Development of a Midwifery Student Peer Debriefing Tool: An interpretive descriptive study.

BACKGROUND: Psychosocial traumatisation associated with giving birth, can occur in those present with the woman giving birth, a phenomenon known as vicarious trauma. It has been identified that there are currently no interventions available for midwifery students who have experienced vicarious trauma following difficult birth experiences. OBJECTIVE: To explore whether the counselling intervention developed by Gamble et al. (2005), can be adapted for midwifery students to be appropriately and feasibly used as a counselling intervention with peers who have experienced midwifery practice-related vicarious trauma. DESIGN: Interpretive descriptive methodology. SETTING: This study was set at two Australian universities from which pre-registration midwifery courses are delivered. PARTICIPANTS: The work of reviewing the original tool and adapting it for use by and with midwifery students associated with this project was conducted by a key stakeholder group of seven representative midwifery students and five midwifery academics. METHODS: Ethics were approved. Data were collected via one face to face and two online conversations using the Microsoft Teams™ platform. Reflexive Thematic analysis were applied to revise the tool following each round of data collection and to finalise the adaptation of the intervention for its new intended purpose. RESULTS: The Midwifery Student Peer Debriefing Tool is presented as a six-step intervention that guides the midwifery student through a process of debriefing with their peer. The feasibility of the tool resulted in an overarching theme labelled "I want this to mean something" and captures the therapeutic power of peer debriefing toward a meaningful outcome that fostered growth, and a deeper understanding of the profession. CONCLUSION: Vicarious trauma is widely recognised as a core reason for midwives and midwifery students leaving the workforce. The peer debriefing tool helps midwifery students move through the process of recovering from adversity but also fostered learnings about midwifery practice and the profession.

Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth.

BACKGROUND AND PROBLEM: During childbirth, one of the most common diagnoses of pathology is 'failure to progress', frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus. AIM: To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women's labour trajectory and birth outcome. METHODS: Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data. FINDINGS: This study found that the conceptualisation of plateauing labour depends largely on health professionals' philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby. DISCUSSION: Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological. CONCLUSION: This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice.

"I believe " - graduating midwifery students' midwifery philosophies and intentions for their graduate year: A longitudinal descriptive study.

OBJECTIVE: Midwifery graduates may experience transition shock that makes them question their fit for their workplace and the profession and in extreme cases, may lead to them leaving. Understanding graduate midwives' worldviews, job intentions and work experiences is important to inform retention strategies. Factors such as having a strong professional identity and experiencing strong job satisfaction are important for midwife retention. Conversely, stress, trauma and work-life imbalances are examples of factors that lead to attrition from midwifery. Transition shock experienced by some graduates can exacerbate these factors if not managed effectively. This study aimed to identify causes and impact of any changes in graduate and early career midwives' philosophy, practice, and intention to stay in the profession. DESIGN, SETTING AND PARTICIPANTS: We invited the 2021 and 2022 cohorts of graduating midwifery students from all educational pathways in Victoria, Australia to participate in a longitudinal descriptive study using a questionnaire with both closed and open -ended questions. This paper reports the findings from 16 participants that completed the first survey of a five-year longitudinal descriptive study. FINDINGS: The sixteen participants predominantly held a woman centred philosophy and ideally wanted to work in a midwife-led model of care. Although excited about moving into practice, they also disclosed a sense of needing to 'survive' in a maternity care system that their beliefs were not fully in alignment with. KEY CONCLUSIONS: The hopes, expectations and concerns of midwifery students who are anticipating moving into practice in this study resonate with those previously reported and demonstrate the need to consider personality-job fit in supporting this vulnerable group to transition. IMPLICATIONS FOR PRACTICE: This study provides insights into graduating midwives' hopes for, expectations of, and concerns about transitioning into practice that may inform the design of transition programs and support expansion of midwifery led models of care.

What is known about midwives' well-being and resilience? An integrative review of the international literature.

BACKGROUND: Internationally, the midwifery workforce is facing a professional crisis due to numerous organizational and individual factors that have led to midwives leaving the profession. These factors include high levels of workplace stress, systemic barriers to providing woman and person-centered care, trauma, and burnout. The COVID-19 pandemic magnified these pre-existing stressors and adversities and has further disrupted midwives' ability to practice within their professional norms. In order to understand how midwives can be better supported, there is a need to understand what contributes to and detracts from their well-being and resilience. AIM: To investigate and synthesize the extant international knowledge on midwives' well-being and resilience in the context of workplace stress and adversity. METHOD: Integrative review of the literature published in peer-reviewed journals. RESULTS: Thematic analysis of the literature resulted in three core themes: (1) risk factors and adversity; (2) protective factors and resilience; and (3) sustaining factors and well-being in midwifery. Findings from this integrated review highlight that several factors associated with workplace adversity can also be sources of protection depending on their presence or absence. Within the included studies, there exists a broad use of concepts and definitions that are applied to well-being and resilience, resulting in a lack of uniformity and cohesion. CONCLUSIONS: In this review, we identified a high level of workplace adversity and the subsequent impacts on midwives' well-being and resilience. A series of protective factors and strategies that can be used to improve the well-being of midwives and support resilience within the profession were also identified; however, further research of the population is required. In addition, the development of cohesive well-being and resilience concepts specific to midwifery is recommended, as is the development and application of uniform terminologies and definitions.

Working with private hospital midwives in Victoria, Australia to identify practice change priorities: Outcomes of a Delphi study.

OBJECTIVE/AIM: In this study, we invited midwives working at one metropolitan private hospital in Victoria, Australia to identify their workplace change needs and priorities for research. METHODS: In this two-round Delphi study, all midwifery staff within the maternity unit of a private hospital in Melbourne, Australia were invited to participate. In round one, participants joined face-to-face focus groups to put forward their ideas for workplace change and research ideas, and these data were developed into themes. In round two, participants ranked the themes in priority order. FINDINGS: The top four themes identified by this cohort of midwives were: 'Ways of working - investigating alternate ways of working to enable greater flexibility and opportunities'; 'Understanding midwifery - working with the executive team to highlight the nuances of maternity care'; 'Education - increase in staff in the education team to provide a greater presence and opportunity for education'; and 'Postnatal specific - review ways of working in postnatal areas'. KEY CONCLUSIONS: A number of priority research and change areas were identified which, if implemented, would strengthen both midwifery practice and midwife retention in this workplace. The findings will be of interest to midwife managers. Further research to evaluate the process and success of implementing the actions identified in this study would be valuable.

Building the plane while it's flying: implementation lessons from integrating a co-located exercise clinic into oncology care.

BACKGROUND: Despite its therapeutic role during cancer treatment, exercise is not routinely integrated into care and implementation efforts are largely absent from the literature. The aim of this study was to evaluate a strategy to integrate the workflow of a co-located exercise clinic into routine care within a private oncology setting in two clinics in the metropolitan region of Western Australia. METHODS: This prospective evaluation utilised a mixed methods approach to summarise lessons learned during the implementation of an integrated exercise workflow and supporting implementation plan. Data collection was informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Reports detailing utilisation of the exercise service and its referral pathways, as well as patient surveys and meeting minutes documenting the implementation process informed the evaluation. RESULTS: The co-located exercise service achieved integration into routine care within the clinical oncology setting. Patient utilisation was near capacity (reach) and 100% of clinicians referred to the service during the 13-month evaluation period (adoption). Moreover, ongoing adaptations were made to improve the program (implementation) and workflows were integrated into standard operating practices at the clinic (maintenance). The workflow performed as intended for ~70% of exercise participants (effectiveness); however, gaps were identified in utilisation of the workflow by both patients and clinicians. CONCLUSION: Integration of exercise into standard oncology care is possible, but it requires the ongoing commitment of multiple stakeholders across an organisation. The integrated workflow and supporting implementation plan greatly improved utilisation of the co-located exercise service, demonstrating the importance of targeted implementation planning. However, challenges regarding workflow fidelity within and across sites limited its success highlighting the complexities inherent in integrating exercise into clinical oncology care in a real-world setting.

What are the benefits and challenges of mentoring in midwifery? An integrative review.

AIM: The aim of this review was to synthesize best available evidence on mentoring programmes for midwives who have worked within the clinical setting for more than 1 year. BACKGROUND: Lack of job satisfaction, stress, burnout and limited managerial support contributes to midwifery workforce attrition and the ongoing global shortage of midwives. Mentoring may be one way to improve staff retention, leading to positive clinical and organizational outcomes. DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute for conducting systematic reviews, was used to develop a search strategy, selection criteria, method for quality appraisal and the extraction and synthesis of data. METHODS: Relevant articles were sought from the following databases: Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, MIDIRS and Scopus. The search and screening process was guided by the Preferred Reporting Items for Systematic Reviews and Meta Analysis 2009 checklist. Narrative analysis was used to develop four main categories derived from the results from the included studies. RESULTS: Eight studies were included in this review from which four themes were developed that are relevant to mentoring in midwifery; the impact on midwives' direct environment, their immediate relationships with peers and management, and the overarching influence of the organization directly impact the accessibility and support midwives receive in mentoring programmes. CONCLUSION: To enhance staff retention in the workforce, midwives require support from the wider organization in which they work. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' perspectives of mentoring programmes will directly influence the development of midwifery-specific mentoring programmes, which may lead to improved staff retention in the midwifery workforce.

Does midwifery-led care demonstrate care ethics: A template analysis.

BACKGROUND: Ethical care in maternity is fundamental to providing care that both prevents harm and does good, and yet, there is growing acknowledgement that disrespect and abuse routinely occur in this context, which indicates that current ethical frameworks are not adequate. Care ethics offers an alternative to the traditional biomedical ethical principles. RESEARCH AIM: The aim of the study was to determine whether a correlation exists between midwifery-led care and care ethics as an important first step in an action research project. RESEARCH DESIGN: Template analysis was chosen for this part of the action research. Template analysis is a design that tests theory against empirical data, which requires pre-set codes. PARTICIPANTS AND CONTEXT: A priori codes that represent midwifery-led care were generated by a stakeholder consultative group of nine childbearing women using nominal group technique, collected in Perth, Western Australia. The a priori codes were applied to a predesigned template with four domains of care ethics. ETHICAL CONSIDERATIONS: Ethics approval was granted by the Edith Cowan University research ethics committee REMS no. 2019-00296-Buchanan. FINDINGS: The participants generated eight a priori codes representing ethical midwifery care, such as: 1.1 Relationship with Midwife; 1.2 Woman-centred care; 2.1 Trust women's bodies and abilities; 2.2. Protect normal physiological birth; 3.1. Information provision; 3.2. Respect autonomy; 4.1. Birth culture of fear (midwifery-led care counter-cultural) and 4.2. Recognition of rite of passage. The a priori codes were mapped to the care ethics template. The template analysis found that midwifery-led care does indeed demonstrate care ethics. DISCUSSION: Care ethics takes into consideration what principle-based bioethics have previously overlooked: relationship, context and power. CONCLUSION: Midwifery-led care has been determined in this study to demonstrate care ethics, which suggest that further research is defensible with the view that it could be incorporated into the ethical codes and conduct for the midwifery profession.

Support needs of parents in neonatal intensive care unit: An integrative review.

BACKGROUND: Having an infant in the neonatal intensive care unit (NICU) is associated with intense emotional stress for both mothers and fathers. However, with the right support from staff, this stress can be reduced significantly. Although evidence on needs of parents in the neonatal unit exists, there is lack of a systematic integrative review on the support needs of parents in the neonatal unit. Current review evidence is needed to support busy neonatal unit clinicians in their practice. AIM AND OBJECTIVES: The purpose of this integrative review is to explore the current available evidence to describe and understand the support needs of parents of infants in the NICU. METHODS: The integrative review process of Whittemore and Knafl (2005) was used to guide this study. Six databases-MEDLINE, CINHAL, PubMed, Scopus, Google Scholar and PsycINFO-were searched for eligible studies using relevant keywords. Primary studies published in English language from 2010 to 2021 were reviewed following a pre-determined inclusion criteria. Studies that met the inclusion criteria were critically appraised using the Mixed Methods Appraisal Tool (MMAT). The review report is guided by the PRISMA 2020 checklist for systematic reviews. RESULTS: Overall, 24 primary qualitative, quantitative and mixed methods studies were included in the review. Analysis of included studies resulted in six themes that demonstrate the support needs of parents in the NICU; 1. Information needs; 2. Emotionally intelligent staff; 3. Hands-on support; 4. Targeted support; 5. Emotional needs; and 6. Practical needs. CONCLUSION: This review has presented the current evidence on the needs of parents from their own perspective. Healthcare workers' understanding and supporting these needs in the NICU is likely to increase parental satisfaction and improve health outcomes for parents, infants and their family. RELEVANCE TO CLINICAL PRACTICE: Parents of infants in the NICU require staff support to enhance their experiences, well-being, caring and parenting confidence during admission and post-discharge. As parents are in constant need for informational, emotional and practical support, continuing professional development for NICU staff should place emphasis on effective communication strategies, enhancing emotional intelligence and empathy among staff. NICU staff should build positive ongoing relationships with parents and provide targetted support for mothers and fathers.

Midwives' strategies for coping with barriers to providing quality maternal and neonatal care: a Glaserian grounded theory study.

BACKGROUND: Midwives face direct and indirect barriers in their workplaces that have negative consequences on their ability to provide quality care to women and neonates, however, they still carry on with their duties. This study aimed at investigating the coping strategies that Ghanaian midwives adopt to be able to complete their work. METHODS: Glaserian Grounded theory was used in this study. Data were collected through non-participant observations and semi-structured interviews. The study participants included 29 midwives who worked in labour/birthing environments and a pharmacist, a social worker, a national Health Insurance Scheme manager and a health services manager. FINDINGS: The midwives' motivation due to their strong desire to save the lives of women and neonates and their strong affection for the midwifery profession was identified to help them cope with the barriers that they faced in their workplaces. The midwives' motivation was found to spur actions such as improvising, taking control of the birthing process and the birthing environment and the maintenance of social and professional networks to help them to complete their duties. CONCLUSION: Ghanaian midwives face myriad barriers in their workplaces; however, they are able to adopt coping strategies that enable them to complete their duties. The provision of care resources for maternity services in the country will reduce the barriers that the midwives face and improve the quality of maternal and neonatal care. In the short term however, pre and post midwifery educational programmes should focus on developing resilience in the midwifery workforce to help midwives cope more effectively with the challenges that they face in their workplaces.

How is organisational fit addressed in Australian entry level midwifery job advertisements.

BACKGROUND: Midwifery job retention is an ongoing global issue. Prior research has recognised that considering an individual's attributes in relation to their work environment may assist in improving job satisfaction among midwives, leading to improved long-term job retention in the midwifery profession. The aim of this study was to evaluate whether, and how organisational fit is addressed in current entry level midwifery job advertisements within Australia. METHODS: Midwifery jobs were searched for within 12 search engines, using the search term 'midwife', including Seek.com , Indeed.com , government employment websites for all Australian states and territories, and private health organisation websites. Data were extracted from eligible job advertisements by three independent researchers. Extracted data encompassed elements addressing person-job fit and person-organisation fit. Content analysis involving chi-square and Fischer exact tests were completed on extracted data. RESULTS: Key findings demonstrate private health care organisations (29.2%) are more likely than public health care organisations (8.8%) to ask potential candidates to have additional qualifications, however, public health care organisations (34.1% vs. 16.7%) are more likely to ask for dual registration as a midwife and nurse. This is further supported by private health care organisations being more likely to refer to the candidate as a midwife (72.9% vs. 48.4%) than as a nurse. Private health care organisations more often noted access to support for employees and were more likely to mention access to employee assistance programs (41.7% vs. 13.2%), orientations (16.7% vs. 0%) and included benefits (72.9% vs. 42.9%). Clinical skills and personality traits were more frequently addressed in public health organisation advertisements; these included a requirement of employees to be accountable (49.5% vs. 6.3%), innovative (28.6% vs. 0%), have teamwork (69.2% vs. 52.1%) and conflict resolution skills (36.3% vs. 8.3%), and have knowledge of legislation (44.0% vs. 25.0%) and contemporary midwifery issues (28.6% vs. 4.2%). CONCLUSION: This study highlights that organisations employing midwives may be unwittingly contributing to the problem of midwife attrition through inattention to factors that endear midwives to workplaces in job advertisements. Further work developing employee selection and recruitment processes that are informed by the concept of person-job-organisation fit, is necessary.

Sociocultural Practices Affecting the Care of Preterm Infants in the Ghanaian Community.

INTRODUCTION: Although culture is an integral part of health, there is scarcity of evidence on the influence of culture on caregiving experiences of parents of preterm infants. The aim of this study was to explore the influence of sociocultural practices on caring for preterm infants in the Ghanaian community. METHOD: Narrative inquiry was utilized to explore the influence of sociocultural practices on the care of preterm infants from 21 mothers, 9 fathers, and 12 household members. Data were collected through face-to-face semistructured interviews and observations at participants' homes. RESULTS: Analysis of data resulted in three threads/themes-respect for the elderly, use of herbal medicines, and communal living. DISCUSSION: Community and extended family members have great influence on the care of preterm infants. Traditional herbal medicines are considered effective in treating traditional illnesses among preterm infants. Understanding the influence of culture on the care of vulnerable preterm infants in the community is essential in developing interventions for infant survival.

Midwifery leaders' views on the factors considered crucial to implementing evidence-based practice in clinical areas.

PROBLEM: The evidence-to-practice gap continues to persist in healthcare and midwives report limited knowledge and use of effective intervention strategies to support the implementation of new evidence-based practices in clinical settings. BACKGROUND: Despite ongoing development and dissemination of high quality research findings, the translation of latest research evidence by midwives into new evidence-based practices remains sub-optimal. This inefficiency places consumers at risk of obsolete or potentially dangerous healthcare interventions. AIM: To explore midwifery leaders' views on what information and support midwives require to lead practice change initiatives in clinical areas. METHODS: The study formed part of a broader Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical settings. The study employed a qualitative design and was guided by the methodological underpinnings of Action Research (AR). FINDINGS: One core finding emerged to fulfil the aim and objectives of the study. To lead implementation of evidence-based practices, midwives need practical solutions and a map of the process, packaged into a centralised web-based resource. DISCUSSION: The findings reported in this study provide valuable insight into the specific needs of midwives wanting to improve the uptake and longevity of new evidence based practices in clinical areas. This includes information specific to evidence implementation, support networks and knowledge of Implementation Science. CONCLUSION: To lead practice change initiatives, midwives require a web-based resource that standardises the process of evidence implementation, while providing midwives with clear direction and the support needed to confidently champion for evidence base change in clinical areas.

Graduating midwifery students' preferred model of practice and first job decisions: A qualitative study.

OBJECTIVES: To explore and describe the preferred model of practice and first job decisions of final stage midwifery students from three Western Australian universities. DESIGN: Qualitative descriptive. SETTING: Three Western Australian (WA) universities offering courses leading to registration as a midwife. PARTICIPANTS: Twenty-seven midwifery students from undergraduate and postgraduate (pre-registration) courses. METHODS: Data were collected from recorded interviews and focus groups. Thematic analysis of interview transcripts was used to identify commonalities. Data saturation guided when recruitment ceased and final sample size was achieved. FINDINGS: Participants' preferred model of maternity care was influenced by learning about and witnessing both autonomous midwifery practice and collaborative care during their studies. The greatest influence was clinical experience, with most preferring a continuity of midwifery model (CoM) but first consolidating their practice in a public hospital. Most students reported that they would not choose a private hospital as their first option. Work/life balance was also considered, with some accepting that family commitments and a need to work close to home may prevent them from choosing a CoM model. CONCLUSION AND IMPLICATIONS: Although many Australian midwifery students start their midwifery course with preconceived ideology of their eventual workplace, the influences of their educators, clinical placement environment, preceptors and continuity of care experience relationships with women helped determine their final direction. To provide students with the experiences to become woman-centred autonomous practitioners it is important for universities and all maternity care providers to carefully consider their responsibility in how they influence midwifery students in education and practice.

"I love being a midwife; it's who I am": A Glaserian Grounded Theory Study of why midwives stay in midwifery.

AIMS AND OBJECTIVES: To understand why Western Australian (WA) midwives choose to remain in the profession. BACKGROUND: Midwifery shortages and the inability to retain midwives in the midwifery profession is a global problem. The need for effective midwifery staff retention strategies to be implemented is therefore urgent, as is the need for evidence to inform those strategies. DESIGN: Glaserian grounded theory (GT) methodology was used with constant comparative analysis. METHODS: Fourteen midwives currently working clinically area were interviewed about why they remain in the profession. The GT process of constant comparative analysis resulted in an overarching core category emerging. The study is reported in accordance with Tong and associates' (2007) Consolidated Criteria for Reporting Qualitative Research (COREQ). RESULTS: The core category derived from the data was labelled-"I love being a midwife; it's who I am." The three major categories that underpin the core category are labelled as follows: "The people I work with make all the difference"; "I want to be 'with woman' so I can make a difference"; and "I feel a responsibility to pass on my skills, knowledge and wisdom to the next generation." CONCLUSION: It emerged from the data that midwives' ability to be "with woman" and the difference they feel they make to them, the people they work with and the opportunity to "grow" the next generation together underpin a compelling new middle-range theory of the phenomenon of interest. RELEVANCE TO CLINICAL PRACTICE: The theory that emerged and the insights it provides will be of interest to healthcare leaders, who may wish to use it to help develop midwifery workforce policy and practice, and by extension to optimise midwives' job satisfaction, and facilitate the retention of midwives both locally and across Australia.

Midwives' use of best available evidence in practice: An integrative review.

AIMS AND OBJECTIVES: To synthesise international research that relates to midwives' use of best available evidence in practice settings and identify key issues relating to the translation of latest evidence into everyday maternity care. BACKGROUND: Midwifery is a research-informed profession. However, a gap persists in the translation of best available evidence into practice settings, compromising gold standard maternity care and delaying the translation of new knowledge into everyday practice. DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute (JBI) for conducting systematic reviews, was used to facilitate development of a search strategy, selection criteria and quality appraisal process, and the extraction and synthesis of data to inform an integrative review. METHODS: The databases CINAHL, MEDLINE, Web of Science, Implementation Science Journal and Scopus were searched for relevant articles. The screening and quality appraisal process complied with the PRISMA 2009 checklist. Narrative analysis was used to develop sub-categories and dimensions from the data, which were then synthesised to form two major categories that together answer the review question. RESULTS: The six articles reviewed report on midwives' use of best available evidence in Australia, the UK and Asia. Two major categories emerged that confirm that although midwifery values evidence-based practice (EBP), evidence-informed maternity care is not always employed in clinical settings. Additionally, closure of the evidence-to-practice gap in maternity care requires a multidimensional approach. CONCLUSION: Collaborative partnerships between midwives and researchers are necessary to initiate strategies that support midwives' efforts to facilitate the timely movement of best available evidence into practice. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' use of best available evidence in practice will direct future efforts towards the development of mechanisms that facilitate the timely uptake of latest evidence by all maternity care providers working in clinical settings.

Factors associated with midwives' job satisfaction and intention to stay in the profession: An integrative review.

AIMS AND OBJECTIVES: To conduct an integrative review of the factors associated with why midwives stay in midwifery. BACKGROUND: Midwifery retention and attrition are globally acknowledged as an issue. However, little is known as to why midwives stay in midwifery as the focus has previously focussed on why they leave. DESIGN: A structured six-step integrative review approach was used, and this involved the development of a search strategy, study selection and critical appraisal, data abstraction and synthesis, interpretation of findings and recommendations for future practice. METHODS: The review was conducted using the databases MEDLINE, CINAHL and PsychInfo. Included studies were in the English language with an unlimited publication date. RESULTS: Six studies were included in this review: one qualitative, two quantitative and three using mixed methods. Seven themes emerged from synthesisation of the data reported for the six included studies that together help answer the question of why midwives stay in midwifery. CONCLUSION: This integrative review has highlighted some important factors that assist in answering the question why midwives stay in midwifery. However, it has also highlighted the need for quality data that reflects the range of contexts in which midwifery is practised. RELEVANCE TO CLINICAL PRACTICE: There is an abundance of literature focussing on why midwives leave the profession; however, the gap exists in the reasons why midwives stay. If we can uncover this important detail, then changes within the profession can begin to be implemented, addressing the shortage of midwives issue that has been seen globally for a large number of years.

Fighting a losing battle: Midwives experiences of workplace stress.

AIM: The aim of this study was to examine the nature of midwives' work-related stress and the implications, if any, for midwives overall emotional well-being and career decisions. METHODS: A classic Glaserian grounded theory methodology was used, which included 21 in-depth individual face-to-face interviews with registered midwives. FINDINGS: The core category that emerged from the data labelled 'Fighting a Losing Battle' consisted of the causal, contextual and conditional factors that together form the core problem faced by the midwives. Participants depicted contemporary midwifery practice environments as 'war like' and described levels of work-related stress that, for many, were unbearable and led them to conclude that the job was not worth it. CONCLUSION: This study reveals that as the number and extent of stressors increase, the negative implications and effects for midwives rise as the opportunities to 'do' midwifery in the way they value decrease, and that commitment to and engagement with the work diminishes. Although the midwives said that midwifery itself could be stressful, their responses clearly identify that it is not the actual job but other related, contextual and other environmental factors that make it so.

Australian midwives' experiences of implementing practice change.

OBJECTIVE: The introduction of the best available evidence into health care practice is a complicated and uncertain process. Attempts to translate even highly reliable evidence into care provision are known to flounder. The objective of this study was to investigate midwives' experiences of leading practice change. DESIGN: This study was conducted using Glaserian Grounded Theory methodology. SETTING: Australian midwifery practice contexts provided the setting for this study. PARTICIPANTS: Midwives who had led practice change initiatives. FINDINGS: Sixteen Australian midwife change leaders participated in this study. Each had sought to implement a workplace practice change. The core problem experienced by the participants was labelled 'So many barriers on so many levels'. KEY CONCLUSIONS: Although some participants were encouraged, supported and enabled to enact change to some degree, even when the change was initiated by the practice site, all participants experienced a number of obstacles at many levels in their implementation efforts. For most, this meant that their endeavours to move the best available evidence into practice took many years or did not progress at all. IMPLICATIONS FOR PRACTICE: The findings of this study will be of interest to midwives, midwifery leaders and midwifery educators. Understanding the factors in midwifery care environments that support or limit the uptake of best evidence into practice will help to inform and develop midwifery context-specific mechanisms to expedite sustained practice innovation.