Chapter 18 Working in collaboration
Learning outcomes for this chapter are:
Collaborative practice is integral to the safety of midwifery practice. Midwives, as primary caregivers, need to make evidence-based decisions regarding when an individual woman in their care may need a referral or consultation with another caregiver during pregnancy, labour, birth or the postnatal period. This chapter outlines the means of collaboration between midwives, the women they care for and the other healthcare professionals with whom they may need to collaborate.
Engagement in collaborative effort is the midwife’s raison d’être. ‘Working together’ is the thread that runs through every aspect of midwifery practice. The most fundamental understandings of the midwifery partnership model involve women and midwives working together to achieve positive experiences for all (see Ch 16). Collaboration between women and midwives has undergone widespread political change throughout the late 1980s and 1990s, and has brought about the establishment of a truly women-centred maternity service in New Zealand, and a movement towards this in Australia (see Ch 1). At every level, from the individual woman and midwife through the professional and regulatory bodies, it is women and midwives working collaboratively who determine the vision and direction for the future of maternity services (Department of Health 1993; NMAP 2002; NZCOM 2008).
Midwifery care is centred on promoting and protecting birth as a normal physiological process. For most birthing women, the totality of their care falls within the scope of midwifery practice. There are occasions, however, when the complexity of a woman’s experience may require that she also have some input from other midwifery colleagues or other healthcare professionals. Midwives are skilled at assessing whether referral for consultation or transfer of clinical responsibility is necessary. To assist midwives with their decision-making, in both New Zealand and Australia referral guidelines have been developed that outline a range of circumstances where referral may be warranted.
Collaborative practice is integral to the safety of midwifery practice and enshrined in midwifery policy. The New Zealand College of Midwives Code of Ethics states that: ‘Midwives have a professional responsibility to refer to others when they have reached the limit of their expertise’ (NZCOM 2008, p 12). Similarly, the Midwifery Scope of Practice, which legally defines midwifery in New Zealand, requires that: ‘When women require referral, midwives provide midwifery care in collaboration with other health professionals’ (MCNZ 2004).
The competencies for entry to the Register of Midwives provide further clarification of what generally and specifically constitutes midwifery practice, in terms of the profession’s and the public’s expectation of woman-centred care. The Definition and Scope of Practice provides the broad boundaries of midwifery practice, whereas competencies provide the detail of how a midwife is expected to practise and what she is expected to be capable of doing (MCNZ 2004, 2007). There is a set of minimum competencies required of all midwives who register in New Zealand and Australia. It is expected that all midwives will demonstrate that they are able to meet the competencies relevant to the position they hold (Homer et al 2005, p 5). Specific competencies relating to collaboration are reproduced in Box 18.1.
Systems that enable midwives to work collaboratively are valued. The components of supportive systems include effective communication, consultation and referral between professionals. A collaborative relationship with medical colleagues is an important aspect of midwifery practice.
Collaboration also includes working with others when the care of women falls outside the midwives’ scope of practice. For example, the care of women with mental health conditions is seen as one area where collaboration is particularly needed (Homer et al 2005).
THE NATURE OF COLLABORATION
Successful collaborative practice requires several conditions. First, and most importantly, the woman must remain at the centre of the process. In order that she may participate in informed decision-making, information-sharing must occur in a context where her values and philosophical beliefs are respected and upheld. Midwives can assist women to critically examine the evidence presented to them, and help them make sense of those aspects that appear conflicting or inconclusive. When the woman is central to the collaborative process, her ability to tease out the important elements (to her) of both midwifery and obstetric practice will mean that she can formulate a plan of care that will best meet her needs. Edwards (2000, p 81) uses the phrase ‘a potentially radicalising effect on the maternity system’ to describe what can happen when the relationships between caregivers and women become the organising principle around which care is structured.
Many scholars have added depth to the discussion of preconditions for successful collaborative practice. Dorne has drawn together a number of these in what she describes as the Ten Major Tenets of Collaboration (Dorne 2002, p 17). They are as follows:
• provision of a non-competitive/non-hierarchical environment
• partnership between parties based on shared power and authority
• the ability to jointly define work processes, relationships, mutual objectives and goals
• joint responsibility/accountability for decision-making
• secure self-identity enabling clearly defined roles, with an emphasis on the function of each party
• power based on knowledge/expertise as opposed to power based on role and role function
• mutual trust, respect, cooperation and commitment
• time and space for open and effective communication and conflict resolution
• recognition/valuing of how differing perspectives inform decision-making
• interdependence of work with dependent/independent functions within the collaborative practice.
It is easy to see how these theoretical aspects could fit within the context of midwifery/obstetric collaborations. In practice it must be acknowledged that a maternity service that contains all these elements is rare, but certainly an admirable goal. It must be remembered also that midwives are accountable for their midwifery actions, regardless of who accepts ‘clinical responsibility’.
Stapleton (1998) builds on the idea of mutual trust and respect as essential attributes of collaboration, and explores the notion of professional maturity. She believes that ‘individuals who feel secure and competent professionally can communicate their discipline’s strengths, value, limitations and contributions to colleagues from other disciplines’ and adds that this requires ‘a high level of professional maturity and confidence in one’s professional knowledge and clinical skills’ (Stapleton 1998, p 14). Effective communication is another crucial prerequisite for working together. It requires that ‘members listen to each other’s perspective yet are assertive in presenting their point of view’ (Henneman et al 1995, p 106).
Midwives participating in a reflective midwifery partnership are in a position to have a positive impact on women’s experiences in situations where referral is required. In addition to honouring the woman’s own knowing about herself and her body, midwives can assist the woman to educate herself well, so that the consultation is not one in which the ‘specialist’ is the only ‘expert’. Thus a woman will ask the questions that will meaningfully aid her decision-making, rather than following a predetermined protocol that may not reflect her values or beliefs. While it is true that some obstetricians find this challenging, it can only serve to expand their horizons and increase their understanding of childbirth not just being about the removal of a baby from a woman’s uterus.
Midwives need to remain mindful of the fact that within midwifery there is an enormous resource and body of knowledge, and that sometimes it is to our colleagues that we should turn for discussion and advice. A recent (unpublished) study by one of the authors (SM) uncovered how collaboration between midwives can be protective of women’s experiences in a labour context. This study explored labour and birth outcomes of first-time mothers in different birth settings. It revealed that when a woman’s labour became complex and required additional input from the obstetric service, in situations where a second midwife was also involved in the woman’s care she was more likely to achieve a spontaneous birth (68%) than when only an obstetrician was consulted (51%) (Miller 2008).
Experienced midwives know well how judicious one needs to be about some indications for referral—the ‘large-for-dates’ baby, for example. We need to be clear that the experience of consultation will not negatively affect the woman’s confidence in her ability to birth normally when the obstetrician has told her she has a high likelihood of needing a caesarean section. We are of course obliged to discuss the recommendation for referral with the woman, and support her decision to consult or not, as the case may be. But we need to balance the content of her obstetric consultation with midwifery knowledge about moulding, pelvic mapping, optimal baby positioning, working with labour pain, and mobility in labour to enhance her likelihood of normal birth.
Sometimes the woman may request referral, or may self-refer to healthcare professionals other than obstetricians/paediatricians/anaesthetists. It might be an acupuncturist, osteopath, homeopath or naturopath who can best assist with the particular issue the woman faces. A respectful collaborative process can be achieved here also. Indeed, because of a greater appreciation for holism displayed by complementary therapists, many midwives find working alongside these practitioners very fruitful and mutually satisfying for all involved.
COLLABORATION IN THE CONTEXT OF THE AUSTRALIAN MATERNITY REFORMS 2009
In Australia, following the introduction of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 on 24 June 2009, the Minister for Health Nicola Roxon proclaimed that midwives wishing to provide treatment under Medicare and prescribe certain medicines under the PBS would need to demonstrate that they met the eligibility requirements and that they had collaborative arrangements in place, including appropriate referral pathways with hospitals and doctors to ensure that patients receive coordinated care and the appropriate expertise and treatment as the clinical need arose. In the context of the Australian reforms, the nature of collaboration is discussed very briefly below.
Collaboration in healthcare occurs when experts from different disciplines work together in a combined effort to improve patients’ needs (Martín-Rodríguez et al 2005; Saxell et al 2009). Although the proposed maternity reforms intend to make interprofessional collaboration mandatory, it is usually by its very nature a negotiated process founded on all of the following key components: interprofessional willingness to collaborate; trust; mutual respect; and good communication. Successful collaborative practice in midwifery is based on two broad categories of collaboration: interprofessional collaboration and patient-centred (or more specifically ‘woman-centred’) partnership. Both aspects are integral to the safety of midwifery practice.
Interprofessional collaboration occurs when two or more experts from different disciplines take joint ownership of decisions and collective responsibility for outcomes when working across professional and functional boundaries, for example within the hospital setting (Liedtka et al 1998). A collaboration of healthcare professionals share responsibility for outcomes, see themselves playing a crucial role within a larger social system (healthcare service), and manage their relationships across organisational boundaries (Cohen et al 1997). Successful collaboration in healthcare teams can be attributed to several key elements, including interpersonal relationships within the team and favourable conditions within the organisation and the system within which collaboration takes place (Martín-Rodríguez et al 2005).
Few studies have investigated the influence of all these determinants of collaboration on interprofessional collaboration. However, an Australian randomised controlled trial of collaboration in the maternity services published by Homer and colleagues (2001) demonstrated that a community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. Collaboration with medical colleagues in that study demonstrated how working together strengthened the ability of midwives to work to their full scope of practice, providing safe, high-quality care. Research published in 2003 and funded by the Australian Research Council and four state Departments of Health as industry partners found that in Australia one of the major barriers to collaborative practice is the competitive approach that exists both between professionals and between healthcare institutions (Barclay et al 2003). Traditional medical and nursing department structures have tended to concentrate and optimise the provision of care within their ‘silos’ from a provider perspective, rather than optimising the larger system from the patient’s perspective.
The second key element of collaboration in midwifery practice relates to the relationship formed between women and midwives in a collaborative partnership. In the midwifery model of care, women are at the centre of their pregnancy and birth care and from that point all decisions are made. In this way, collaboration plays a central role in coordinating care across the continuum of sites and services. For example, in the hospital setting resources are organised around the provision of care for women and their families, rather than around various specialised departments. In order that women participate in informed decision-making, information-sharing occurs in a context where her values and philosophical beliefs are respected and upheld.
The midwifery profession is becoming increasingly involved in building relationships with the professional bodies of other healthcare disciplines. This is to ensure that those involved in the production of clinical guidelines for practice and in policy discussions are aware of the full scope of midwifery practice. This ‘top-down’ approach also ensures that the voice of pregnant women is heard at the highest levels, as an expectation of consumer involvement operates at this level also.
Two examples of this in New Zealand have been the participation by midwives in the GBS New Zealand Consensus Working Party, which has produced guidelines for risk assessment and treatment approaches for Group B Streptococcus infection (MOH 2005), and the New Zealand Guidelines Group, a collaboration between midwives, obstetricians, consumers, paediatricians, general practitioners, maternity managers and midwifery and medical educators, which has produced best-practice guidelines in relation to the care of women with breech presentation or previous caesarean birth (NZGG 2004). These documents contribute much to our understanding of evidence-based care and will lead to increased consistency of advice to pregnant women faced with making decisions about aspects of their care.
THE NEW ZEALAND REFERRAL GUIDELINES
In New Zealand, since 1 July 2007, the Referral Guidelines sit alongside the Primary Maternity Services Notice (Section 88) (Ministry of Health 2002). This notice is pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000. Although previously appended to the Section 88 Notice, it was felt that in order to facilitate frequent review of the Guidelines they needed to sit outside the legislation, as otherwise any changes would require an Amendment to the Act. It is anticipated that the Guidelines will be reviewed at two-yearly intervals.
The stated purpose of the Guidelines is that they be ‘used to facilitate consultation and integration of care, giving confidence to providers, women and their families’ (Ministry of Health 2007, p 1). Circumstances in which the Guidelines may be varied are outlined, acknowledging the fact that midwives and others providing maternity services have a wide range of skills, and that where one’s level of expertise allows, departures from the Guidelines may occur. In this instance, the midwife should be able to justify her course of action, and documentation reflecting the process of information-sharing and decision-making with the woman should appear in the clinical record.
The process of referral can take many forms. In general, the booking interview is often the time when the woman will disclose a situation that may require referral. If this is because of something in her medical or maternity history, the midwife can discuss the recommendation for referral and, with the woman’s informed consent, initiate the process immediately. Other indications for referral may arise later in the pregnancy—for example, the discovery of a twin pregnancy, or breech presentation that persists near term. Referral will occur in such instances as the particular issue arises.
If after discussion of the recommendation for referral the woman consents to consult, the midwife is responsible for writing a letter to request a consultant review. This letter should provide enough pertinent information to enable the obstetrician to adequately assess the woman’s situation. At the very least, the letter will contain:
• the woman’s name, address, date of birth, National Health Index number, gravidity/parity and contact details
• the reason that referral is sought
• a brief statement outlining her medical and/or maternity history
• any relevant supporting documentation (e.g. blood test or ultrasound reports)