Introduction

We live in rapidly changing times, particularly for those involved in providing and receiving health care. The health sector primarily aims to meet the needs of service users. There are various levels of ‘user’ within the health service environment. For example, within contemporary maternity services there is the woman, who has specific expectations of the obstetrician and/or midwife; the obstetrician, who has specific expectations of the women and the midwives; the midwife, who has specific expectations of the obstetrician; and the maternity manager, who in turn has expectations of the hospital management to provide certain levels of resources in a timely way to support the service they manage. When planning change it is useful to identify these ’users’ and find out:

In making change to meet the needs of one set of these service ‘users’, it is likely that the change will also impact on others within this service as the system is interdependent. Sometimes this is detrimental and brings unanticipated consequences. When the service extends into the community (as is the case in maternity care), the relationships become even more complex. Many groups of service users are influenced by the setting up of a midwifery continuity of care program or project and it is important to be aware of these considerations and the connections between them.

This chapter is designed to explore the use of a process called ‘contextual scanning’ as a tool for mapping the territory to identify these service interconnections and co-dependencies; maximise ownership of the change process; and increase the likelihood that the change will have a positive impact on the majority. I will use examples from my practice as a maternity service development midwife in New Zealand to illustrate the usefulness of this tool as a framework for mapping the territory, clarifying issues and identifying potential strategising processes, and collective decision making in maternity service development.

Most of us who have worked in the health system long enough will have experienced the introduction of a new service or service enhancement that requires considerable change to the way people work. It is clear that where there has been little consideration of whether the context of the change, namely, the environment, is conducive to the change, success is likely to be more challenging. Introducing a model of care based on midwifery continuity of care and a named midwife (particularly if making the transition from traditional ward-based care) will have a profound impact on layers of service users. Those who can predict the risk of service chaos best are the people at the ‘coal-face’, in the ward or delivery suite. They are also most likely to be able to identify actions to mitigate the risk since they are also the ones most likely to be affected by the change. Contextual scanning acknowledges their wisdom and uses it to inform the change process.

This chapter tells the story of how contextual scanning was used during a process of consultation that I undertook in New Zealand. It is my story and so I have written much of the experience in the first person. I hope my story gives others the confidence to embark upon a similar process in their own setting using the principles and approach that I took.

The New Zealand midwifery continuity of care context

From 1990 onwards, individual midwives in New Zealand were able to directly access public health funding for the provision of midwifery care to women. This achievement saw a steady rise in the number of midwives moving out of hospital employment and into community-based continuity of care practices in a self-employed capacity. In recognition of this, and to have some control over the development of these services, the government (Health Funding Authority 1996) established a framework for service provision and payment based on a modular system in 1996. This required the identification of one maternity practitioner, either a midwife or a doctor, as the Lead Maternity Carer (LMC). Once registering with the woman as her LMC, the practitioner would be required to take personal responsibility for provision of maternity care (even when the woman is in hospital) 24 hours a day until 6 weeks following the birth.

This resulted in profound changes to maternity services, particularly in the way that midwives constructed their practices and developed relationships with obstetricians and with maternity hospitals. The changes to other services required to accommodate the ‘continuity of care’ model seemed endless. In gaining this professional autonomy, that is, no longer needing to receive authority from another profession but being accountable for their own actions and decision making, midwives needed access to:

It is difficult to quantify the changes that resulted from the simultaneous national introduction of continuity of maternity care because of the inextricable links within the health sector as a whole. As a midwife manager at the time, this experience forced me to acknowledge the influence of the community outside of the hospital on the construct of maternity services for the future.

Background

After a 20-year career in clinical practice, initially as a nurse then as a midwife, I moved into the area of maternity service development and planning. Over the past 10 years I have been involved in a variety of roles, such as health service auditing, service redesign and strategic planning. I am currently managing the implementation of a district wide Maternity Services Strategic Plan for a District Health Board and am also Executive Director of the Midwifery and Maternity Provider Organisation (MMPO), which provides practice management services for about 700 Lead Maternity Carer midwives throughout the country. It is through the experience of working with and within a variety of different organisations in a number of different localities that the complexities associated with ‘change’ became an interest of mine.

Research into the evolution of maternity services in different localities in New Zealand following the introduction of the LMC model of maternity care (Hendry 2003) led me to believe that the ‘context’ of a service influences the unique characteristics of each maternity service. These contexts include the geographic location, the demographics of the catchment population, the local health service staff mix, proximity to hospitals and specialists, and the traditional roles of medical practitioners in maternity care. Furthermore, the description of these services is influenced by the positioning and knowledge of the person describing the service. Their perception will be based on their relationships with or within the service, their previous experiences and their current role. For example, pregnant women are likely to describe their maternity service differently from a midwife, and midwives will describe the service in another way to the doctor. Midwives in a labour ward are likely to feel they already provide continuity of care to women, if they have a named midwife assigned to each labouring woman on admission. How would you justify the establishment of a ‘midwifery continuity of care’ model to these midwives?

As it became increasingly clear to me that the ‘context’ of service provision had a profound impact on the understanding by midwives and doctors of the maternity care that women received, it occurred to me that service changes should be approached with caution and with a good level of local knowledge and ‘buy in’. Change to a maternity or midwifery service deemed successful in one locality may not be as effective or even appropriate within another. I was keen to explore this more, but needed to find a tool to enable this process.

Environmental scanning

The process of developing appropriate services led me to investigate the concept of environmental scanning, which was created initially by the disciplines of architecture and town planning (Beal 2000). Historically, service planning activities have tended to rely on traditional discipline-specific knowledge rather than new knowledge. Environmental scanning was developed to obtain a snapshot or construct a map of the current situation. This method recognises that:

The use of scanning as a tool to map the territory values a number of individual perspectives of the situation in order to collectively identify current and potential trends, as well as threats and opportunities, which contribute constructively to strategic planning and evaluation (Beal 2000, Boehm & Litwin 1999). Scanning also provides a useful benchmarking method by comparing earlier scans with more recent ones in order to identify and plot change and/or the impact of change (Hatch & Pearson 1998).

The most attractive aspect of this tool is that it enables the capture and analysis of a broad range of data over a short period of time. The inwardly-focused methods of traditional long-range planning models, which relied heavily on historical data analysed by ‘experts’ away from the context of the service, did not encourage decision makers to anticipate environmental changes and assess their impact on the organisation as a whole (Morrison 2000). Scanning is particularly useful when the organisation under investigation is quite complex and interfaces with a number of others. The short time frame for data collection and analysis enables results to be produced and decisions for action made before the contextual or environmental determinants change too much. A long time lag between a scanning ‘picture’ of the services and agreed action could render those actions ineffective or dangerous because of a shift or reconfiguration of the context in the meantime (Choo 2001).

I applied the principles of environmental scanning to a method I describe as ‘contextual scanning’ (Hendry 2003). This method has the capacity to map out both the internal and the external contexts of a health service by positioning it within the community it services. This involves a staged process of systematically analysing information on both the community and the health service through the active engagement of a number of informants from within both the service and the community. This process enables the information to be triangulated in order to construct a multi-dimensional ‘picture’ of the service from the perspective of as many participants as possible, highlighting key issues that impact on service potential, thus providing a collective focus for change.

It has always been a concern to me that well-intentioned and seemingly logical service changes, such as the introduction of new midwifery continuity of care models that have not previously been successfully introduced, profoundly increase resistance to change in that service. In some circumstances I have known service relocation as the only way to introduce change in services that have been subjected to numerous attempts to change the model of care.

Contextual scanning process

Initial development of this method was explored while I was lecturing in a postgraduate midwifery program. I developed a half-day workshop for students using a standardised contextual scanning tool I had constructed (described later) with the object of identifying the similarities and differences in maternity services within the various regions the students came from. I was keen to see how these midwives made sense of any patterns that emerged.

While I first honed the contextual scan as a reflective tool for postgraduate midwife students to examine the organisation of their hospital or practice within the context of the community, I subsequently developed this during my doctoral research (Hendry 2003). I used this process to explore the way midwives had developed rural maternity services and the aspects of this service that they felt made these services vulnerable.

In my role with the Maternity and Midwifery Provider Organisation, I have developed a version of this process for use by individual midwifery practices. This enables them to reflect on their practice development and identify areas that need to be addressed. The process enables midwives to view their services more objectively and holistically through appreciation of others’ perspectives and publicly available information. I have also included consumers, community representatives and health managers in this process to analyse district-wide maternity services as an initial step in the development of a strategic maternity services plan for a whole geographic region. This process forms a critical first step in service analysis prior to implementing change.

Contextual scanning using a group process

The process outlined here can be undertaken with a group of 10–20 participants over a full day. Participants can be divided into smaller subsets for work on each phase. At the end of each phase there is a focussed review of findings within the large group and construction of a shared or consensus response, picture or map.

Each phase of the process is timed, with a set of key questions placed on an overhead or distributed to the groups as a prompt. Each group is given a set of blank overhead transparencies or large pieces of paper on which to place their responses and descriptions. When working on site with a group, I generally allow about one hour for each phase, which includes at least 15–20 minutes feedback to the larger group. To shorten the time, questions can be distributed prior to the session with the group sessions focussing on a collation of agreed responses. A consensus process is fostered by the facilitator during the workshop.

Phase 1: The current maternity service within its community context

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