘with woman’: I don’t think I can say “I’m going to go in and show you how to be with woman”, I can’t do that. I’ve learned watching different people and just being a little intuitive with the woman you’re working with, that’s how you are with woman (P10KM). The implicit nature of teaching this important and necessary skill of midwifery was described by one midwife: I don’t think it’s something that most midwives are necessarily conscious of but I think I always assumed that that’s what everyone does (P2KM). The common assertion that being ‘with woman’ is taught by modelling in practice, in conjunction with the ‘unseen’, perhaps even sub-conscious and, embedded nature of being ‘with woman’ highlighted a lack of explicit teaching when working with students: I don’t articulate that as being with woman. I think my actions and my explanations and my discussion [with the woman] contribute towards that picture of what that student thinks midwifery is (P8UM).
Reliance on Observation, Comprehension and Assimilation Midwives reflected on the challenges of relying on the implicit nature of modelling being ‘with woman’, which assumed that the student noticed and comprehended the features of ‘with woman’ care being demonstrated: I guess I’ve taken it that they [midwifery students] would [understand]… we shouldn’t assume they would learn that that is being with woman… but we don’t teach it [smiling and shaking her head] (P10UM). Not only are students expected to understand the implicit modelling of being ‘with woman’ but it is then assumed that students would assimilate this learning into their own practice: I hope by 18 months of watching what I do and watching what other midwives do then they learn, this is what it is to [be with woman] it doesn’t always work, but sometimes something rubs off on them (P7UMKO). This pervasive assumption that students observe what is intended, comprehend and apply the skill of being ‘with woman’ was commonly expressed among the midwife participants:
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[learning to be ‘with woman’] just kind of happens because they [students] are working with you in the room, so what you’re demonstrating to the student that I am being with this woman because this is what I’m doing. So the student is hopefully learning from that. And then watching, observing, the students observe a lot so then the student would be observing the rapport, hopefully (P7UM). Discussion This is the first study to explicitly explore midwives’ experiences of learning and teaching the central midwifery practise of being ‘with woman’. Findings revealed insights into how midwives themselves learned to be ‘with woman’ uncovering a range of strategies including observation of (other) midwives, connection with inspirational leaders, learning from women, accumulating a variety of experiences and continuing to develop practices over time. The themes of ‘watch and learn’ from how midwives themselves learned to be ‘with woman’ were strongly transposed into the ways they taught student midwives to be ‘with woman’. Where approaches of being ‘with woman’ were modelled by the midwife, it was assumed that these were being taught. This demonstrated the implicit nature of teaching and relying on students to observe what was intended to be taught, to comprehend that which was intended to be transferred and then to assimilate these practices into their own developing skills complement. Whilst there are no previous studies that have explored the learning or teaching of midwifery practices from the perspective of qualified midwives, the extant literature connects with some of the themes that emerged from this research. An American cross-sectional study surveyed 125 midwifery students explored the relationship between student perception of preceptor practice and student self-efficacy. Findings revealed that role-modelling by preceptor midwives is key to developing confidence and is conceptualised as self-efficacy for embedding practices advised by midwifery philosophy into care (Jordan and Farley, 2008). Still in the US, a qualitative study of 38 stories written by midwifery students revealed the essential nature of positive midwife preceptor modelling which enhanced midwifery students’ socialisation to the profession (Ulrich, 2004). Similar findings were revealed in our study where participants reflected on the importance of observing other midwives being ‘with woman’ to develop the confidence and skills to do the same in their own practise.
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A recent descriptive qualitative study interviewed nineteen Western Australian student midwives to explore their perceptions and experiences of being ‘with woman’. Students reported that exposure to positive role models was key to consolidating their understanding of how the practice elements of woman-centred care enabled midwives to be ‘with woman’ (Kuliukas et al (under review)). The importance of role models is supported in the findings of our study where qualified midwives revealed the pivotal role of observation of other midwives who were perceived to have been ‘with woman’ in exemplary ways; this was both in their previous roles as students and in their current roles as experienced midwives. A key message from the descriptions of the ways in which midwives taught others (usually students) to be ‘with woman’, was the reliance on the practice of modelling being ‘with woman’. The accounts revealed the implicit nature of knowledge and skill transference. Interconnected with the implied nature of the teaching was a reliance on the student observing and recognising skills or practises the midwife was performing that constituted being ‘with woman’. Assuming the student had observed that which was intended, it was then offered that the students would understand how and why these practices constituted being ‘with woman’ and then begin to assimilate these into their own midwifery practice in an authentic way. Recent commentary from a midwifery academic in the UK described the process of expert midwives’ use of perceptual observation to notice obvious and subliminal cues from women in their care as an integral component of midwifery ‘knowing’ (Power, 2015). It is plausible that this expert reliance on perceptual observation contributes to the implicit nature of teaching the practice of being ‘with woman’ (Finlay, 2013, Lopez and Willis, 2004). The role of preceptors’ modelling as a way of teaching is discussed in extant healthcare literature but lies predominantly focussed on the usefulness to transfer clinical skills such as communication (Gibbs and Kulig, 2017) and more recently, critical thinking (Raymond et al., 2018). One cross sectional study from the US conducted with 125 midwifery students sought to understand the influence that preceptor practice behaviours had on student self-efficacy for two key concepts within midwifery philosophy, therapeutic presence and non-intervention (Jordan and Farley, 2008). The findings of the US study confirmed that preceptor practices strongly influenced socialisation of students to philosophically- based midwifery care which is supported by findings from our study. In both learning and teaching domains, the strategies for transference of midwifery skills that are advised by professional philosophy have been hampered by a lack of clear direction from evidence informed sources
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regarding a comprehensive understanding of the attributes of midwifery philosophy in practice. In addition to the lack of clear direction from the evidence, midwives in a recent study revealed that they found it challenging to describe the phenomenon of being ‘with woman’; despite insisting that it is an essential and identifying feature of midwifery practice (blinded article). The identified struggle of describing characteristics inherent in midwifery practice underpinned by professional philosophy was echoed in a qualitative study where 16 American academics were asked to describe how they incorporated midwifery philosophy into their teaching. The descriptions from the academic midwives were generic and included comments such as , “it’s just a part of me, I don’t think consciously about it” , “I’m on a mission to get the message of the midwifery model of care across to my students” (Doherty, 2017). Noticeably, there were no descriptions of how midwifery philosophy was taught, or what was taught, just that it was important. The challenges experienced by these midwife academics are reinforced in the findings of our WA study which reveal the absence of explicit teaching of midwifery philosophy by clinical midwives either verbally or directly through skills training. This revelation highlights the importance of developing professional language around describing the elements inherent to professional philosophy in order to begin to convey the tangible constructs of practice advised by philosophy. Strengths and Limitations The strengths of this study lie in the diverse sampling that has sought to understand the variety of midwives’ experiences of learning and teaching being ‘with woman’. In-depth interviewing and the use of descriptive phenomenology has resulted in rich descriptions of the process of how midwives have learned and now teach others to be ‘with woman’. Self-selection into this study may indicate that the midwife participants hold distinctive views about being ‘with woman’ compared to other midwives and findings should be considered in this context. Comprehensive demographic data allows the reader to assess the potential transferability of the findings of this research to comparable maternity settings. Conclusion Findings from this study reveal the unique experiences of midwives in learning about and teaching the phenomenon of being ‘with woman’ to others. Midwives reflected on the implicit nature of the way in which they learned, taking inspiration from midwifery leaders and relying on observation of midwives in practice.
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These ways of knowing and learning were echoed in the approaches to teaching others to be ‘with woman’. The new knowledge gained in this study provides important insight into understanding the natural stance of midwives in learning and teaching practices underpinned by professional philosophy. Areas of knowledge where implicit concepts might be made explicit offer opportunities for consideration by educators providing entry to registration and post registration education. The identified importance of clinical modelling for both learning and teaching being ‘with woman’ offers insight for clinical managers and education providers alike as they consider ways of enhancing student and midwife access to positive modelling of practices supported in midwifery philosophy. Abbreviations ACM
Australian College of Midwives
ACMN
American College Nurse Midwives
KM
Known Midwife
NMBA
Nursing and Midwifery Board of Australia
RCM
Royal College of Midwives
UK
United Kingdom
UM
Unknown Midwife
UMKO
Unknown Midwife Known Obstetrician
US
United States
WA
Western Australia
References ACM 2004. Midwifery Philosophy. Australian College of Midwives. ACM 2013. National Midwifery Guidelines for Consultation and Referral. Canberra: Australian College of Midwives. ACMN 2012. Our Philosophy of Care. Silver Spring, Maryland: American College of Nurse - Midwives. BEVAN, M. T. 2014. A Method of Phenomenological Interviewing. Qualitative Health Research, 24, 136-144. CLEARY, M., HORSFALL, J. & HAYTER, M. 2014. Data collection and sampling in qualitative research: does size matter? Journal of Advanced Nursing, 70, 473-475. CROWTHER, S., DEERY, R., DAELLENBACH, R., DAVIES, L., GILKISON, A., KENSINGTON, M. & RANKIN, J. 2019. Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study. Women and Birth, 32, 39-49.
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CYPRESS, B. 2018. Qualitative Research Methods: A Phenomenological Focus. Dimensions of Critical Care Nursing, 37, 302-309. DAHLBERG, U. & AUNE, I. 2013. The woman's birth experience—The effect of interpersonal relationships and continuity of care. Midwifery, 29, 407-415. DOHERTY, M. E. 2017. The Experience of Nurse-Midwives in Teaching Roles. Journal of Nursing Education. FAHY, K. 1998. Being a midwife or doing midwifery? Australian College of Midwives Incorporated Journal, 11, 11-16. FINLAY, L. 2013. Unfolding the Phenomenological Research Process. Journal of Humanistic Psychology, 53, 172201. FLOOD, A. 2010. Understanding phenomenology. Nurse Researcher, 17, 7-15. GIBBS, S. S. & KULIG, J. C. 2017. “We definitely are role models”: Exploring how clinical instructors' influence nursing students' attitudes towards older adults. Nurse Education in Practice, 26, 74-81. GILKISON, A., PAIRMAN, S., MCARA-COUPER, J., KENSINGTON, M. & JAMES, L. 2015. Midwifery education in New Zealand: Education, practice and autonomy. Midwifery. GIORGI, A. 1997. The Theory, Practice, and Evaluation of the Phenomenological Method as a Qualitative Research Procedure. Journal of Phenomenological Psychology, 28, 235-260. GIORGI, A. 2009. The descriptive phenomenological method in psychology: A modified Husserlian approach, Pittsburgh, Duquesne University Press. GUILLILAND, K. 2010. The midwifery partnership : a model for practice / Karen Guilliland and Sally Pairman, Wellington, N.Z.], New Zealand College of Midwives. HUNTER, B., BERG, M., LUNDGREN, I., OLAFSDOTTIR, O. A. & KIRKHAM, M. 2008. Relationships: The hidden threads in the tapestry of maternity care. Midwifery, 24, 132-137. HUNTER, L. 2003. An interpretive exploration of the meaning of being with women during birth for midwives. 3088664 Ph.D., University of San Diego. HUNTER, L. 2015. Being with woman: claiming midwifery space. Practising Midwife, 18, 20-22 3p. HUNTER, L. P. 2002. Being With Woman: A Guiding Concept for the Care of Laboring Women. Journal of Obstetric, Gynaecologic, & Neonatal Nursing, 31, 650-657. ICM 2014. Philosophy and Model of Care. The Hague: International Confederation of Midwives. ISHERWOOD, K. 1992. Are British Midwives With Woman? - The Evidence. Midwifery Matters, 14-17-17. JORDAN, R. & FARLEY, C. L. 2008. The Confidence to Practice Midwifery: Preceptor Influence on Student SelfEfficacy. Journal of Midwifery & Women's Health, 53, 413-420. LEAP, N. & HUNTER, B. 2016. Supporting Women for Labour and Birth. A Thoughtful Guide, Oxon UK, Routledge. LOPEZ, K. & WILLIS, D. 2004. Descriptive versus interpretive phenomenology: their contributions to nursing knowledge. Qualitative Health Research, 14, 726-735. LUNDGREN, I. & BERG, M. 2007. Central concepts in the midwife-woman relationship. Scandinavian Journal of Caring Sciences, 21, 220-228 9p. MOUSTAKAS, C. E. 1994. Phenomenological research methods / Clark Moustakas, Thousand Oaks, Calif., SAGE. NMBA 2018. Midwife standards for practice. Nursing and Midwifery Board of Australia. PAGE, L. 2003. One-to-one Midwifery: Restoring the “with Woman” Relationship in Midwifery. Journal of Midwifery & Women s Health, 48, 119-125. POWER, A. 2015. Contemporary midwifery practice: Art, science or both? British Journal of Midwifery, 23, 654657 4p. RAYMOND, C., PROFETTO-MCGRATH, J., MYRICK, F. & STREAN, W. B. 2018. Balancing the seen and unseen: Nurse educator as role model for critical thinking. Nurse Education in Practice, 31, 41-47. RCM 2014. High Quality Midwifery Care. London: Royal College of Midwives. SIM, J., SAUNDERS, B., WATERFIELD, J. & KINGSTONE, T. 2018. Can sample size in qualitative research be determined a priori? International Journal of Social Research Methodology, 21, 619-634. TRITTEN, J. 2000. A new season in midwifery. Midwifery today with international midwife, 1. ULRICH, S. 2004. First birth stories of student midwives: Keys to professional affective socialization. Journal of midwifery & women's health, 49, 390-397. WHITEHEAD, D., DILWORTH, S. & HIGGINS, I. 2016. Nursing and midwifery research : methods and appraisal for evidence-based practice / Zevia Schneider, Dean Whitehead ; Geri LoBiondo-Wood, Judith Haber. In: SCHNEIDER, Z. (ed.) 5th edition ; Australia and New Zealand edition.. ed.: Chatswood, NSW : Elsevier Australia
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Table 1. Participant Demographic Profile (N= 31)
Demographic variables Gender Female Age 35 to 44 45 to 54 55 to 64 Years of experience as a midwife ≤ 5 years 6 to 15 16 to 25 26 to 35 Level of midwifery education Undergraduate midwifery degree Postgraduate midwifery qualification Hospital –based diploma Country of midwifery education Australia England Scotland New Zealand Current midwifery model Known Midwife (KM) Unknown Midwife Known Obstetrician (UMKO) Unknown Midwife (UM) TOTAL
Participant numbers 31 10 8 13 3 13 4 11 6 13 12 23 6 1 1 10 11 10 31
Conflict of Interest Declarations – Nurse Education in Practice NEP_2019_826 Conflict of Interest The authors confirm that they each have no conflict to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical Approval This study was approved by Curtin University Human Research Ethics Committee (HREC) (HREC 2016–0450).
S1471-5953(19)30877-7
DOI:
https://doi.org/10.1016/j.nepr.2020.102699
Reference:
YNEPR 102699
To appear in:
Nurse Education in Practice
Received Date: 15 October 2019 Revised Date:
21 December 2019
Accepted Date: 13 January 2020
Please cite this article as: Bradfield, Z., Yvonne Hauck, , Duggan, R., Kelly, M., Midwives' experiences of learning and teaching being ‘with woman’: A descriptive phenomenological study, Nurse Education in Practice (2020), doi: https://doi.org/10.1016/j.nepr.2020.102699. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
CRediT Author Statement Dr Zoe Bradfield: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Project administration Prof Yvonne Hauck: Conceptualization, Methodology, Formal analysis, Writing - Review & Editing, Visualization A/ Prof Ravani Duggan: Conceptualization, Methodology, Formal analysis, Writing - Review & Editing A/ Prof Michelle Kelly : Conceptualization, Methodology, Formal analysis, Writing - Review & Editing
Title Midwives’ Experiences of Learning and Teaching Being ‘With Woman’: A Descriptive Phenomenological Study
Author’s Names Dr Zoe Bradfield 1, 2 Bentley, Western Australia 6845
Professor Yvonne Hauck 1, 2 Bentley, Western Australia 6845
Associate Professor Ravani Duggan 1 Bentley, Western Australia 6845
Associate Professor Michelle Kelly 1 Bentley, Western Australia 6845
Affiliations 1
Curtin University
Hayman Road Bentley, Western Australia 2
King Edward Memorial Hospital
Subiaco, Western Australia
Corresponding Author Dr Zoe Bradfield [email protected] +61 439 930 206 +61 8 9266 9484 51 Eglinton Crescent HAMERSLEY WA 6022
Acknowledgements The authorship team would like to thank the midwives who were interviewed for this study, for their time and for sharing their wisdom. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest None.
TITLE Midwives’ Experiences of Learning and Teaching Being ‘With Woman’: A Descriptive Phenomenological Study.
ABSTRACT Being ‘with woman’ is a fundamental concept of midwifery philosophy. Minimal evidence explicates ways this important construct is learned or taught. This paper reflects one part of a larger study and explored midwives’ experiences of learning and teaching related to the phenomenon of being ‘with woman’. Using a descriptive phenomenological approach, 31 midwives working in a variety of models in Western Australia were interviewed to explore the phenomenon of being ‘with woman’. Rich descriptions of how midwives learned and taught others to be ‘with woman’ were obtained. Descriptive phenomenology is useful in revealing features of the phenomenon through description of lived experiences of purposively sampled participants. Giorgi’s method was used to analyse data from the two main interview questions. The themes for learning to be ‘with woman’ were observing midwives; inspirational leaders; learning from the women; a variety of experiences enhances learning; and, develops over time. The themes for teaching being ‘with woman’ were, approaches for teaching; teaching is implicit; reliance on observation, comprehension and assimilation. Insights into the learning and teaching of practices supported by professional philosophy offer educators and leaders new knowledge and ways to enhance the transfer of knowledge and skills of being ‘with woman’. Highlights • • • •
Midwives learned to be ‘with woman’ by observing other midwives, women and leaders The ways in which midwives learned to be ‘with woman’ influenced their teaching Teaching was implicit and rarely intentionally taught Reliance on observation, comprehension and assimilation of practices inherent to being ‘with woman’
Keywords: learning, teaching, ‘with woman’, midwifery, philosophy
Background
Being ‘with woman’ is a central construct of the profession of midwifery. The importance of midwives being ‘with woman’, by providing woman centred care is written into the professional philosophy statements, codes
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of conduct and standards for practice of midwifery associations and regulators around the world (ACM, 2004, ICM, 2014, ACM, 2013, ACMN, 2012, Guilliland, 2010, NMBA, 2018, RCM, 2014). International midwifery leaders have emphasised the importance of the phenomenon in professional commentary, urging midwives to apply the philosophical guidance of being ‘with woman’, prioritising the development of a trusting relationship and partnership with the women they offer care to (Isherwood, 1992, Leap and Hunter, 2016, Tritten, 2000). Midwifery academics around the world have reinforced the necessity for midwifery curricula to be aligned with the midwifery philosophy of being ‘with woman’ by providing woman-centred care (Fahy, 1998, Crowther et al., 2019, Gilkison et al., 2015, Hunter, 2015). Despite its centrality, until recent times, there had been very little research conducted on the phenomenon of being ‘with woman’. This lack of empirical knowledge resulted in a reliance on an assumed common understanding about how midwives themselves identify the phenomenon and experience it in the context of clinical practice [reference removed for blinding]. Early research conducted in the United States (US), used a hermeneutic phenomenological approach to explore birth poetry written by ten midwives, which revealed that being ‘with woman’ is a specific and unique attribute of midwifery care (Hunter, 2003). Hunter’s research articulated a definition of being ‘with woman’ derived from a review of professional commentary and research that sought to understand the phenomenon from the perspective of women who had received exemplary care. “…being with woman, a midwifery concept, is defined as presence by midwifery/nursing professionals and social support … a willing and desired relationship between the midwife/nurse and the woman for which the care provider acts as a companion and guide” (Hunter, 2002). This early definition offered a genesis for the conceptualisation of being ‘with woman’. The recognised limitations are that the voice or understanding of practising midwives was not captured in the literature review or development of the definition, as published data were not available. A larger study conducted in Australia, of which this current research forms a part, included interviews from 31 midwives to explore midwives’ perceptions and experiences of being ‘with woman’ in the intrapartum period across a variety of clinical models. Midwives from all models conceptualised the phenomenon of being ‘with woman’ similarly. The findings confirmed that being ‘with woman’ is essential to the professional identity of being a midwife, underpins the partnership midwives form with women and is manifested through womancentred practice. In this research, midwives made clear that providing ‘woman centred’ care was the physical
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outworking; or the way a philosophical alignment to being ‘with woman’ was demonstrated in practise. Features that demonstrated woman-centred care were also provided including advocacy, facilitation of informed decision making, therapeutic presence, kindness and others [reference removed for blinding]. When working in continuity models, midwives described how this model consolidated the partnership between women and midwives enabling them to work with women in a way that aligned with their professional philosophy to provide woman-centred care [reference removed for blinding]. Midwives working in models where care was provided by an unknown midwife, described the essential skills of adaptive expertise and importance of developing a rapid rapport in order to be ‘with woman’ and align care that is centred on the woman’s agenda [reference removed for blinding]. Finally, within the private obstetric model, midwives referred to the importance of the collaborative relationship-triad between the midwife, woman and her contracted obstetrician to facilitate being ‘with woman’ [reference removed for blinding]. This recent Australian research in conjunction with the plethora of professional commentary from midwifery leaders around the globe reinforces the importance of midwives being ‘with woman’ to the identity, professional relationships and the practise of woman-centred midwifery care (Crowther et al., 2019, Dahlberg and Aune, 2013, Hunter et al., 2008, Lundgren and Berg, 2007, Page, 2003). Despite the centrality of the phenomenon to midwifery philosophy and practice, there is no available evidence that addresses how midwives themselves have learned to be ‘with woman’; or, how they teach it to midwifery students and new graduates. An explanation for this gap in knowledge based in evidence is offered by midwifery academic Suzan Ulrich who asserts that there has been minimal research focusing upon the essential features of midwifery practices as guided by philosophical principles (Ulrich, 2004). This identified gap in knowledge highlights a void between the assertions of the centrality of being ‘with woman’ to midwifery philosophy and the calls for inclusion in midwifery curricula despite no currently available empirical evidence about how the phenomenon is learned or taught by midwives. This research fills the current gap in knowledge by describing midwives’ experiences of learning and teaching being ‘with woman’.
Methods Descriptive phenomenology was selected for the study; the methodology has its genesis in the philosophy of phenomenology made popular by Edmund Husserl in the late 1800’s. Originally a mathematician, Husserl was
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interested in the functional and systematic exploration of the lived experience of participants in a way that reduced the influence of the researcher through the process of phenomenological reduction and produced essences representing the necessary and invariant features of a particular phenomenon (Finlay, 2013, Lopez and Willis, 2004). Descriptive phenomenology is known to expound poorly understood aspects of phenomena by uncovering the lived experience of participants (Giorgi, 1997, Moustakas, 1994). This methodology is useful for revealing constituents of a phenomenon in a way that “... neither adds nor subtracts from the invariant intentional object arrived at, but describes it precisely as it presents itself” (Giorgi, 2009). By ‘reducing’ any prior assumptions about being ‘with woman’, the researchers were freed to follow the descriptions of the phenomenon offered by the midwives, revealed in the accounts of their experiences. Owing to the previous dearth in evidence around how midwives themselves learned or continue to teach student midwives to be ‘with woman’, descriptive phenomenology was considered ideal to address our aim to describe midwives’ experiences of the phenomenon. This study was approved by XXX University Human Research Ethics Committee (HREC) (HREC 20XX – XXXX). Study Setting Midwives working in Western Australia (WA) who had provided care to women during labour and birth in the previous 12 months were invited to participate. Participants were recruited from each of the three main models of maternity care where labour and birth care is provided by (1) a known midwife (KM), (2) unknown midwife (UM), or; (3) an unknown midwife working with a known obstetrician (UMKO). These models and how they articulate with place of birth are further explicated in Figure 1. The study was initially advertised at a local midwifery conference with over 170 midwives in attendance, purposively sampled midwives who met the inclusion criteria and expressed an interest were contacted. Participants were recruited as they presented, irrespective of the model they practised in, no preference was given to recruiting one model before the other. Further recruitment occurred through snowball sampling where purposively sampled participants were able to connect the researcher to other midwives with lived experience of the phenomenon of being ‘with woman’, working in a variety of settings. Potential participants were contacted by email and provided an information letter. Written informed consent was obtained by the primary researcher prior to participation.
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Figure 1. Models of Midwifery Labour and Birth Care in Western Australia.
There is no prescribed method for determining the required sample size within qualitative studies. Scholars of descriptive phenomenological research offer differing assertions of ‘up to 20 participants’ (Cleary et al., 2014), and ‘between 3 and 30 participants’ (Cypress, 2018). Giorgi (2006) maintains that the number of participants is of less importance than the variation in the sampling which results in the necessary richness of description. We invited midwives working in all of the different models of care in WA. A cautious approach was taken with regard to recruitment, ensuring that differences in experiences described by participants would be captured, resulting in confirmability within the data (Sim et al., 2018). Recruitment continued until descriptions from within each of the models was complete and repetition of descriptions and concepts was confirmed. In total, 31 female midwives participated; their ages ranged from 35 to 62 years with a range of 3 to 35 years of midwifery experience. Ten midwives worked in standard public models where labour and birth care was provided by an unknown midwife; 11 were from private obstetric-led models where labour care was provided by an unknown midwife and known obstetrician; and a further ten worked in midwifery continuity models
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where care was provided by a known midwife. Nine participants had worked as midwives in countries outside Australia including 7 in England, 1 in Scotland and 1 in New Zealand. Participants had a range of midwifery education levels from different countries; and a total of 22 had previously worked in an alternate model of care; additional demographic data is presented in Table 1. Table 1. Participant Demographic Profile (N= 31)
The first author, a midwife academic with previous clinical experience in each of the three models described, conducted the interviews. The interviewer was known to two participants as past professional acquaintances, the potential for influence on participant responses was considered minimal as there had been a short (position-equivalent) working relationship with two midwives over five years ago. The remaining authors, all
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experienced qualitative researchers, were co-investigators and contributed in proposal development and data analysis. Data Collection Data were collected between December 2016 and July 2017. One to one, in-depth interviews were digitally recorded and transcribed verbatim by a professional transcription service which required the transcriber to provide written assurance of confidentiality. The interviews were conducted at a time and place convenient to the midwife participants who were on-call or shift workers. To facilitate inclusion of midwives working in rural and remote areas, four midwives were interviewed over the telephone which is an acceptable strategy in phenomenological research. This fulfilled the methodological requirement of prioritising potential variation in participant experiences. Data were collected concurrently from midwives working in each of the models. Central to the philosophy and practice of descriptive phenomenological research is the process of adopting a phenomenological attitude which requires the researcher to suspend prior conceptions of the phenomenon under study (Giorgi, 1997). Unique to descriptive phenomenology, this process of phenomenological reduction provokes a deliberate naïveté toward the phenomenon under study which facilitates the researcher to follow the accounts of the participants (Bevan, 2014). Interview questions advised by the philosophy of descriptive phenomenology are broad and open ended in order to allow full and rich descriptions of participant experiences of the phenomenon (Bevan, 2014, Giorgi, 1997). The initial question was ‘please would you describe your experiences of learning how to be ‘with woman’’? This was followed by, ‘thinking about your work with students and other midwives, please describe your experiences of teaching others to be ‘with woman’. The intentional adoption of a deliberate naïveté; with a mandate to describe the phenomenon as the participants experienced it, enabled the interviewer to follow the accounts of the participants adding prompts or questions only as required and if they offered the opportunity to further clarify the phenomenon. For many participants it was observed that there was an apparent ‘discovery’ about the importance of the phenomenon; reflecting on how they themselves learned; and, realising the implied nature that assumed other midwives or students would also learn the practice of being ‘with woman’ in the same way they had (Flood, 2010). Data Analysis
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Giorgi’s 4 step framework for phenomenological data analysis was used and was preceded by the process of phenomenological reduction previously described. Although the steps are presented in a linear fashion for convenience, the process was iterative and commenced at the point of data collection. The 4-step data analysis framework offered by Giorgi (1997) was applied: 1) data immersion, undertaking digital recording of the interviews enabled the primary researcher to be ‘fully present’ and focussed on participant descriptions during the interviews. Each audio interview was transcribed to facilitate review, listening back to the audio recordings ensured consistency and enhanced immersion in the data; 2) dividing the data into parts, individual meaning units or conceptualisations were extracted. Qualitative data analysis software Nvivo (v.12) facilitated management and grouping of the large amounts of data; 3) organisation and transformation of the data. Commonalities and divergence in descriptions of learning and teaching being ‘with woman’ were arranged and expressed to reveal essential features of the phenomenon; and 4) expressing constituents. In this final step, application of the ‘researchers’ disciplinary intuition’ was used to describe concepts which revealed the necessary and invariant constituents of the phenomenon. A key feature of the methodology, disciplinary intuition supports the conveyance of the constructs in the ‘language of the discipline’ from a phenomenological perspective. (Giorgi, 1997). The first author analysed all transcripts which were concurrently and independently analysed by at least one other member of the research team. Initial findings were presented at research team meetings and discussed where consensus was reached regarding themes arising from the two main interview questions which added rigor to the data analysis (Whitehead et al., 2016). The themes are presented in Figure 2.
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Figure 2. Themes for Learning and Teaching being ‘with woman’. The constructs of the phenomenon of learning and teaching being ‘with woman’ are supported by verbatim quotations from the participants. Participant quotes are italicised; and, to enhance clarity and brevity, nonessential words have been omitted and are indicated by an ellipsis (...). In addition, words added, with the intention of providing context are not italicised and have been indicated by square brackets [ ]. A unique
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th
identifier code indicates the participant and the model of care worked in, for example, (P6KM) indicates the 6 midwife interviewed who worked in the Known Midwife (KM) model. Results Analysis revealed descriptions in response to the two main interview questions (Fig 2). Descriptions of midwives’ experiences of learning to be ‘with woman’, revealed five main themes: observing midwives; inspirational leaders; learning from the women; variety of experiences and; develops over time. Midwives’
descriptions of teaching being ‘with woman’, revealed three main themes: approaches for teaching; teaching is implicit and; reliance on observation, comprehension and assimilation. Learning To Be ‘With Woman’ The themes from learning to be ‘with woman’ arose from midwives’ descriptions of the lived experiences of how they themselves learned to be ‘with woman’. Descriptions centred on the factors that influenced their learning of this important midwifery philosophy and practice embedded in woman-centred care. Observing Midwives Midwives described the process of learning to be ‘with woman’ by observing other midwives. This commenced while in the student role and followed through as a continuous professional process of learning through observation: I’ve watched as a student, learnt how to be with women ‘cause it is a learnt thing, you’ve got to see people do it well to learn how to do it well… you actually do learn from other midwives how to be with woman (P6KM). The process of observation then led to an incorporation in praxis: Watching others, watching how they do it. I think when I was a more junior midwife, very much I would watch others and more senior staff …watch what they do and try and model my practice on what they do (P7UM). Participants reflected on desirable and undesirable modelling in clinical practice: Observation of other midwives and how they practice I think has both positive and negatively influenced how I approached [being with woman] (P11UMKO). This strategy resulted in a posture of critical appraisal of characteristics and traits that were seen as either desirable or not in the process of learning to be ‘with woman’. …nearly every midwife you worked with did things differently so it was hard to nail down what the actual skill or information was that you needed to keep but it allowed you to see so many different ways of working and pull out, this is what I do want to be like, this is what I don’t want
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to be like…I loved seeing how different people did that. How did different people set up that relationship (P5UMKO). Inspirational Leaders Individuals identified as inspirational leaders influenced midwives’ conceptualisation and understanding of being with woman which impacted their learning. The importance of inspirational leaders was described as beneficial in facilitating a theoretical understanding of the importance of being ‘with woman’: I was amazingly lucky with the education I got with the lecturers I had when I was at uni [university]. At the time you didn’t realise how amazing it was but you know I had wonderful people like Nicky Leap and Pat Brodie and Hannah Dahlen and all these people were regular lecturers (P5KM). Other well-known international leaders were identified as being pivotal to developing an understanding of the importance of being ‘with woman’: I found out about these revolutionary midwives out there, like Ina May Gaskin (P2KM). Another participant offered: Michel Odent, you know, the knitting midwife … to be more like that (P5UMKO). Knowledge that was evidenced in applied midwifery practice also offered inspiration in the context of the clinical setting. One participant reflected on the strength and guidance provided by clinical mentors that influenced the development of woman-centred practices: my mentor, she was a very officious midwife. I had four midwives that really influenced me and they were all very strong women (P10UM). Another participant described the qualities of a midwife that had offered inspiration which influenced her own development of being ‘with woman’: When she went in the room everyone would just kind of exhale, like that really calming kind of presence I remember this midwife [being ‘with woman’] (P2UM). Learning from the Women Participants reflected on learning to be ‘with woman’ by observing and learning from women themselves. Midwives listened to women’s descriptions of elements of care that were valued, including what they liked or disliked about previous midwifery care: ...learning and talking to women. Of course you know talking to them about their past experiences and oh this amazing midwife or whatever (P7UM). Midwives working in continuity models described how the relationship developed in the context of this model of care provided an environment that fostered hearing and learning from the woman: when you already know a woman’s wishes before she arrives you can be, it’s easy to be with woman and do what she needs rather than try and to put
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something onto her that maybe she doesn’t necessarily want (P5KM). Another strategy to be ‘with woman’ was to listen and learn from the woman’s experience during debriefing opportunities: it’s really important that debrief [to receive] feedback to see how they felt about it [midwifery care] (P2UMKO). Other less formal methods such as taking the time to listen and being open to being led by women were seen equally as valuable ways for midwives to learn what is important to the individual woman, and, therefore, how to be with this woman: [women] do tell you their stories, you very much learn what not to do from that.... physically as well as emotionally, [women] will put your hands where they want them and without having to do anything will get you where they need you to be to support them (P5UMKO). Variety of Experiences Midwives who had the opportunity to work in a variety of clinical settings reported that this helped them to understand and learn various ways of being ‘with woman’ in different contexts: So I think having the variety of background and working in the public and then moving to the private, I think that’s helped ‘round me out’ ‘cause I know, I understand the both models (P3UMKO). Another midwife reflected on how learning to be ‘with woman’ in a different model influenced practices in the current model: I’m lucky in that I’ve had a good grounding and gained a good understanding of midwifery and being with women…because I’ve had what I’ve had previously I find it makes, for me it’s easier to be with the women and overlook some of the stuff that comes from the obstetric led care (P4UMKO). Others reflected on features inherent in the clinical context of previous employment that led them to become aware of factors that might impact on being ‘with woman’ …you were given rooms to look after not women. So I guess that tipped me to the other side [different model] as well, you can’t look after people properly if you’re not ‘with’ them (P3UM). Other participants described that the variety of experiences enabled them to learn that midwives can be ‘with woman’ in whichever circumstance they worked but identified features that facilitate being ‘with woman’ inherent to their current model: I’ve spent a bit of time working in standard models… for my first two years working at this hospital I did rotational [midwifery]. You can still do it [be ‘with woman’]. I mean it’s still wonderful [in fragmented models] but I feel like it’s a hundred times more wonderful when you’ve had the whole [continuity] experience (P5KM). Develops Over Time Participants described that learning to be ‘with woman’ is a continuous process that develops through experience: it [being ‘with woman’] comes with knowledge and experience P3 (UMKO). The accumulation of
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knowledge and understanding through experience reveals both the philosophical and practical elements of the phenomenon of being ‘with woman’. Midwives were emphatic that the knowledge and skills required to be ‘with woman’ could be learned: [being ‘with woman’] can be developed, it definitely can be learned or developed over time (P2UM). Another participant confirmed: It [being ‘with woman’] is something you develop all the time (P4KM). Others shared that in addition to experience, the process of learning to be ‘with woman’ was aided through critical reflection: that experience of doing it, every day you learn something new, how to do something better. So by being with woman you just learn, it’s a skill that I suppose by your experiences… “oh that went well, that didn’t go so well”, just putting together your tool kit (P7UM). Teaching Being ‘With Woman’ The themes describing midwives’ experiences of teaching midwifery students to be ‘with woman’ arose from responses to this related interview question. The themes highlighted the implicit nature of the transference of this central skill and described the approaches that midwives utilise to teach the practices of being ‘with woman’ to students. Approaches for Teaching Midwives shared the approach of modelling practice-behaviours that demonstrate the skill of being ‘with woman’: I guess you can teach it [being ‘with woman’] because it’s by leading by example. I’ve had feedback from students saying “I never thought by watching you that I could do the things that you’ve done” and it’s simple things. If a woman’s on a CTG, you’ve come in and you’re the afternoon shift she’s been on the CTG all morning and you know she’s got an epidural and you come in and ask what she wants and you’ve got your student and then the woman says “I wanted a vaginal birth but look this is what’s happened to me now. I wanted to be upright” and then I’ll say “let’s stand up next to the bed, let’s get a fit ball, let’s do these things” (P10UM) There was a reluctance among midwives to be ‘instructional’ about the ‘right way’ to be ‘with woman’ instead they encouraged students to develop practices unique to them: when I’m with students I’d always say “look this is my practice, then you have to shape your practice” (P7KM). Midwives reported being aware of balancing woman-centered care with teaching opportunities which added to the nuanced nature of clinical
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modelling as a teaching approach: … by modelling and teaching it [being ‘with woman’], if you get a chance you can step out of that situation and bring it up … you have to be very mindful of what’s actually happening in the room without making it a teaching concept (P8UMKO). Teaching is Implicit Midwives disclosed the implicit nature of the teaching of being ‘with woman’: I don’t think I can say “I’m going to go in and show you how to be with woman”, I can’t do that. I’ve learned watching different people and just being a little intuitive with the woman you’re working with, that’s how you are with woman (P10KM). The implicit nature of teaching this important and necessary skill of midwifery was described by one midwife: I don’t think it’s something that most midwives are necessarily conscious of but I think I always assumed that that’s what everyone does (P2KM). The common assertion that being ‘with woman’ is taught by modelling in practice, in conjunction with the ‘unseen’, perhaps even sub-conscious and, embedded nature of being ‘with woman’ highlighted a lack of explicit teaching when working with students: I don’t articulate that as being with woman. I think my actions and my explanations and my discussion [with the woman] contribute towards that picture of what that student thinks midwifery is (P8UM).
Reliance on Observation, Comprehension and Assimilation Midwives reflected on the challenges of relying on the implicit nature of modelling being ‘with woman’, which assumed that the student noticed and comprehended the features of ‘with woman’ care being demonstrated: I guess I’ve taken it that they [midwifery students] would [understand]… we shouldn’t assume they would learn that that is being with woman… but we don’t teach it [smiling and shaking her head] (P10UM). Not only are students expected to understand the implicit modelling of being ‘with woman’ but it is then assumed that students would assimilate this learning into their own practice: I hope by 18 months of watching what I do and watching what other midwives do then they learn, this is what it is to [be with woman] it doesn’t always work, but sometimes something rubs off on them (P7UMKO). This pervasive assumption that students observe what is intended, comprehend and apply the skill of being ‘with woman’ was commonly expressed among the midwife participants:
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[learning to be ‘with woman’] just kind of happens because they [students] are working with you in the room, so what you’re demonstrating to the student that I am being with this woman because this is what I’m doing. So the student is hopefully learning from that. And then watching, observing, the students observe a lot so then the student would be observing the rapport, hopefully (P7UM). Discussion This is the first study to explicitly explore midwives’ experiences of learning and teaching the central midwifery practise of being ‘with woman’. Findings revealed insights into how midwives themselves learned to be ‘with woman’ uncovering a range of strategies including observation of (other) midwives, connection with inspirational leaders, learning from women, accumulating a variety of experiences and continuing to develop practices over time. The themes of ‘watch and learn’ from how midwives themselves learned to be ‘with woman’ were strongly transposed into the ways they taught student midwives to be ‘with woman’. Where approaches of being ‘with woman’ were modelled by the midwife, it was assumed that these were being taught. This demonstrated the implicit nature of teaching and relying on students to observe what was intended to be taught, to comprehend that which was intended to be transferred and then to assimilate these practices into their own developing skills complement. Whilst there are no previous studies that have explored the learning or teaching of midwifery practices from the perspective of qualified midwives, the extant literature connects with some of the themes that emerged from this research. An American cross-sectional study surveyed 125 midwifery students explored the relationship between student perception of preceptor practice and student self-efficacy. Findings revealed that role-modelling by preceptor midwives is key to developing confidence and is conceptualised as self-efficacy for embedding practices advised by midwifery philosophy into care (Jordan and Farley, 2008). Still in the US, a qualitative study of 38 stories written by midwifery students revealed the essential nature of positive midwife preceptor modelling which enhanced midwifery students’ socialisation to the profession (Ulrich, 2004). Similar findings were revealed in our study where participants reflected on the importance of observing other midwives being ‘with woman’ to develop the confidence and skills to do the same in their own practise.
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A recent descriptive qualitative study interviewed nineteen Western Australian student midwives to explore their perceptions and experiences of being ‘with woman’. Students reported that exposure to positive role models was key to consolidating their understanding of how the practice elements of woman-centred care enabled midwives to be ‘with woman’ (Kuliukas et al (under review)). The importance of role models is supported in the findings of our study where qualified midwives revealed the pivotal role of observation of other midwives who were perceived to have been ‘with woman’ in exemplary ways; this was both in their previous roles as students and in their current roles as experienced midwives. A key message from the descriptions of the ways in which midwives taught others (usually students) to be ‘with woman’, was the reliance on the practice of modelling being ‘with woman’. The accounts revealed the implicit nature of knowledge and skill transference. Interconnected with the implied nature of the teaching was a reliance on the student observing and recognising skills or practises the midwife was performing that constituted being ‘with woman’. Assuming the student had observed that which was intended, it was then offered that the students would understand how and why these practices constituted being ‘with woman’ and then begin to assimilate these into their own midwifery practice in an authentic way. Recent commentary from a midwifery academic in the UK described the process of expert midwives’ use of perceptual observation to notice obvious and subliminal cues from women in their care as an integral component of midwifery ‘knowing’ (Power, 2015). It is plausible that this expert reliance on perceptual observation contributes to the implicit nature of teaching the practice of being ‘with woman’ (Finlay, 2013, Lopez and Willis, 2004). The role of preceptors’ modelling as a way of teaching is discussed in extant healthcare literature but lies predominantly focussed on the usefulness to transfer clinical skills such as communication (Gibbs and Kulig, 2017) and more recently, critical thinking (Raymond et al., 2018). One cross sectional study from the US conducted with 125 midwifery students sought to understand the influence that preceptor practice behaviours had on student self-efficacy for two key concepts within midwifery philosophy, therapeutic presence and non-intervention (Jordan and Farley, 2008). The findings of the US study confirmed that preceptor practices strongly influenced socialisation of students to philosophically- based midwifery care which is supported by findings from our study. In both learning and teaching domains, the strategies for transference of midwifery skills that are advised by professional philosophy have been hampered by a lack of clear direction from evidence informed sources
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regarding a comprehensive understanding of the attributes of midwifery philosophy in practice. In addition to the lack of clear direction from the evidence, midwives in a recent study revealed that they found it challenging to describe the phenomenon of being ‘with woman’; despite insisting that it is an essential and identifying feature of midwifery practice (blinded article). The identified struggle of describing characteristics inherent in midwifery practice underpinned by professional philosophy was echoed in a qualitative study where 16 American academics were asked to describe how they incorporated midwifery philosophy into their teaching. The descriptions from the academic midwives were generic and included comments such as , “it’s just a part of me, I don’t think consciously about it” , “I’m on a mission to get the message of the midwifery model of care across to my students” (Doherty, 2017). Noticeably, there were no descriptions of how midwifery philosophy was taught, or what was taught, just that it was important. The challenges experienced by these midwife academics are reinforced in the findings of our WA study which reveal the absence of explicit teaching of midwifery philosophy by clinical midwives either verbally or directly through skills training. This revelation highlights the importance of developing professional language around describing the elements inherent to professional philosophy in order to begin to convey the tangible constructs of practice advised by philosophy. Strengths and Limitations The strengths of this study lie in the diverse sampling that has sought to understand the variety of midwives’ experiences of learning and teaching being ‘with woman’. In-depth interviewing and the use of descriptive phenomenology has resulted in rich descriptions of the process of how midwives have learned and now teach others to be ‘with woman’. Self-selection into this study may indicate that the midwife participants hold distinctive views about being ‘with woman’ compared to other midwives and findings should be considered in this context. Comprehensive demographic data allows the reader to assess the potential transferability of the findings of this research to comparable maternity settings. Conclusion Findings from this study reveal the unique experiences of midwives in learning about and teaching the phenomenon of being ‘with woman’ to others. Midwives reflected on the implicit nature of the way in which they learned, taking inspiration from midwifery leaders and relying on observation of midwives in practice.
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These ways of knowing and learning were echoed in the approaches to teaching others to be ‘with woman’. The new knowledge gained in this study provides important insight into understanding the natural stance of midwives in learning and teaching practices underpinned by professional philosophy. Areas of knowledge where implicit concepts might be made explicit offer opportunities for consideration by educators providing entry to registration and post registration education. The identified importance of clinical modelling for both learning and teaching being ‘with woman’ offers insight for clinical managers and education providers alike as they consider ways of enhancing student and midwife access to positive modelling of practices supported in midwifery philosophy. Abbreviations ACM
Australian College of Midwives
ACMN
American College Nurse Midwives
KM
Known Midwife
NMBA
Nursing and Midwifery Board of Australia
RCM
Royal College of Midwives
UK
United Kingdom
UM
Unknown Midwife
UMKO
Unknown Midwife Known Obstetrician
US
United States
WA
Western Australia
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Table 1. Participant Demographic Profile (N= 31)
Demographic variables Gender Female Age 35 to 44 45 to 54 55 to 64 Years of experience as a midwife ≤ 5 years 6 to 15 16 to 25 26 to 35 Level of midwifery education Undergraduate midwifery degree Postgraduate midwifery qualification Hospital –based diploma Country of midwifery education Australia England Scotland New Zealand Current midwifery model Known Midwife (KM) Unknown Midwife Known Obstetrician (UMKO) Unknown Midwife (UM) TOTAL
Participant numbers 31 10 8 13 3 13 4 11 6 13 12 23 6 1 1 10 11 10 31
Conflict of Interest Declarations – Nurse Education in Practice NEP_2019_826 Conflict of Interest The authors confirm that they each have no conflict to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical Approval This study was approved by Curtin University Human Research Ethics Committee (HREC) (HREC 2016–0450).