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Midwives’ social and emotional competence key to quality maternity care

Midwives social and emotional skills matter – they matter to women and families, and they matter when working in a maternity care team.  Social and emotional competence starts with self-awareness, identifying one’s own reactions to situations and people, then developing the ability to widen the gap between our reaction and our response. Managing and self-regulating the emotional response when communicating with others is key to sustaining positive relationships – including when conflict arises. But empathy, self-regulation and conflict resolution skills may not come naturally and are rarely taught in undergraduate midwifery programs (Hastie & Barclay, 2021).

Interactions within the healthcare team

Positive workplace culture and effective teams are built by staff who demonstrate social and emotional competence (Hughes & Albino, 2017; Black et al., 2019). When teamwork is compromised, often through negative workplace culture, it harms mothers and babies (Rönnerhag et al., 2019), and leads to staff burnout and high turnover (Catling et al., 2017). An Australian national survey of midwifery workplace culture largely described poor communication, lack of leadership and support, and bullying (Catling et al., 2020). Teamwork function is undermined by poor communication between team members, an absence of shared goals, or lack of social and emotional skills (Best & Kim, 2019).

Skills required for teamwork can be taught

PhD candidate Carolyn Hastie recently examined whether teaching and assessing teamwork skills prepares undergraduate midwifery students to be effective team members when they graduate (Hastie & Barclay, 2021 – see article here). The researchers analysed interviews with 19 early career midwives who had learnt, practised, and assessed each other on teamwork skills developed through group assignments in their Bachelor of Midwifery program.

Teamwork central to practice

The research found that in their first year, midwifery students did not appreciate how central teamwork was to their future practice as a midwife (Hastie & Barclay, 2021). Participants described that group assignments were hard and tiresome, and some wrote off social and emotional skills as less important and “fluffy”. However, as new graduates they reflected that teamwork at university had prepared them for teamwork in the hospital setting.

Conflict inevitable but manageable

The participants acknowledged that conflict was an inevitable part of midwifery work (Hastie & Barclay, 2021). Participants found they had learnt how not to take rude or challenging behaviour personally. They reflected that they were more likely to see the situation from the other person’s viewpoint. This stance helped them to regulate their emotional reactions and to respond in a more considered and constructive way.

Advocating for self and others

These midwives used strategies they had learnt to have courageous conversations and address issues early, with one stating “rather than letting it fester, nip it in the bud”. When interacting with colleagues, that could mean asking direct questions (e.g., what was your rationale?) – or providing an alternative viewpoint (i.e., politely disagreeing, and explaining why). These skills are particularly important in terms of speaking up for safety and advocating for women.

Recommendations for practice

Midwives can strengthen their social and emotional competence by increasing their self-awareness. This might include reflecting on difficult interactions in practice through journaling or debriefing with a trusted colleague, participating in clinical supervision, or learning and practising mindfulness. Maternity services should consider the social and emotional competencies managers and midwives need to contribute to an effective team and positive workplace culture – and which steps would increase staff capability. Social and emotional competence matters to safe, quality maternity care.

References 

Best, J. A., & Kim, S. (2019). The FIRST curriculum: Cultivating speaking up behaviors in the clinical learning environment. Journal of Continuing Education in Nursing, 50 (8) (2019), pp. 355-361. https://doi.org.10.3928/00220124-20190717-06

Black, J., Kim, K., Rhee, S., Wang, K., & Sakchutchawan, S. (2019). Self-efficacy and emotional intelligence. Team Performance Management: An International Journal, 25(1/2), 100-119. https://doi.org/10.1108/tpm-01-2018-0005

Catling, C. J., Reid, F., & Hunter, B. (2017).  Australian midwives’ experiences of their workplace culture. Women and Birth, 30(2) (2017), pp. 137-145. https://doi.org/10.1016/j.wombi.2016.10.001

Catling, C., & Rossiter, C. (2020). Midwifery workplace culture in Australia: A national survey of midwives. Women Birth, 33(5), 464-472. doi:10.1016/j.wombi.2019.09.008

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery, 102997. https://doi.org/10.1016/j.midw.2021.102997

Hughes, M., & Albino, J. (2017). Assessing emotional and social intelligence for building effective hospital teams. The Psychologist-Manager Journal, 20(4), 208-221. https://doi.org/10.1037/mgr0000058

Rönnerhag, M., Severinsson, E., Haruna, M., & Berggren, I. (2019). A qualitative evaluation of healthcare professionals’ perceptions of adverse events focusing on communication and teamwork in maternity care. Journal of Advanced Nursing75(3), 585–593. https://doi.org/10.1111/jan.13864

How can we best prepare graduates to provide midwifery continuity of carer?

Less than 10% of Australian women can access midwifery continuity of carer. This model provides women with a known and trusted midwife, who is on-call to provide care throughout pregnancy, birth and the first six weeks afterwards. However, most women receive fragmented care from midwives on rostered shifts. For women this usually means a different midwife for each visit – and an unfamiliar midwife with them during labour and birth.

Benefits of midwifery continuity

Midwifery continuity of carer for women of any risk has outcomes that are similar or better than fragmented care – and it is cheaper to provide (Tracy et al., 2013). Women perceive care from known midwives as higher quality (Allen et al., 2019) and are more likely to feel satisfied with their care (Forster et al., 2016). Midwives working in these relationship-based models are less likely to experience burnout and more likely to feel empowered and autonomous in their roles (Fenwick et al., 2018). Despite these benefits, one barrier to expansion of midwifery continuity of carer is having enough midwives prepared and motivated to work in this way.

Learning midwifery through continuity of carer

Australian midwifery programs that lead to registration as a midwife require students to complete at least 10 Continuity of Care Experiences (CoCEs). Through CoCEs, students follow women through their pregnancy, birth, and postpartum experience – either in a fragemented or continuity model. In countries where the majority of women access midwifery continuity of carer, students are prepared with a higher number of midwifery continuity experiences. For example, New Zealand standards require students complete 25 CoCEs (New Zealand College of Midwives). While in Canada, students spend 50% of their clinical placement with community-based midwives who provide continuity of carer with hospital or homebirth options (Butler et al., 2016). There is considerable debate in Australia about the optimum number of CoCEs student need to facilitate learning and to prepare them to work in continuity models (Gamble et al., 2020).

Midwifery student experiences of continuity

Master of Primary Maternity Care student Joanne Carter was supervised by Transforming Maternity Care Collaborative’s Deputy Director, Associate Professor Mary Sidebotham, and Dr Elaine Dietsch. Together they investigated completing students’ motivation and preparedness to provide midwifery continuity of care after completing 20 CoCEs (Carter, Sidebotham & Dietsch, 2021). Survey data were collected using the Midwifery Student Evaluation of Practice (MidSTEP) tool which measures students’ experiences of clinical learning during placement (Griffiths et al., 2020), as well as free text response items. Over 120 students from one Australian university responded to the survey during 2017-2019.

Being prepared to provide midwifery continuity

Approximately 80%  of students indicated they felt well-prepared to work within a midwifery continuity of carer model on graduation (Carter, Sidebotham & Dietsch, 2021). Students explained, in their own words, that providing midwifery continuity of care had consolidated their clinical knowledge. Students described witnessing  how beneficial the model was to the women they followed. They also perceived that midwives were able to practice autonomously and in alignment with midwifery philosophy.

Being motivated to provide midwifery continuity

Approximately 50% of respondents indicated they would prefer to work in midwifery continuity of care on graduation. These students felt motivated to work to their “full scope of practice” and saw midwifery continuity of care as their “dream job”. Students who did not feel ready to graduate and move directly into a midwifery continuity models cited reasons such as wanting more skill or experience, although they did not identify which specific skills. Whilst students referred to other barriers (such as balancing on-call with family commitments), the majority indicated a preference to work in midwifery continuity of care in the future.

Over 90% of respondents who had been embedded in a midwifery continuity model and had a dedicated mentor, felt well-prepared and motivated to work this way.  This finding is consistent with international research that highlights the value of midwifery mentors within these models.

Recommendations from the research

A workforce prepared and motivated to work in this way is crucial to the expansion and sustainability of midwifery continuity of carer models. To achieve this, Carter et al. (2021) recommend:

  1. Increasing midwifery students’ access to continuity of care within clinical placement and CoCE.

  2. Co-designing placements with services and midwifery mentors who provide continuity of care.

  3. Offering flexible modes of learning to enable students to attend appointments and births.

  4. Reviewing midwifery accreditation standards so that all midwifery education programs prioritise midwifery continuity of care in program design.

You can currently access the free full-text article here

References

Allen, J., Kildea, S., Tracy, M. B., Hartz, D. L., Welsh, A. W., & Tracy, S. K. (2019). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. 46(3), 439-449. https://doi.org/10.1111/birt.12436

Butler, M. M., Hutton, E. K., & McNiven, P. S. (2016). Midwifery education in Canada. Midwifery, 33, 28-30. https://doi.org/10.1016/j.midw.2015.11.019

Carter, J., Sidebotham, M., & Dietsch, E. (2021). Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students’ perspectives. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.013

Fenwick, J., Sidebotham, M., Gamble, J., & Creedy, D. K. (2018). The emotional and professional wellbeing of Australian midwives: A comparison between those providing continuity of midwifery care and those not providing continuity. Women Birth, 31(1), 38-43. https://doi.org/10.1016/j.wombi.2017.06.013

Forster, D. A., McLachlan, H. L., Davey, M. A., Biro, M. A., Farrell, T., Gold, L., . . . Waldenstrom, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth, 16, 28. https://doi.org/10.1186/s12884-016-0798-y

Gamble, J., Sidebotham, M., Gilkison, A., Davis, D., & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women Birth, 33(2), 111-118. https://doi.org10.1016/j.wombi.2019.09.002

Griffiths, M., Fenwick, J., Gamble, J., & Creedy, D. K. (2020). Midwifery Student Evaluation of Practice: The MidSTEP tool — Perceptions of clinical learning experiences. Women and Birth, 33(5), 440-447. https://doi.org/10.1016/j.wombi.2019.09.010

New Zealand College of Midwives. Undergraduate midwifery education. Retrieved from https://www.midwife.org.nz/midwives/education/undergraduate-midwifery-education/

Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B., . . . Kildea, S. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet, 382(9906), 1723-1732. https://doi.org/10.1016/S0140-6736(13)61406-3

 

Towards value-based maternity care: Validation of the ICHOM Standard Set for Pregnancy and Childbirth

Valerie Slavin, PhD candidate, Midwife, Transforming Maternity Care Collaborative, Griffith University & Gold Coast University Hospital

Professor Jenny Gamble, Transforming Maternity Care Collaborative, Griffith University

Professor Debra Creedy, Transforming Maternity Care Collaborative, Griffith University

Maternity services aim to provide high quality and high value care that women want to access. A challenge lies in how to measure the quality and value of maternity care. In Australia, evidence of widespread variation in maternity care, costs, and outcomes suggests over-use of services for some women and under-use for others. Unexplained variation raises concerns regarding the equity, effectiveness, and efficiency of care.

Traditional maternity measures used to report on the quality of maternity care are limited and generally focus on outcomes such as mortality, mode of birth, post-partum haemorrhage, and severe perineal trauma; or processes such as induction of labour, postnatal readmission, or length of stay. Although these are important outcomes, in isolation they reveal little about performance, quality, or value of maternity care.

Having tools that can reliably report on a range of outcomes over time, and that are important to childbearing women, care providers, and healthcare funding bodies, provides a means to inform real-time clinical decision-making, monitor and benchmark performance, and drive quality improvement activities.

PROMs and PREMs

Person-reported outcome/experience measures (PROMs/PREMs) can supplement traditional measures by assessing the efficacy of maternity care and interventions from the woman’s perspective. Without consistent use of the same questions however, data generated from PROMs and PREMs are of limited value.

Standardised outcome measures

Standard Sets are collections of standardised outcomes and instruments. They represent the missing link to measure the quality and value of care but must be developed using rigorous methods. Since 2012 the International Consortium for Health Outcomes Measurement (ICHOM) has been developing global Standard Sets including outcomes, measurement tools, time-points, and risk adjustment factors to improve value-based healthcare. In 2016 ICHOM developed a Standard Set to measure the value of maternity care which included measures of health-related quality of life, incontinence, emotional wellbeing, pain during sex, birth experience, breastfeeding experience and self-efficacy, and mother infant bonding. To be implemented in practice, maternity services must have confidence that the outcomes and measures included in the Set were developed using rigorous methods and that the measures are valid and reliable in childbearing women. Until recently, the quality of the set had not been evaluated.

Ensuring the validity of PROMs in maternity care

As a group of researchers from the Transforming Maternity Care Collaborative we evaluated the quality and feasibility of the ICHOM Standard Set for Pregnancy and Childbirth. Firstly, we conducted two systematic reviews to assess the quality of the Standard Set development process (manuscript currently under review), and the quality and suitability of the PROMs included in the Set. While the Set was developed using rigorous methods, five included PROMs had not been previously been validated in childbearing women.

We conducted a program of work to evaluate the psychometric performance of these unvalidated PROMs in childbearing women. We conducted a study with 309 consecutive women from one large tertiary hospital in Queensland and collected survey data at five time-points as prescribed by ICHOM (at booking, and 36 weeks of pregnancy and one, six and 26 weeks after birth). We also collected electronic hospital data at six weeks following birth. We provided women with the option of using a tablet device while attending an antenatal care visit, electronic survey completion on their own device, or to complete the survey by phone with the research midwife. The ICHOM Standard Set was acceptable to women. Almost all women invited agreed to participate (95%), and response rates were high at all time-points; being highest at booking (92%) and lowest at 26-weeks post birth (71%).

We conducted psychometric analysis on five PROMs and developed recommendations and/or refinement of the tools to measure health related quality of life (Slavin, Gamble, Creedy, Fenwick, & Pallant, 2019), urinary and anal incontinence (Slavin, Gamble, Creedy, & Fenwick 2019; Slavin, Creedy, & Gamble, 2019), depression symptoms (Slavin, Creedy & Gamble, 2020a), and social support (Slavin, Creedy and Gamble, 2020b).

Our findings support the implementation of the revised Standard Set for Pregnancy and Childbirth to measure value of maternity care. If your health service is interested in using the ICHOM Standard Set and you would like assistance designing methods for women to report their experiences, our study team can assist you.

References
Slavin, V., Gamble, J., Creedy, D. K., Fenwick, J., & Pallant J. (2019). Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population – validation of the PROMIS Global Short Form. BMC Pregnancy and Childbirth, 19, 370.

Slavin, V., Gamble, J., Creedy, D. K., & Fenwick, J. (2019). Perinatal incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire –Urinary Incontinence Short Form and Wexner Scale. Neurology and Urodynamics, 38(8), 2209-2223.

Slavin, V., Creedy, D. K., & Gamble, J. (2019). Benchmarking outcomes in maternity care: Perinatal incontinence–a framework for standardised reporting. Midwifery, 102628, 1-11.

Slavin, V., Creedy, D. K., & Gamble, J. (2020a). Comparison of screening accuracy of the Patient Health Questionnaire–2 using two case-identification methods during pregnancy and childbirth. BMC Pregnancy and Childbirth, 20, 211.

Slavin, V., Creedy, D. K., & Gamble, J. (2020b). Single Item Measure of Social Supports: Evaluation of construct validity during pregnancy. Journal of Affective Disorders, 272, 91-97.