Cultural safety and its importance for Australian midwifery practice

Cultural safety is an important concept in health care that originated in Aotearoa (New Zealand) to address Maori consumer dissatisfaction with health care. In Australia and internationally, midwives are now expected to provide culturally safe midwifery care to all women. Historically, Australia has received large numbers of immigrants from the United Kingdom, European countries and the Middle East. There have also been refugees and immigrants from South-East Asia, and most recently, from Africa. Australia continues to become more culturally diverse and yet to date no studies have explored the application of cultural safety in Australian midwifery practice. This paper explores how cultural safety has evolved from cultural awareness and cultural sensitivity. It examines the importance of cultural safety in nursing and midwifery practice. Finally, it explores the literature to determine how midwives can apply the concept of cultural safety to ensure safe and woman centred care.     

Changing practice through action research: an interview with Rachel Stevenson. Interview by Pamela J. Wood, Lynne S. Giddings

Nurses and midwives in Aotearoa/New Zealand use a broad range of research methodologies to explore aspects of practice. This is the second article in a series based on interviews with nursing and midwifery researchers, designed to offer the beginning researcher a first-hand account of the experience of using particular methodologies. This article focuses on action research. After describing briefly the key elements of this methodology, the article presents an interview with Rachel Stevenson (RGON, MA) who used action research to explore the experience of nurses and people with asthma in the secondary care setting.     

Thinking differently: Re‐framing family violence responsiveness in the mental health and addictions health care context

Aotearoa New Zealand’s high rates of intimate partner violence (IPV) and child abuse and neglect point to a clear need to develop and resource equitable mental health and addiction practices that are responsive both to people experiencing and using violence, and to their families. Current responses to IPV in mental health and addiction settings in Aotearoa New Zealand require a critical re‐framing, from an individualistic autonomy and empowerment framework that constrains practitioners’ practice, to an understanding IPV as a form of social entrapment. Using a composite story constructed from 28 in‐depth New Zealand family violence death reviews, we highlight current problematic practice and discuss alternative responses that could create safer lives for people and families. Re‐framing IPV as a form of social entrapment acknowledges it as a complex social problem that requires collective steps to secure people’s safety and well‐being. Importantly, a social entrapment framework encompasses interpersonal and structural forms of violence, such as the historical and intergenerational trauma of colonization and links to ongoing structural inequities for Māori (the indigenous people of Aotearoa) in Aotearoa New Zealand.     

The methodological journey of a grounded theorist: an interview with Denise Dignam. Interview by Lynne S. Giddings, Pamela J. Wood

Nurses and midwives in Aotearoa/New Zealand are making a unique contribution to the development and application of various research approaches (methodologies) to nursing and midwifery practice. This is the first of a series of articles based on interviews with nursing and midwifery researchers, giving stories of their research journeys in relation to a particular methodology. The articles will give beginning researchers some real life examples of what it is like to carry out research. They are not in-depth explorations of the various methodologies. What we have attempted to capture is how real people actually use the various research methodologies we read about in textbooks and that frame the research which influences our practice. The stories are presented in interview format so that each interviewee's unique style and approach can emerge. The first researcher in our series is Denise Dignam (RGON, BA, DipSocSci) who in her PhD research is using a grounded theory approach to investigate issues related to breastfeeding.     

A mixed-method evaluation of a New Zealand based midwifery education development unit

The Midwifery Development Education Service was established in the Birthing Unit at Middlemore Hospital in South Auckland New Zealand in 2007. The service is unique in the New Zealand midwifery context for the way it operates as a collaboration between the education and health provider to optimise the clinical learning experience of student midwives. This paper reports on the evaluation of the Midwifery Development Education Service that was undertaken in 2015. The evaluation captured the views and experience of students and midwives who had been involved with, or had worked alongside, the service. A mixed-method approach was adopted for the evaluation study, comprising of an anonymous on-line survey, qualitative interviews and focus group discussion. Considerable satisfaction with the service was identified. This article draws attention to participants’ perceptions of the service as supporting student midwives; the significance of quality time in the provision of the clinical midwifery education; the situating of the service at a unique vantage point (overseeing the needs of the university and the hospital) and its impact upon the learning culture of education within the unit. A potential tension is also identified between the provision of a supportive learning environment and the assessment of student performance.     

Review Article: Genetic competence of midwives in the UK and Japan

In the UK and Japan, midwives provide health services for women with concerns about a genetic condition or who are considering antenatal screening. In both countries, competences related to genetic health care have been devised but there is little evidence about midwifery competence in practice. A systematic literature review was undertaken to determine the extent to which midwives are achieving the genetic competences that are prescribed for their practice. English and Japanese literature from January 1999 to March 2009 was retrieved. Original studies or reviews, in which an aspect of midwifery practice was related to genetic competences, were eligible for inclusion. After a critical appraisal, six UK and five Japanese papers were eligible for inclusion. The findings indicated that midwives are not achieving the competences, nor are they confident about their genetics knowledge. Moreover, women are not being supported to make informed decisions regarding antenatal screening. We have confirmed that little research is being undertaken in both countries regarding competency achievement in practice. Changes to midwifery curricula and further continuing education are required to ensure that midwives are able to provide effective care regarding genetics.     

Nurse- and midwife-led trials in Australia and New Zealand: Scoping review protocol

BackgroundResearch led by nurses or midwives has the potential to successfully address current issues in clinical care. High-quality randomised controlled trials are needed to inform evidence-based practice; however, nursing and midwifery research has commonly been nonexperimental. Two connected scoping reviews of nurse- and midwife-led randomised controlled trials within Australia and New Zealand will be conducted to highlight potential research directions and identify resources for future research.AimThe purpose of the two reviews is to map the number and types of randomised controlled trials led by nurses or midwives within Australia and New Zealand.MethodsThe concept of interest is randomised controlled trials with a lead principal investigator holding nursing or midwifery credentials. The lead principal investigator must report an institutional affiliation in Australia or New Zealand, and the trial must recruit at a minimum of one site in Australia or New Zealand. Searches for academic literature will be conducted using Pubmed, Emcare, and Scopus. Sources for grey literature will include the Australian New Zealand Clinical Trials Registry, and grant outcomes published by the National Health and Medical Research Council, Medical Research Future Fund, and Health Research Council of New Zealand. Data analysis and presentation will be conducted separately for each review.DiscussionThese reviews will comprehensively map the experimental research activity of nurses and midwives within Australia and New Zealand and highlight potential research directions. From this, strategies to facilitate high quality nurse- and midwife-led trials can be developed, which are vital for informing evidence-based practice.     

Reflective education for professional practice: discovering knowledge from experience

To continually develop as a discipline, a profession needs to generate a knowledge base that can evolve from education and practice. Midwifery reflective practitioners have the potential to develop clinical expertise directed towards achieving desirable, safe and effective practice. Midwives are 'with woman', providing the family with supportive and helpful relationships as they share the deep and profound experiences of childbirth. To become skilled helpers students need to develop reflective skills and valid midwifery knowledge grounded in their personal experiences and practice. Midwife educators and practitioners can assist students and enhance their learning by expanding the scope of practice, encouraging self-assessment and the development of reflective and professional skills. This paper explores journal writing as a learning strategy for the development of reflective skills within midwifery and explores its value for midwifery education. It also examines, through the use of critical social theory and adult learning principles, how midwives can assist and thus enhance students learning through the development of professional and reflective skills for midwifery practice.     

A study of skill mix issues in midwifery: a multimethod approach

BACKGROUND: While skill mix studies are quite commonplace in health care, most have focused on the most effective use of staff and skill distribution in the field of nursing; few relate specifically to the midwifery profession. In Ireland there is no recognized midwifery assistant grade. AIMS: This paper describes a study that investigated the skill mix requirements of a midwifery service based in the Republic of Ireland. The project was built on previous research, which showed that due to undertaking a number of 'nonmidwifery duties', midwives were unable to undertake fully the work for which they were trained. RESEARCH METHODS: Data were collected using a variety of methods. These included postal questionnaires and the Delphi technique. The 'Delphi' was used to gain a level of consensus from hospital midwives (all grades) (n=194) and student midwives (n=79) on what are and what are not nonmidwifery duties. Analysis of secondary data (duty rotas and staff turnover data) was also undertaken. RESULTS: Findings indicate that the respondents spent a large proportion of their time undertaking clerical, domestic, portering and stock duties. They would welcome the introduction of midwifery assistants into the ward team and were able to identify those duties that such persons could undertake. CONCLUSIONS: Skill mix requirements and organizational strategies to deal with the workforce changes are highlighted. Due to the current shortage of midwives in many countries and the dearth of extant research in this area, the results and recommendations have implications for midwives nationally and internationally.     

Inequalities in health care provision: the relationship between contemporary policy and contemporary practice in maternity services in England

AIM: The project Addressing Inequalities in Health: new directions in midwifery education and practice (Hart et al. 2001) was commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB). Here, we draw on those research findings to consider current midwifery policy and practice in England. BACKGROUND: Little guidance on providing equality of care exists for midwives. The Code of Conduct [United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 1992] makes no specific requirement for midwives to address issues of inequalities of health in their practice. Recent policy documents emphasize the need to work towards reducing inequalities and to target practice to 'disadvantaged clients' without giving guidelines on how to identify and care for target groups. METHODS: In-depth studies of midwifery education and service provision were conducted in three very different parts of England. Three months of fieldwork were undertaken at each site, comprising a series of interviews with midwifery educators, managers, students, midwives and service users. Focus groups were also held and observation of classroom sessions and midwifery practice undertaken. Findings. A lack of clear and specific strategies concerning inequalities in health was evident at managerial level. Patchy knowledge of current policy was also evident amongst practising midwives. Specific projects with disadvantaged clients usually resulted from a particular midwife's personal interest or evident local need. All midwives emphasized the importance of 'equality of care'. How this was operationalized varied, and 'individualized' or 'woman-centred' care was assumed to encompass the concept. In the few examples where care was systematically targeted in accordance with policy directives, the midwife's public health role was increased. CONCLUSION: In the absence of a co-ordinated strategic vision driven by managers, practitioners find difficulty in prioritizing care and targeting resources to disadvantaged clients in line with policy directives. Tensions between policy and practice in the care of 'disadvantaged' women clearly exist. Successful implementation of policy at practice level needs: commitment from managers; clarity of purpose in documentation; and provision of specific targets for practitioners. However, the latter should remain flexible enough for the delivery of care to be appropriate and sensitive to individual needs.     

'With woman' philosophy: examining the evidence, answering the questions

'With woman', 'woman centred' and 'in partnership with women' are new terms associated with midwifery care in Australia, and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women's experiences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women, those with 'high risk' pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to initiate a discussion of 'with woman' midwifery care as it applies to Australian practice.     

Reflective midwifery practice: Facilitating midwives'practice insights using a distance education reflective practitioner model

A study was undertaken to evaluate a reflective practitioner model with midwives, who self-selected into the project when they were studying the Bachelor of Health Science (Nursing) unit NR278, Advanced Nursing Practice, Midwifery. The theoretical assumptions that influenced the research were those forwarded by Schon (1983) and Boud, Keogh and Walker (1985), who argued that practitioners are often unaware of the sophisticated knowledge they have regarding the intricacies of their practice, but that this personal knowledge can be made explicit through reflective processes. The aim of the study was to research the use of a distance education reflective practitioner process that encouraged midwives to examine their practice with a view to making changes where necessary. All the research objectives were met to some extent, although each experience of the research process was particular to the individual participant. Analysis consisted of: interpretation of the participant's insights into their individual experiences; the researcher's interpretations of participant's experiences; and collective themes arising out of the research. This paper concentrates mainly on the participant's insights into their individual experiences of practising midwifery, using a reflective practitioner model.     

‘Risk or Right’: a discourse analysis of midwifery and obstetric colleges’ homebirth position statements

Within the context of global debates about safety and ethics of supporting women to give birth at home, it is important to analyse documents governing midwifery and obstetric practice and influence decision‐making around place of birth. In Australia, the United States and the United Kingdom, relatively small numbers of women choose to give birth at home despite their midwifery colleges' support. In the United States and Australia, the obstetric colleges do not support homebirth and these countries have lower numbers of women who birth at home, compared with the United Kingdom. There are numerous regulatory and industry challenges for midwives attending homebirths. This paper reports on a Foucauldian analysis of Australian obstetric and midwifery colleges' position statements about homebirth, who have conflicting views, with the view to understanding their arguments and underlying assumptions. The documents highlighted tensions between competing discourses of risk and autonomy and differences in academic argument. Opportunities for strengthening their statements are highlighted. The methodology is applicable for future analysis of similar documents governing practice in other countries.     

Women and midwives in partnership: a problematic relationship?

Midwives in New Zealand have been practising independently of medicine and nursing since 1990 using the concept of partnership as a basis for their practice. This article shows, however, that the beliefs which underpin the practice of the midwives are not always the same as those of their clients. Supporting evidence is provided in the form of verbatim data provided by participants. Three major areas in which contradictions were found were in the work of midwives, the knowledge for practice and reflections on the experience. It is recommended that midwives become more visible by removing themselves from hegemonic structures, valuing alternative forms of knowledge and respecting the knowledge of their clients.     

Discourse analysis--making connections between knowledge and power: an interview with Debbie Payne by Lynne S. Giddings and Pamela J. Wood

Discourse analysis is a relative newcomer to the variety of qualitative research methodologies used in nursing and midwifery research in Aotearoa/New Zealand. This is the seventh article in a series based on interviews with nursing and midwifery researchers, designed to offer the beginning researcher a first-hand account of the experience of using particular methodologies. This article focuses on discourse analysis as interpreted by Debbie Payne (RGON, MA [Hons]) in interview. Debbie has recently finished her PhD thesis (submitted for examination) and is a Senior Lecturer at the Auckland University of Technology. For her thesis Debbie used Foucauldian discourse analysis to explore the use of the term 'elderly primigravida' to describe mothers who are pregnant for the first time when aged 35 years or over.     

Cultural competence in New Zealand and Canada: occupational therapy students' reflections on class and fieldwork curriculum

The first year of a twin study undertaken between two occupational therapy programs in Canada and New Zealand is described. The primary aims of the study were to illuminate the lived experiences of students as they learn about cultural difference and had contact with clients of differing cultural backgrounds to themselves during fieldwork placements. While there are similarities between educational programs and the demographic profiles of the two cohorts of students, there are curricular differences primarily based on the described socio-political content of the two countries; Aotearoa/New Zealand as a bicultural society and Canada as multicultural. The paper discusses how these cultural differences interweave with other aspects of the students' educational program, as perceived and experienced by the students. Narrative data was thematically analyzed to reflect the experiences and the attendant thoughts and feelings of the participants.     

Transforming possibilities of care: Goan migrant motherhood in New Zealand

Little is known about the maternity experiences of migrant mothers in Aotearoa/New Zealand--and in particular the ways in which women adapt and survive when separated from traditional postnatal practices and family support. This paper reports on a study of the maternity care experiences of women from Goa (India) in Auckland, New Zealand. Multiple research strategies were incorporated into the process to prevent reproduction of deficiency discourses. Interviews were carried out with Goan women who had experiences of migration and motherhood. The findings revealed that as a consequence of motherhood and migration, migrant mothers were able to reclaim and re-invent innovative solutions. Nurses and other health professionals can have a significant role in supporting women and their families undergoing the transition to parenthood in a new country and develop their knowledge and understanding of this dual transition.     

Intrapartum care in the twenty-first century

Women will continue seeking obstetrical care from nurses, midwives, and physicians throughout the twenty-first century. In many areas of the country, they will be able to find a midwife who will assist them in having a very personal birth experience. The ACNM remains committed to producing more midwives. More midwives may mean that practitioners educated in normal pregnancy will attend the vast majority of normal births, freeing physician colleagues to best use their skills and expertise in caring for women with medical and obstetrical problems. As most midwives are likely to continue working in hospital settings, those settings will continue to change, offering women more of the comforts and amenities of home. Home birth and water birth may continue to be available with midwives in attendance, though the forces of economics and insurers may restrict the availability of these options for women. Women desiring care in a birth center may find it difficult to locate one within a reasonable distance. The in-hospital "birthing suite", with a midwife in attendance, will be the most likely setting for the vast majority of midwifery attended births. A collection of more evidence through research will stir debate amongst health care providers. Increased access to that information will bring consumers into the debate as well. In the twenty-first century, information will be a very powerful force of change in obstetrical health care. In recent years, legal liability and economics have strongly influenced obstetrical practice. Though this may continue to be true, the impact of more evidence on which to base practice, and the new access that women have to that information, will undoubtedly affect the way care is delivered. A central slogan of the ACNM is "Listen to Women". That will happen more than ever in the twenty-first century. There will be more midwives, more evidence to support midwifery care, and more women learning that birth can and should be a personal, healthy, and empowering experience. These women will seek midwives who practice wisely, blending science with art and intuition. They will learn that the childbirth wisdom that has been passed down through the ages, from woman to midwife to healer to nurse and to midwife, again, delivers the birth experience back to the mother and the healthy baby to the world [3,7].     

The developments and trends in relaation to men practising midwifery: a review of the literatur

The literature shows that throughout history the duties and responsibilities of the female midwife have been eroded and impinged upon by better-educated and better-equipped male medical men. Although several of these early 'men midwives' greatly improved midwifery practice, they tended to commandeer not only the best methods and the kudos but also the most interesting cases. The midwives of the past failed to stop the growth of obstetrics, and their contemporaries through the intercession of the 1951 Midwifery Act attempted to block entry into the profession by male nurses. Prior to the mid 1970s, it was assumed by the leadership of the Royal College of Midwives (RCM) that the introduction of male midwives would be unpopular not only with the expectant mothers but also with their husbands. Subsequent research demonstrated that this was not necessarily the case. Rather it was female midwives themselves who did not welcome the invasion of male practitioners into their domain. A review of the research literature suggests that the fears expressed by the RCM were unfounded and, by the late 1970s through to the Equal Opportunities Commission, the Sex Discrimination Act and several political machinations, male nurses were undertaking midwifery training.