The barometer of moral distress in midwifery: A pilot study.

BACKGROUND: Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery. AIM: The aim of this study was to pilot the Barometer of Moral Distress in Midwifery. METHODS: This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity. FINDINGS: A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores. DISCUSSION/CONCLUSION: This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

Digital transformation of antenatal education: A descriptive exploratory study of women's experiences of online antenatal education.

PROBLEM: Research on how women experience online antenatal education is currently limited. A more nuanced understanding may assist organisations to tailor future digitalisation that best meets the needs of users. BACKGROUND: COVID-19 emergency measures forced a rapid implementation of online antenatal education. Women are known to enjoy some aspects of online antenatal education, but still desire social interaction. A marked digital divide is evident for more vulnerable populations. AIM: To explore how pregnant women experience an online antenatal education program. METHODS: A descriptive exploratory study was undertaken through collection of two concurrent data-sets. Quantitative data was collected from the online Parent Education Feedback Form (n = 38) Based on the six-stage process of Braun & Clarke, reflexive thematic analysis was used to analyse data sourced from semi-structured interviews with women (n = 5) who had undertaken online antenatal education. FINDINGS: Four themes, and eight associated sub-themes, were identified to better understand how women experience online antenatal education. The four primary themes identified were: Experiential Digital Learning; Desired Journey; Contemporary Representation; and Human Connection in the Digital Age. DISCUSSION: Well-designed digital platforms provide opportunities for interaction, content personalisation and self-tailored approaches in online antenatal education. Women require caregivers who hold specialist digital capabilities. Further research is warranted to better understand how digitalisation of antenatal education impacts women disadvantaged by digital exclusion. CONCLUSION: The digital transformation of antenatal education impacts a vast array of factors in women's experiences during pregnancy. A specialist skill-set from midwives is needed to champion quality antenatal education in the digital age.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia.

INTRODUCTION: In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken. OBJECTIVE: The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers. DESIGN: The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services. FINDINGS: The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'. DISCUSSION: All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals. CONCLUSION: This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

Moral distress in midwifery practice: A Delphi study.

BACKGROUND: Moral distress is a psychological concept that describes the harm associated with actions or inactions that oppose an individuals' moral beliefs. Moral distress is linked to moral compromise in the workplace that may negatively impact mental wellbeing. Current tools available to assess moral distress are not specific for the Australian health care system or midwifery practice. AIM: The aim of this study was to develop a list of situational and outcome statements associated with moral compromise and levels of moral distress in midwifery to inform the development of a tool to measure levels of moral distress in midwives. METHODS: This e-Delphi study was the third stage of a sequential exploratory mixed-methods study. Using an online strategy, three iterative rounds of e-Delphi were collected and analysed for consensus on situations leading to moral distress and the associated psychological outcomes. FINDINGS: Twenty participants contributed across the three rounds. Consensus was met in 40 morally compromising situation statements. The highest level of consensus related to excessive workloads and the associated negative impact of this on women and families. Consensus on outcomes following exposure to morally distressing situations led to the development of a continuum scale from moral frustration to moral injury. DISCUSSION/CONCLUSION: This is the first study to use a consensus method to establish different levels of moral compromise, frustration, distress, and injury in midwifery practice. The findings of this study contribute to a growing body of literature that supports the concept of moral distress occurring across a continuum.

Effectiveness of female genital mutilation/cutting education for health professionals: An integrative review.

INTRODUCTION: A plethora of research has identified the lack of educational opportunities for health professionals to support the biopsychosocial and cultural needs of women who have experienced female genital mutilation/cutting (FGM/C). As a result, some women with FGM/C can feel unsupported, discriminated against and fear to communicate their concerns with health providers. The aim of this review is to identify studies that have investigated the effectiveness of FGM/C education for health professionals. METHOD: Toronto and Remington's six-step framework for conducting an integrative literature review was used to identify studies that met the inclusion criteria. Searches were conducted across five primary databases and grey literature, between August and October 2021. The Joanna Briggs Institute critical appraisal tools for quasi-experimental studies was used to critically appraise included studies. The findings of the search were reported using preferred reporting items for systematic reviews and meta-analysis. RESULTS: A total of five studies met the criteria for inclusion. Studies examined education provided to midwives, nurses, obstetricians, gynaecologists, psychosexual counsellors and student nurses, from England, USA, Mali and Kenya. All studies demonstrated that the implementation of FGM/C education was effective in improving learning outcomes (knowledge, attitude and self-efficacy), However, the quality rating of the evidence ranged from very low to moderate and limited inferential analysis reported. CONCLUSION: This review confirms that FGM/C education, which is informed by evidence and developed in collaboration with practicing communities, is an effective way of improving FGM/C knowledge and attitudes among health professionals. STUDY REGISTRATION: Open Science Framework Register 10.17605/OSF.IO/SMJHX.

Examining the transformation of midwifery education in Australia to inform future directions: An integrative review.

BACKGROUND: Integral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions. AIM: To critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia. METHODS: A structured integrative literature review using Whittemore and Knafl's five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results. FINDINGS: The literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education. DISCUSSION: Extensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality. CONCLUSION: There is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services.

Agency in change: Learning experiences of international midwifery students in South Australia.

PROBLEM: While literature reports broadly on the experiences of international students of health professions in higher education, the experience of students undertaking an undergraduate midwifery program outside their country of origin has not previously been reported. BACKGROUND: Midwifery studies incorporate distinct clinical practice and discipline-specific therapeutic relationships which can challenge students familiar with the health system, so it is necessary to understand their impact on the learning needs of international students, who contribute to the diversity of our workforce. AIM: To explore learning experiences of international students of an undergraduate midwifery program to identify their perceptions and personal strategies which impacted their participation in the program. METHODS: A qualitative descriptive study, with a purposive sample of nine current international students and recent graduates of a midwifery program at a South Australian university. Participants attended a focus group or individual phone interview to explore their learning experiences, and data were thematically analysed. FINDINGS: Five themes and sub-themes were identified, built around a core concept of the international midwifery student experience as agency in change: language and culture, teaching and learning, isolation and integration, services and support, and motivation and resilience. Studying abroad was associated with personal and professional growth. Continuity of care for women presented challenges and produced learnings unique to this cohort. CONCLUSION: Tailored support, such as specialized clinical facilitation and organized peer networking, is required for international midwifery students in Australia. Additionally, effective approaches to facilitate bilingualism to support language concordant care are needed.

Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women's experiences and birth outcomes.

INTRODUCTION: The ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women's experiences and birth outcomes. AIM: To evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care. METHOD: An anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included. FINDINGS: The response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6-8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes. CONCLUSION: This innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators.

Exploring moral distress in Australian midwifery practice.

PROBLEM: Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. BACKGROUND: Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. AIM: To explore Australian midwives experience and consequences of moral distress. METHODS: Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. FINDINGS: Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. DISCUSSION: It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. CONCLUSION: This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia.

BACKGROUND: The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change. METHODS: A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant's commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey. RESULTS: Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12-60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, "People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements "People who work here are determined to implement this change", "People who work here want to implement this change", and "People who work here are committed to implementing this change. CONCLUSION: Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

The learning experiences of international students in nursing and midwifery programs: A literature review.

Globally, education continues to diversify, with a growing body of literature that describes the experiences of international higher education students. While the research includes representation from the health sciences, nursing and midwifery programs are underrepresented; understanding the experiences of international students therein may assist in determining whether discipline-specific teaching, learning and support is required. This review aims to summarise international nursing and midwifery students' perceptions of challenge and enablement when undertaking an undergraduate or baccalaureate program. A total of 408 articles were identified and after duplicates were removed and inclusion/exclusion criteria applied, eight primary studies were included. No papers were identified that reported on the experiences of international midwifery students. For international nursing students, five themes emerged: language and culture, isolation and segregation, teaching and learning, services and support, and resilience and growth. This review concludes that the available data both affirms the existing body of knowledge around international students and illuminates unique challenges and opportunities for nursing students undertaking clinical placements. There is a need for increased language and peer support, socialisation and specially educated support staff. Research is required to identify best practice in teaching methodology for an increasingly diverse cohort and importantly, to provide a midwifery perspective.

Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016.

BACKGROUND: Birth Centres (BC) are underpinned by a philosophy of woman- centred care and were pivotal in growing models of midwifery-led care in South Australia (SA). AIM: To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades. METHODS: The SA Perinatal Statistics Collection was used to describe women birthing from 1998 to 2016. Number of births through midwifery-led services from 2004 to 2016 were obtained from unit managers. Analyses are descriptive. FINDINGS: Women who birthed in BC in SA from 1998 to 2016 comprised approximately 6% of all births per year, and numbers have remained static. Three BC models operate in SA, all with different capacity. Proportionally, women not born in Australia are as likely to birth in BC as labour wards. The proportion of women who received midwifery-led care (whether affiliated with a BC or not), increased from 8.3% in 1998 to 19.2% of all births in 2016. Of the women who received midwifery-led care in 2016, 15.3% went on to birth in a midwifery-led model of care. CONCLUSION: Whilst the overall number of BC births has not increased, women seeking midwifery-led care has more than doubled over the past two decades. BC encompass the midwifery philosophy, quality of care, and a physical home-like environment. The BC models in SA are managed through the three tertiary maternity units enabling women to access publicly funded midwifery care and should be more widely available.

Midwifery-led care in South Australia: Looking back to move forward.

BACKGROUND: From the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established. AIM: To better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future. METHODS: Semi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis. FINDINGS: Three overarching themes and several sub-themes were identified, these included: 'Midwifery suffragettes' which explored 'activism', 'adversity' and 'advocacy'; 'Building bridges' captured the importance of 'gathering midwives', a 'movement of women' and 'champions and influencers'; and 'Recognising midwifery' identified the strong 'sense of identity' needed to outface 'ignorance and opposition' and the importance of 'role reformation'. CONCLUSION: These midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.