The practice reality of ward based midwifery care: An exploration of aspirations and restrictions

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Contents lists available at ScienceDirect

Women and Birth journal homepage: www.elsevier.com/locate/wombi

The practice reality of ward based midwifery care: An exploration of aspirations and restrictions Lucy Lewisa,b,* , Courtney Barnesc , Lauren Robertsc, Laura McLeodc, Angela Elliottc , Yvonne L. Haucka,b a b c

School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Perth, Western Australia, 6102, Australia Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Perth, Western Australia, 6008, Australia King Edward Memorial Hospital, Subiaco, Perth, Western Australia, 6008, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 5 July 2019 Received in revised form 25 August 2019 Accepted 26 August 2019 Available online xxx

Background: This paper reports on research that explores the experience of the ward based midwife, as research suggests workplace balance is problematic. Aim: To explore the processes and practices around ward based clinical engagement and its impact in an Australian public tertiary obstetric unit. Methods: A qualitative descriptive study was undertaken. Focus groups were used to gather data. Groups were audio recorded and transcribed verbatim. Thematic analysis was continued until data saturation was achieved. Findings: Seven focus groups involving 40 midwives were conducted. Midwives’ voices suggested tensions arose when their aspirations around core professional values and camaraderie were compromised by the practice realism of the ward. Furthermore, they described frustration with imposed restrictions which governed their working environment. These occurred outside the ward, had a direct impact on how it functioned, and were perceived to be out of the midwives’ control. Midwives experiencing emotional distress revealed they were carrying a burden. Two burdens were described: disengagement and what have I missed? Conclusion: Thought must be given to how the art of midwifery is practiced on the ward. Ignoring the growing body of literature on this subject will be problematic for both midwives and women, as midwives will be disempowered to foster women’s capabilities through tailored, supportive and respectful care. © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Keywords: Qualitative Focus groups Thematic analysis Midwives’ perceptions Ward based care Workplace balance

Statement of significance

Problem or issue Midwives’ workplace balance has the potential to be problematic, as the processes and practices around ward based clinical engagement can negatively impact wellbeing.

* Corresponding author at: School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Perth, Western Australia, 6102, Australia. E-mail addresses: [email protected] (L. Lewis), [email protected] (C. Barnes), [email protected] (L. Roberts), [email protected] (L. McLeod), [email protected] (A. Elliott), [email protected], [email protected] (Y.L. Hauck).

What is already known Midwives’ emotional wellbeing is challenged by their working conditions. Problematic workplace variables include: not working in a continuity of care model; lack of autonomy; low collegial support; and being short staffed. What this paper adds Midwives’ perceptions of their working environment were conceptualised as four categories: aspirations; compromised aspirations; imposed restrictions; and carrying a burden. Of these categories, two were perceived to challenge midwives’ emotional wellbeing: compromised aspirations and imposed restrictions. Midwives experiencing emotional distress revealed they were carrying a burden. Two burdens were described: disengagement and what have I missed?

http://dx.doi.org/10.1016/j.wombi.2019.08.010 1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: L. Lewis, et al., The practice reality of ward based midwifery care: An exploration of aspirations and restrictions, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.010

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1. Introduction This paper explores the lived experience of the ward based midwife in a tertiary obstetric environment, as research suggests workplace balance is problematic for midwives emotional wellbeing. Additionally, research1 has linked midwives emotional distress to the standard of care women and their families’ receive. Therefore, understanding the sources of midwives emotional distress has implications for quality of care. To contextualise our study it is important to consider what constitutes midwifery, as opposed to obstetric practice. Whilst the concept of midwifery practice is unique to each individual, midwives professional identity is aligned with the inception of the word ‘midwife’. Derived from two Old English words ‘mid’ (with) and ‘wif’ (woman),2 the art of midwifery has evolved from the action it represents, that of ‘being with’ a woman during childbirth. A recent integrated review performed to gain a contemporary overview of midwives ‘being with woman’ revealed this concept is synonymous with midwifery practice, being entwined with the profession’s philosophy.3 We propose this definition is of importance to the current paper because ‘being with woman’ represents a key set of professional values held by the midwifery profession. The core of these values is the notion of holistic care guided by a professional framework of autonomy, ethics and accountability.4 Renfrew et al.5 delved further into this topic, utilising international definitions and current practice models. They mapped the scope of midwifery and surmised the provision of midwifery care should strengthen women’s capabilities, being tailored, preventive, supportive and respectful. Having defined the concept of what it means to be a midwife, it is important to consider the culture in which midwifery care is delivered. Davis-Floyd6 produced the formative work in relation to how the normative components of midwifery care are balanced within professional and organisational constraints. Starting with the stance that the ritual of birth is culturally reflective, two paradigms were initially presented: technocratic and holistic.6 The technocratic model categorises birth as a mechanical process subjugated by medical knowledge, its mirror image is the holistic model where women undertake the hard work of birth guided by their intuitive knowledge. Building on these two paradigms DavisFloyd introduced a third intermediate paradigm, where science and technology were balanced with humanism.7 In this paradigm information and decision making is shared between midwife and woman. There is also a balance between the individual needs of the midwife and the institution they work under. This workplace balance is potentially problematic, as it is dependent on individuals being able to sustain their values and aspirations within the organisational constraints of one’s place of work.8 Newly qualified midwives are vulnerable to their working environment.9–12 Having the confidence to question and advocate for women is often difficult for the transitioning midwife.10 There is evidence that having continuity with women and midwifery colleagues enhances confidence9,10 and that working in an environment where newly qualified midwives are hindered from providing woman-centred care can be disadvantageous.9 Having exposure to positive role models, helps build communication skills.13 The importance of having constructive, positive support from midwifery mentors/preceptors is particularly beneficial.11 However, in cultures where workplace adversity exists newly qualified midwives and preceptors often find it difficult to meet due to staff shortages, time constraints and being rostered to work different shifts.11,13 There is an absence of longitudinal research exploring how the newly qualified midwife integrates with their workplace. As an analogy can be drawn between the newly qualified midwife and the nursing neophyte, we use this example to illustrate how

integration into the workplace over time relates to an individual’s core satisfaction. Maben et al.8 illustrated that organisational constraints were a threat to being able to implement one’s ideals and values into practice. After two years in practice, neophytes were categorised as either sustained, compromised or crushed idealists. Further research led by Maben et al.14 explored how nurses’ work experiences impact patient experiences. Their research concluded that the two were entwined, with patient experience being closely linked to nurses’ work experiences.14 This approach to ideals and dissatisfaction has been questioned,15 as it fails to incorporate how nurses socialise themselves in terms of their professional identity. Using a backdrop of theories around professional identity in nursing and medicine, this research positioned itself to explore nursing neophytes’ experience within the workplace.15 Findings illuminated two suppositions alongside idealism: neophytes distanced themselves from qualified nurses who provided poor care and did not challenge those who provided poor care. The author’s surmised socialisation in nursing is problematic, as it can prompt individuals to endorse group solidarity but also prompt distance from senior members of the profession.15 Although the focus of this paper is not solely around the experience of the neophyte midwife, it illustrates the negative impact a health system may have on being able to align the professional values and aspirations of ‘being with woman’ and the tenets of the midwifery model they work under. Therefore, before we move on it is important to consider the historical and current context of this analysis, because it illustrates this work was undertaken within a pressured system, and that this pressure was sustained and cyclical. 1.1. Historical context of the study An inquiry was commissioned by the Metropolitan Board of Western Australia to investigate the provision of care at the study centre between 1990 and 200016 . Key findings from the inquiry raised important issues about: leadership and culture; accountability and responsibility; systems for safety and quality; support and development of staff; and concern and compassion for women and their families. The report surmised that safe, exemplary care requires skilled health care clinicians as well as well-designed systems of care, and that systematic failures had led to adverse events.17 Research investigating midwives’ experiences of the inquiry found they perceived their working environment as unsafe and developed coping strategies to protect themselves. This had a negative impact on their: confidence; clinical decisions; interdisciplinary relationships; and their relationships with women. Some midwives revealed they did not believe care for low risk women was possible in the tertiary environment.18 1.2. Context of the current study The data presented in this paper were collected in alignment with a hospital wide review to evaluate clinical engagement in our Health Service, requested by the study site’s Chief Executive and Board in 2018. The review was prompted by senior clinicians at the hospital who were concerned about timely involvement in decision-making and transparency of communication with the hospital executive and its governing board. As the study was being undertaken, a series of media reports claiming that Australia’s maternity system was failing new mothers,19 hit Australia. These included an opinion piece purporting ‘a shambolic birth system’.20 Two national news broadcasts21,22 sensationalised the articles’ findings, detailing staff shortages, substandard care and new mothers being discharged early without adequate support. Whilst our analysis was being

Please cite this article in press as: L. Lewis, et al., The practice reality of ward based midwifery care: An exploration of aspirations and restrictions, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.010

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undertaken, a further national news segment was shown,23 airing the sentiments of two whistle-blowers. Their concerning sentiments ‘as a mum myself I would not give birth in the hospital I work in’ and harrowing predictions ‘babies are going to die and so are mums’, provided a shocking and emotive overview of the state of Australia’s maternity system. The aim of this research was to perform a focused examination of midwifery processes and practices around clinical engagement and its impact, by exploring midwives’ perceptions of providing ward based care in an Australian public tertiary obstetric unit. 2. Methods 2.1. Study design Two factors impacted our study design. Firstly, the knowledge gleaned through an overview of the literature which discussed what constitutes midwifery care, the organisational constraints in which it is delivered and the notion midwives enter the profession with an idealised view of the art of midwifery. Secondly, our desire to explore midwives’ perceptions of providing care in an Australian tertiary obstetric hospital, in alignment with the hospital wide review was considered. Therefore the use of a qualitative descriptive design was deemed appropriate.24–27 2.2. The questions Questions for the focus groups were developed from the information gleaned from our review of the literature and through brainstorming within the research team based on their clinical knowledge of the practice setting. Three key questions were developed. Question one asked ‘What do you enjoy about your working environment?’ A prompt was utilised asking midwives to give specific examples in relation to what they enjoyed about their working environment. Question two asked ‘What do you find challenging in relation to your working environment?’ The prompt for this question asked midwives if they could give a description of a situation at work they found challenging. Finally, question three asked ‘How do you deal with workplace challenges?’ The prompt asked midwives to describe any coping strategies they used. 2.3. Sampling The study was undertaken at a public tertiary maternity hospital in Western Australia (WA), which has approximately 5700 births annually. Midwives working on one of the hospital’s three obstetric wards were invited to participate in the study. These wards provide round-the-clock care, predominantly for women and their infants post birth. However, if a pregnant woman requires an inpatient stay, she is also cared for on one of these wards. We utilised a number of recruitment strategies. Posters (containing the research questions, how to register for a focus group and that the research was voluntary) were placed in the communication book, handover area, break room, and behind the toilet door on each ward. Information from the poster was uploaded into the wards’ electronic newsletter. The research was also mentioned during the ‘huddle’ (a pre-shift catch-up). On the day that a focus group was planned, one of our research team spoke with the ward coordinators to remind them that a focus group was scheduled. Finally, midwives interested in participating in the research were asked to contact the Clinical Midwifery Consultant, who booked them into a focus group. Ethics approval was gained from the study setting’s Human Research Ethics Committee (Approval Number QK27231).

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2.4. Data collection The focus groups were held in a mothercraft room on the same ward, over a period of two months from October to December 2018. Before commencing the focus groups, the facilitators (LL, CB and LR) reminded participating midwives: their participation was voluntary; to maintain privacy they would be assigned a unique numerical identifier; discussions/sentiments mentioned during the focus group should ‘remain in the room’; the focus group would be audio recorded; and that two members of the research team would be present during the focus group (one to facilitate the research and the other to observe and take notes on interactions and non-verbal cues between the focus group attendees). Following verbal consent to these conditions, we asked midwives to record their name on a separate sheet of paper if they would like a certificate of acknowledgement for their participation to add to their professional portfolio. We also made the midwives aware that they were free to take a contact card, with details of the free counselling service provided by the hospital. These were placed on a table, at the door entry. Finally, we asked for de-identified information about their age and the number of years they had worked as a midwife. 2.5. Data analysis Data were transcribed by an experienced audio typist. The research team consisted of four clinical and two academic midwives, with varying clinical experiences supporting women in a ward environment. These six team members analysed a crosssection of transcripts ensuring each data source was reviewed by two team members. Using Braun and Clark’s six steps of thematic analysis (familiarisation with the data; initial coding generation; searching for themes based on the initial coding; review of the themes; theme definition and labelling; and report writing)25 our team deconstructed the data, with patterns emerging and similarities being revealed through the midwives’ words and shared experiences.24–26 Throughout the analysis our team met weekly over two months to negotiate, clarify and refine the categories. Disagreements were resolved around interpretation through negotiation and referring back to the data; analysis continued until data saturation was achieved. Finally, member checks25,28 were undertaken with six of the midwife participants, who were asked to check that the final categories and their definitions were aligned with and reflected what was shared during the focus groups. 3. Results 3.1. Description of midwives Of the 40 participating midwives, the minority (15%; 6 of 40) were 25 years or younger, with equal numbers being 26–40 years or 41 years or older (42.5%; 17 of 40). Midwives had spent: <2 years (30%; 12 of 40); 2–5 years (20%; 8 of 40); 6–20 years (40%; 16 of 40); or 21 years (10%; 4 of 40) working as a midwife. 3.2. Focus group characteristics and discourse Midwives supported each other to attend a focus group by taking on each other’s workloads so their colleagues could attend. A number of midwives used their lunch break to attend a group. Of the seven focus groups, six were held in the daytime. To enable midwives to attend a group, they were held in the over-lap between the morning and afternoon shifts. One focus group was held at night. So that night shift midwives could attend a group, midwives working on the afternoon shift altered or extended their

Please cite this article in press as: L. Lewis, et al., The practice reality of ward based midwifery care: An exploration of aspirations and restrictions, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.010

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working times to enable their colleagues to attend. Four focus groups were postponed and rescheduled due to staff not being able to be released from the ward due to their clinical workload. Group interviews lasted between 40 and 50 minutes. There was consensus between groups in relation to the topics discussed, with group members building on and supporting each other’s sentiments. It was clear some of the group members used the groups to vent their fears and frustrations, in these scenarios it was challenging to keep the discourse focused on the topic. Two of the groups were attended by ward managers. In one of these groups the discourse was initially guarded and centred on organisational constraints. While the study was being undertaken, an adverse event occurred on one of the wards. As the ward midwives were still grieving and coming to terms with the event, focus groups were suspended for a month. On one occasion a participant became visibly upset and the focus group was suspended so the midwife could be supported by colleagues. 3.3. Focus group findings Findings are supported with direct quotes from the midwives’ stories. A coding system for each focus group (F1-F7) and participant (P1-P7) was used to ensure midwives’ confidentiality and privacy was respected. Analysis revealed that midwives’ perceptions of their working environment on the ward were conceptualised as four main categories: aspirations; compromised aspirations; imposed restrictions; and carrying a burden. 3.3.1. Aspirations: being the midwife you want to be Many of the midwives revealed the importance of the core professional values they aspired to in relation to working in partnership and alongside women, to strengthen women’s capabilities to care for themselves and their newborn infants. One midwife summarised this as a: ‘shared vision that we are all working towards the same thing. We’re all working towards good outcomes for women and good outcomes for babies . . . you want to walk out feeling like you made a difference’ (F2:P3). This shared vision incorporated values of care such as empowerment of women: ‘A lot of the women are quite complex so it’s really important as midwives we empower them’ (F1:P7) and building trust: ‘I had a lady admitted yesterday and she’s got lots of social issues and she needed to go for a cigarette . . . she trusted me to take care of her baby’ (F1:P1). Enabling values to be achieved took time, which was viewed as an asset and facilitated ‘being with women’: ‘I enjoy spending time with women, building rapport to provide education and send them on their way’ (F4:P6), a rarity: ‘I like the very rare moments where you actually have time to sit with women and speak to them’ (F7:P2) and a luxury: ‘I feel like I’ve had a bit of a lighter load today compared to usual and I feel like I’ve really been able to spend the time with my women that I’ve wanted to and we don’t usually get the opportunity to do that’ (F2:P2). Midwives also aspired to being able to give women continuity of care. As one midwife explained: ‘I’ve had a lady for the last couple of days that was quite intense, but they get more confident with you being there because you’re constantly there, the same person over and over’ (F1:P2). This conversational thread was continued by her colleague: ‘It does make it more enjoyable when you get the same woman two days in a row because you have a relationship with them and you can start where you left off the day before’ (F1:P5). 3.3.2. Compromised aspirations: not giving women the care they deserve Midwives’ discourse revealed their aspirations of ‘being with woman’ were compromised by the practice realism of the ward. Not giving women the care they deserve was the inverse of ‘being

with woman’ and was clearly defined by one midwife: ‘Not only do we feel we’re not giving them [women] the care they deserve, they’re probably leaving the hospital with their heads spinning’ (F3:P5). Whilst another narrated ‘We’re aiming for excellence and I think we all give a lot to try to get there but you don’t have the staff or the time to give that excellent care you want to’ (F5:P2). This caused frustration especially when midwives were not able to be with women who had asked for empathy: ‘You know they [the women] might tell me something deeply personal and I’ve got to go and answer another bell and I feel like I’m letting them down’ (F4:P2). Another midwife clarified: ‘If they’re low risk they don’t get any, very limited care and that’s not fair’ (F6:P4). Midwives proffered numerous recollections of underserved care: ‘That poor mum with twins. I just had to tell her‘look, you’re going to have to do the feeds and temperatures on your own because I’m not going to get in in time and that’s all I can do’ (F7:P2). Another midwife rationalised her reason for not being able to give the care she aspired to: ‘I had another complex one who was a young adolescent . . . I’ve been with this girl for three days and I’ve tried my best but there’s only so much time I can give her and she’s not there yet. I can only do midwifery care for the standard midwifery person’ (F5:P3). 3.3.3. Aspirations: valuing camaraderie The emergence of the concept of camaraderie acknowledged that midwives are social beings who aspire to a working environment where they can work alongside other midwives in a supportive ward based community: ‘It’s about the camaraderie . . . it’s a challenging environment, in challenging environments people bond. I think that’s what happens on a ward’ (F5:P4). Camaraderie was forged on: ‘solidarity’ (F2:P3); a shared ‘understanding’ (F4:P3, F5:P1, F7:3); and working as a ‘team’ (F1:P7, F3P:4, F3:P5, F5:P5). This built community: ‘If we’ve built community with each other, we’re there for each other’ (F6:P3). One midwife explained how she aspired to working in supportive social networks because: ‘Sometimes you have really emotionally difficult days at work with a lot of stuff and horrible stories that you hear and things you’re carrying round and it’s so nice to be able to feel like you’ve got people you can talk to about those things’ (F2:P6). Another described the value of this emotional support: ‘We had a lady who had a FDIU [Fetal Death In Utero] and the midwife came out of the room crying and there was a whole group of us giving her a hug’ (F4:P2). 3.3.4. Compromised aspirations: can’t give or get support Aspirations of camaraderie were compromised by the practice realism of the ward which prevented midwives from being able to be together, form community and reach an understanding with and of each other. One midwife explained: ‘Sometimes I feel that it’s hard to go up and talk to other staff members because they’re so busy and they’re running around and sometimes it’s just like an extra burden’ (F3:P3). Another explained how the nature of her work meant she worked parallel to, but not together with the other midwives on her ward: ‘Unless they [a midwifery colleague] were obviously distressed in front of you. You would not know that. Sometimes when you’re looking after patients and you don’t stop long enough to see anyone else. You know you walk past them [other midwives], if you’re lucky you walk past them in the ward corridor, as they’re walking into another room and you’re going into another room . . . It’s hard then to know whether they’re ok or they’re not ok.’ (F3:P7). Another midwife perceived that flexible shift times were not conducive to building connections and camaraderie with colleagues:

Please cite this article in press as: L. Lewis, et al., The practice reality of ward based midwifery care: An exploration of aspirations and restrictions, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.010

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‘There’s a challenge with all the different start times. Previously everyone was doing eight hour shifts. Everyone would take a break at the same time. It meant you could talk to people and get support which was helpful. Whereas now some people are going at 12 o’clock, others at 2 o’clock. That social interaction is really important and you miss it with all the different start times’ (F7:P1). 3.3.5. Imposed restrictions Midwives aspirations were thwarted by imposed restrictions which occurred outside the practice realism of the ward, but had a direct impact on how it functioned and were perceived to be out of the midwives’ control. Four key restrictions were identified: not necessarily midwifery; we can’t keep up; them and us; and I don’t usually work there. 3.3.5.1. Not necessarily midwifery. Being able to practice the art of midwifery was important. One midwife voiced: ‘Why be a midwife if you’re not going to be a midwife’ (F4:P2). Endeavouring to share her thoughts around the cause of the difficulty she was experiencing in aligning her midwifery philosophy with her clinical practice, another midwife articulated: ‘I’m new to midwifery so my idea of a midwife, this philosophy of supporting women to do it, to be self-determined and to do it themselves, then spend the whole time intervening . . . it does feel like there’s a bit of a disconnect there’ (F2:3) A midwife in another group explained that her core professional values were being eroded due to the medicalised nature of her work: ‘It [the system] erodes your sense of professionalism and pride . . . it’s an assault to your professional standards . . . My role as a midwife, I feel like I’m a high pressure obstetric nurse, just churning’ (F3:P2). Her colleague expanded on this topic: ‘You spend like eight hours on one person who’s quite socially complex and you end up being consumed by a social situation that’s not necessarily midwifery but is a part of their care at the hospital’ (F3:P6). 3.3.5.2. We can’t keep up. The imbalance between the number of midwives on each shift and the acuity of the women and babies they were caring for caused midwives’ stress: ‘A lot of it depends on what your acuity is . . . if you have a Caesar [caesarean birth] coming back, a small baby, someone whose feeding isn’t going well, you’re feeling you’re being pushed from here to there’ (F2:P1). The practice reality of this imbalance was the perception ‘You’re not going to achieve it, it’s unachievable’ (F3:P6). Another midwife echoed these sentiments: ‘We can’t keep up. You’re just chasing your tail the whole time’ (F2:P2). Acuity was described as: ‘bonkers’ (F7:P3), ‘untenable’ (F3:P2) ‘relentless . . . gruesome’ (F1:P7) and ‘unsafe’ (F7:P2). Elaborating on the reason she felt unsafe, one midwife described: ‘I’ve got an emergency background and I’ve felt more unsafe here than the emergency department’ (F7:P2), whilst another midwife voiced: ‘staff are rushing, they’re not getting the chance to do things properly because they feel so under pressure there’s a lot of mistakes being made’ (F1:P7). Other narratives revealed underlying pressure associated with acuity: ‘I’ve found it a really hard month being here as a new grad [graduate midwife]. I’ve had a crap week [starts to cry, comforted by other group members] the acuity of patients compared to staffing is bad’ (F4:P6). 3.3.5.3. Them and us. Midwives also shared a common perception that the hospital executive and its managers did not engage with or support the midwives working on the floor and this was regarded as problematic: ‘You definitely don’t get that same support from higher up. There’s a big gap, it’s a huge big canyon . . . actually listen and engage with the staff. Don’t just shut the door and do whatever

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they do’ (F4:P2). One midwife simply wanted recognition from her managers when things were hard on the ward: ‘It would be nice if they [the managers] could be more involved and that does not mean they have to do shifts on the floor but if stuff is really crap, they could come down and say, ‘hey, you guys are doing a good job’ (F4:P3). Another midwife wanted the psychological impact of the hard ward work acknowledged at a deeper level: ‘A lot of staff in this hospital have significant mental health issues. This is a very stressful job and there is zero support, zero support for that . . . we don’t have a strong support structure for our staff who work in high pressure situations. I think that is really shabby’ (F3: P2). Midwives were pessimistic about whether the disconnection between management and staff could be improved: ‘The big issue is the disconnect. People [midwives] don’t feel valued by higher up managers, I don’t think it’s because they don’t know what’s going on, I think they do but I don’t think they know what the answer is’ (F2:P6). Another midwife stated: ‘We just feel we’ve got no control over any decisions that are being made. There’s no collaboration, poor communication between upper management and staff. I know they’re trying to work on that but unless they’re actually listening to what we’re saying and acting on it nothing’s going to change’ (F6:P1). Another midwife expressed how unsupported she felt when her call for assistance, due to her busy workload was rebuffed: ‘I rang [a senior staff member] and said ‘any chance you could come and talk to this woman and get a breastfeeding plan in place’ . . . I just didn’t physically have time, and she said ‘look I’m sorry we’ve decided we can’t do that support for you guys anymore’ (F5:P4). 3.3.5.4. I don’t usually work there. Midwives’ perceived they were allocated to a core/home ward where they would be rostered to work each shift, however, they were frequently redeployed to other wards that were short staffed: ‘In the past you had your core ward that you stayed on. You had rapport with your colleagues. But now I’m on ward three tonight. I don’t usually work there. So sometimes you’re not familiar with the staff. In the past you had a team you were comfortable with and you knew their skill set which makes you more confident’ (F6:P2). One midwife explained: ‘When I get shuffled around to a different ward I just feel kind of lost. I don’t think people are deliberately trying to isolate you but you feel like that nonetheless and I find that a challenge not a positive’ (F5:P3). Being moved between wards where the midwife was not familiar with staff contributed to their being upset: ‘When you get dumped on another ward with people you don’t know, it’s different. I don’t think that’s taken into consideration when people are moved around and its upsetting people’ (F7:P3). Ward coordinators were especially concerned about not knowing the skill mix and capabilities of the midwives they were allocated: ‘The biggest trouble with people shifting, of not having a home, is the unease. You don’t have the confidence in your allocation and skill set in relation to the midwives coming on. It’s an uneasy sort of feeling’ (F5:P5). One empathetic midwife had the insight to reflect on the coordinators plight: ‘Moving from ward to ward is very, very, difficult for them [the coordinators] and it’s becoming dangerous . . . it’s quite apparent the senior staff are starting to crack’ (F1:P4). 3.3.6. Carrying a burden The psychological impact of working in a practice reality where compromised aspirations and imposed restrictions existed,

Please cite this article in press as: L. Lewis, et al., The practice reality of ward based midwifery care: An exploration of aspirations and restrictions, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.010

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affected midwives’ wellbeing. Carrying a burden incorporated two concepts: disengagement and what have I missed? 3.3.6.1. Disengagement. There were midwives who withdrew themselves from others. These narratives revealed how midwives used emotional detachment to function and continue working: ‘I’m putting on this jovial, happy persona when I come to work, but when I get home . . . just shut up, stop talking to me’ (F1: P1). Another midwife disclosed how she removed herself from people if she felt she wasn’t coping: ‘If I feel I’m going to yell at somebody, I spend a lot of time in bed’ (F3:P5). Emboldened by her colleague’s remarks, another midwife shared her feelings of disengagement: ‘I’ve become increasingly antisocial because I just don’t have any energy to talk to people’ (F3:P2). One midwife recognised how destructive her behaviour was on her family and was trying to change: ‘If you’re tired it has a knock on effect on you. I personally have less time for my kids. I’m more snappy and I’ve got to be conscious of that’ (F1:P6). 3.3.6.2. What have I missed?. It was common for midwives to go home and worry about work they may have missed. One midwife succinctly summarised: ‘I think all of us are constantly dealing with some degree of anxiety and some people have good resilience and cope well, other people don’t have as good resilience or they just run out of resilience, I think ‘what if I’ve stuffed up, oh God what if I haven’t finished’ . . . the uncertainty, am I going to be able to get through everything’ (F3:P2) Her colleague agreed: ‘You go home and you think about what you might have done or not done’ (F3; P5). Midwives in other groups expressed similar sentiments: ‘I always go home and worry I’ve missed something’ (F4:P3) and ‘Most of the time you leave going,‘oh, I haven’t done that, I haven’t done that, I haven’t done that’ . . . you feel bad because you have left all this stuff for the others to do’ (F2:5). ‘Losing sleep’ (F1:P6, F1:P8, F4:P2, F5:P1) over unfinished work was a common phenomenon. 3.3.7. Coping strategies Analysis revealed midwives utilised a number of coping strategies to deal with the practice reality of the ward environment. These techniques were utilised in situations where the midwives had experienced considerable pressure or anxiety around compromised aspirations and/or imposed restrictions. Midwives used four strategies: I leave it at work; I take more time off; sharing with colleagues; and mindfulness (Table 1).

4. Discussion The voices of the midwives in this Australian study suggest tensions arose when their aspirations were compromised by the practice realism of the ward environment. The findings revealed two aspects were of key importance: being the midwife you want to be, and valuing camaraderie. Our findings also suggested that imposed restrictions were problematic. These restrictions occurred outside the practice realism of the ward environment and were perceived to be out of the midwives’ control. Midwives experiencing emotional distress revealed they were carrying a burden. Two burdens were described: disengagement and what have I missed? Our introduction provided a focused examination of the midwifery processes and practices around clinical engagement and its impact on midwives’ wellbeing. We suggested that congruence of individual’s ideals with the tenets of the paradigm in which they work is necessary if a midwife is to be fulfilled with their work and that this alignment is the core of a midwife’s satisfaction. Our findings align with the work of Davis-Floyd,6,7 Maben et al.8 and Traynor and Buss15 . However, we suggest the work of a fourth theorist Habermas be considered, specifically his theory of communicative action.29,30 This is because communicative action can be seen from two viewpoints: understandingorientated communicative action, or success-orientated strategic action.29–32 Midwives in our study valued camaraderie. Communicative reasoning was seen as desirable and something they aspired to as their everyday language was social and understanding-orientated.29,30,32 Others have also suggested that the tensions that dominate the practice of midwifery in late modernity can be viewed through communicative action.31 Our category ‘imposed restrictions’ and specifically the sub category ‘them and us’, reflects the importance of communicative action in reaching an understanding of the tensions that were apparent. We assert that midwives working on the wards may be controlled at two levels: the healthcare system and the hospital. These two actors are utilitarian strategic entities whose central focus is power and money. Moreover, they can negatively impact midwives’ practice whose communicative action is primarily tailored towards understanding.31 Qualitative research from the United Kingdom (UK)12 suggests communicative reasoning may also have a role to play, in relation to workplace resilience. Exploration of clinical midwives’ experience and understanding of resilience, revealed resilience was built through a combination of individual traits and exposure to external environmental factors. Midwives believed they could enhance

Table 1 Midwives coping strategies. Coping strategies

Sample of midwives quotes

I leave it at work

 As soon as I hit that door the whole shifts erased (F1:P2)  I leave it at the door, I go home (F1:P4)  If I’ve had a stressful shift, I can leave it at work (F6:4)

I take more time off

 I feel like I’m getting burnt out. I need another day off (F4:P6)  I don’t use sick days because I’m sick, but because I need a break (F4:P2)  If you are working to the bone, of course you have more sick days (F2:P3)

Sharing with colleagues

 If it’s been a stressful shift, I have a chat about it with the midwife I’m handing over to (F2:P2)  We take them to a private place, we hug, we talk it out (F1:P8)  Debriefing with other staff at lunch and trying to switch off (F5:P6)

Mindfulness

 If I’m having a rough day I take 2 seconds out to do a mindfulness exercise (F2:P4)  I have a meditation app I use to sleep between late/earlies (F4:P3)  It’s about your breathing, concentrating on your breathing. You always get a million thoughts, you just acknowledge that (F2:P1)

F1-F7 denotes the focus group. P1-P7 denotes the assigned participant number for each focus group.

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their resilience and that communication and support from their colleagues could assist them in this journey.12 The concept of resilience is often associated with the sustainability of midwifery practice.33 A recent discussion paper33 used research from the UK and New Zealand to compare the concepts of resilience and sustainability. It concluded that building resilience is not always beneficial for either the individual or the organisation. The authors suggested that resilient midwives might be propping up dysfunctional organisations, promoting unhealthy working behaviours and models of care. This may have a negative impact on the quality of care that women and their families’ receive.34 Indeed, the Australian midwives in our study voiced aspirations around working in partnership with women to give them the care they deserve. Findings align with the proposed evidence-informed framework for high-quality, cost-effective maternal and newborn care.5 This framework acknowledges that midwifery is pivotal to a required system-level shift from fragmented care focused on pathology to ‘skilled care for all’.5 This framework also acknowledges the need for effective teamwork, an aspiration reflected through our category of ‘camaraderie’. Implementation of this framework is imperative as it could enable midwives’ concerns to be addressed around a stressed workforce trying to meet high patient acuity, a need to feel supported by senior staff and the practice of being redeployed from their core ward. The narratives of the midwives in our study aspired to a practice realism where continuity of care fostered a partnership with women. Evidence supporting the effectiveness of midwifery continuity of care is well established.35,36 Although the midwives in this research were not working in a recognised continuity of care model, when midwives were able to work consecutive shifts with the same women this practice did facilitate a level of continuity. Although recognised for the benefit to women,35,36 midwives also benefit emotionally and professionally from being able to provide continuity of care.37 ‘Carrying a burden’ as expressed by the midwives in this study was based on practice realities where their working environment had an undesirable impact on their wellbeing. The relationship between working conditions and emotional wellbeing has been acknowledged in a robust review of 44 research studies.1 This review found specific work place variables had the capacity to negatively impact midwives’ emotional wellbeing. These variables were categorised as non-modifiable or modifiable. The authors concluded key variables for midwifery emotional wellbeing such as continuity of care, autonomy, support from colleagues and staffing were all modifiable, because they were under the control of the hospital leadership team.1 This has implications for our study, as key findings of high workload, low collegial support, lack of continuity of care, challenging clinical situations and low autonomy1 were all found. Additionally, a recent narrative literature review34 concluded that when a maternity organisation invests in the emotional health and wellbeing of their midwives, it also invests in improved care for women and their families. A high prevalence of personal and work-related burnout has been reported in another Australian study of midwives and is associated with physical and psychological exhaustion.38,39 To ensure a sustainable midwifery workforce, initiatives have been proposed to counter workplace stress; such as flexible work options, addressing inter-professional conflict40 and reorienting services to enable a partnership and positive relationship between women and midwives.41 Further evidence to support the need for a system-level shift, are gleaned from the Work, Health and Emotional Lives of Midwives42 study in the UK. This study of 1997 midwives confirmed 67% were experiencing work-related burnout. Midwives at greater risk of emotional distress were: younger midwives; midwives with less than 30 years’ experience; those who

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perceived low levels of resource adequacy; and those who perceived low levels of management support.42 Interestingly, our findings mirror these results in relation to the subcategories ‘we can’t keep up’ and ‘them and us’. This may reflect similarities around resource allocation concerns and perceptions that senior staff are not as supportive as midwives would like. 4.1. Limitations Midwives from the wards of this tertiary obstetric public maternity hospital in WA self-selected to participate in this study. The Clinical Midwifery Consultants facilitated booking arrangements into the study. Coercion was minimised, as it was up to the midwife to identify they wanted to participate in the research. Additionally, immediately before commencing the focus group, midwives were reminded that their participation was voluntary. The findings may not reflect the experiences of all midwives working across a variety of clinical areas. We acknowledge these factors could have had an impact in relation to the findings and should be considered within the interpretation and transferability of the findings to other settings. 5. Conclusion Midwives voices revealed tensions arose when their aspirations were compromised by the practice realism of the ward. Their narratives described frustration with the systems which governed their working environment. Further research should be undertaken to gain insight into the manager’s perspective. This research should focus on the tensions that were apparent in ‘Them and us’, as the psychological impact of working in a practice reality where compromised aspirations and imposed restrictions existed, had the potential to challenge midwives’ wellbeing. Serious consideration must be given to the art of midwifery on the ward, otherwise the current status quo will be maintained. This will be problematic for both midwives and women, as midwives may be disempowered to foster women’s capabilities through care that is tailored, preventative, supportive and respectful. Author statement As first author I declare on behalf of all authors of this manuscript have we have no conflict of interest such as financial or otherwise relating to this submission. Ethics statements Ethics approval was gained from the Women and Newborn Ethics Committee on the 13th of July 2018 (Approval Number QK27231) at King Edward Memorial Hospital, Perth, Western Australia. Acknowledgement We would like to thank the study centre for providing funding for the research staff and the midwives for graciously sharing their experiences. References 1. Cramer E, Hunter B. Relationships between working conditions and emotional wellbeing in midwives. Women Birth 2018;S1871–5192(18):30113–6. doi: http://dx.doi.org/10.1016/j.wombi.2018.11.010. 2. Oxford Dictionaries, British and World English. Definition of midwife [Internet]. 2019 Available from https://en.oxforddictionaries.com/definition/midwife. [Cited 31 May 2019]. 3. Bradfield Z, Duggan R, Hauck Y, Kelly M. Midwives being’ with woman’: an integrative review. Women Birth 2018;31:143–52.

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