Background
Conceptual framework
Methods
Design
Case
Participants
Data collection
Data analysis
Results
Themes | Subthemes | Categories |
---|---|---|
Definition of collaborative work | ||
Interactional factors | Conflict | Conflict over Professional Philosophy |
Conflict over Autonomy, Professional Territory, Work Style | ||
Conflict over Compensation Issue | ||
Organizational factors | Philosophy and Mission | Hospital versus Birth Center Philosophy |
Administration | Lack of Midwives at the Administrative Level | |
Resources | Dedicated Financial Resources | |
Essential Infrastructure and Time | ||
Culture | Culture of Team Work | |
Culture of Interventionism vs. Non-Interventionism | ||
Structure | Organizational Rules and Regulations | |
Systemic factors | Power and status | |
Managing care |
Definition of collaborative work
We are only here for the patient’s sake, for the well-being of baby and mother. Even when I disagree with the way others are practicing, I still have to collaborate with what they are doing for the well-being of the mother and the baby. (Nurse 7)
You have to often work together, not just in looking after a specific patient, but working together for developing agreements and protocols, and making the system flexible to accommodate all the needs for everybody who is looking after pregnant patients. (OB4)
If you have problems, you focus on the problem, not on the people and if you have positive thing, you say it to people, and you respect the people for their professional talents and skills that are different from what you have. (PH2)
Interactional factors
Conflict
Our philosophy is very different, so sometimes it is difficult to understand each other. For us, it’s important that the woman be part of the process, but their protocol and the way they work (obstetricians) don’t put the woman in the center of the care …and they don’t necessarily believe or adopt a normal birth. Sometimes we have the same situation but they would do something different. (Mid 1)
“Their agenda is vaginal delivery at all costs, and that’s not my attitude towards birth. So you obviously have two very different attitudes towards birth”. (OB3)
We like to prevent problems before they arise, or detect things early and intervene more early when things can still be done, and when the risk of complications is lessened….so it is a different philosophy, a different approach. (OB2)
Pregnancy is a healthy issue in the life of a woman and we try to be preventive and try that things go on a good way… they (obstetricians) are coming from the vision when they were trained like “ok there's something wrong and so we have to cure it”. (MidA)
Obstetricians would have said something like “ok…you have to work like we do”, and the midwives didn't want to have to be told that. (PH2)
I think the hardship is that they have a set of expectations and they really feel that the midwifery experience should be a separate experience from the hospital. (OB5)
In Ontario, midwives have hospital privileges, but the way Midwifery Authority in Quebec built the profession here is not like Ontario and Quebec decided that midwives would not have privilege in hospitals. Now we can go to the hospital to have hospital births under our responsibility but it is not a privilege. (Mid1)
It is rare that women ask to have a hospital delivery with a midwife. Most of them – even if they had chosen to have a hospital birth at the beginning of the pregnancy – during the pregnancy are going to change their idea and they ask for birth outside the hospital... If no women wanted to have birth in a birth center, I would agree to go work in the hospital setting, but they do not. They want to have the delivery at the birth center. (Mid2)
I am tired of hearing: “Midwives should go in the hospital”. Yes, but the population comes to see us because they want to give birth outside of the hospital. I will follow the women to where ever they want to go, but if they come to see me, it is not because they want to go inside the hospital. Here, we offer women the possibility to go to the hospital and we have, I would say, three births a year from women that decide to go there with us. (Mid1)
I have never really thought of it, that if they would be here as a colleague, I do not know how it would be; I think a lot of people would not like it. […] We run the department and we are nurses so whenever the midwife come (for transfer), it is like “now the patient is here, she is mine, you have no say”. Yeah, I think a lot of people think that way, … maybe because they feel threatened of having the other one’s opinion. (Nurse 3)
This becomes a particular issue when the patient asks for an epidural, and the midwife says “no, don’t take it now”; so I can see some nurses reacting like this: “the patient wants an epidural, don’t interfere” or “she’s the one who really has a sense of what she's going through so she should be able to decide” which is true. (Nurse 7)
There are personalities in nurses that can be confrontational, that can be disrespectful to the process, or disrespectful to the fact that the midwife and the patient have this bond, so it is really the individual personalities that can make it an unpleasant experience for patient. (Nurse4)
They (obstetricians) are afraid of losing part of their practice to the midwives, which I find is sad because they have much more to do than take care of a low risk pregnancy. (Nurse 6)
Last year, I was about to resign… because they (obstetricians) were telling us we had too many patients that we were delivering. We had to cut back our numbers, while we are not even doing a quarter of the births in the hospital and there is no way to negotiate [] so they do not need the family doctors; family doctor is non-sense, because it takes away dollars from them! (PH1)
There should have to be no fee for service! They (obstetricians) would have to be paid a salary when they are on-call and … then they would not be so much interested in doing a volume. (PH1)
The physicians in hospital settings were afraid when they said, if the government invest in the first line and in the birth centers, then we will lose a part of the money”. (MidA)
The Québec Medical Association was warning everybody of what a threat the advent of midwives was to family doctors and to obstetricians, that they were going to take away the work, and take the place of medical professionals, and that this was a bad thing! (PH2)
Organizational factors
Philosophy and mission
There are high volumes of patients, and it is only by working together that we get through taking care of all those volumes of patients. (Adm1)
We are working together; the midwife is there for the patient’s support and I am doing the nursing part because (the patient) is under doctor’s supervision and the doctor is looking after her. I do not feel there is much difference. (Nurse 7)
We are all working for the same goal; for a healthy delivery, healthy patient, healthy baby… so we do not have any choice. I am going to be honest again… I do not like working with some people, and I am sure some people do not like working with me, but we have to keep our differences outside and just say ok, we’re working for the well-being of the patient’. (Nurse 8)
It is certain that the greatest philosophy of midwifery is to empower women in their process of childbirth….so women make decisions relative to interventions they want or not. (Mid3)
Ok, we believe that women are able to take charge of their own pregnancy and delivery; we believe in empowerment; yes, we believe in the capacity of women to deliver their own babies physiologically. (MidA)
So our goal is simply safety of mother and baby, and their (midwives) goal is that “it has to be a vaginal birth or it is a failure”. We do not look at it that way. (OB3)
Administration
Lack of midwives at the administrative level
You have to put those people in directive positions and then you can go to action…We do not have midwifery representation at the level of the ministry []… In 2005, when the new building for the social and health service came out, midwives were saying that it’s important to have representation from other professionals … ideally, you put a regional midwife to show how to implement midwifery care in the region! (MidA)
Each person is bringing his/her point of view and expertise and so it is important to have all the people that are necessary to create a good plan. That is the reason why sometimes you can have misunderstanding and poor collaboration because decisions at the higher levels are not sound, then the lower levels are not able to follow. (MidA)
I don’t feel that there’s someone really in a management position who is really interested in moving that (collaboration) forward. (Nurse 1)
Resources
Dedicated financial resources
If the government dedicates resources for training midwives and incorporating midwives into our multi-disciplinary team, it would be very welcome. (Adm1)
Right now, resources that are supposed to be going towards maternal child health are going to patients in the emergency department and people who are over the age of seventy. So we're competing within a fixed resource pie and that's where it becomes quite difficult and challenging. (Adm2)
Obstetricians have been studying for 10 years and it costs thousands and thousands of dollars to society, and then they spend 60–70% of their time (taking care of) low risk births. Some countries do a better job respecting first, second and third line care and they have very good outcomes, even better outcomes than we have. (MidA)
Essential infrastructure and time
Even just to discuss how we could improve issues with a certain doctor, or maybe we are having issues with the midwives… we do not have time and I think that is a shame! (Nurse5)
No! Here, we do not have time, because we are on-call one day, and then we are running all over the place after! (PH1)
Everyone is very busy in their schedule…I have a hard time getting nurses to a one-hour teaching session. How am I able to relieve them from their duties… to come and meet with midwives for the goal of collaboration, when I have so many other patient safety priorities that need to be met at the same time? (Adm4)
The nursing station is too small and we are always outside like around… standing. We do not have that space to interact or talk or ask questions or things like that. Even for the doctors it is very difficult. (Nurse6)
Well the problem is the shortage of resources… we cannot increase our numbers any more than we have [ ] it’s a problem that the Minister of Health has been offering solutions like midwives, but have not gone ahead and made any actual changes to the care that we provide; they have not increased the budget, they haven’t increased the beds! (OB5)
It could be a hundred miles away; it does not make a difference. Although it is physically close by, we do not go there and they do not come here unless they have to transfer a patient here. (OB1)
The moment that you have to call an ambulance and step into a car to come to the hospital –I do not care if it is three block or three kilometers – it is the same process. (OB4)
Because we communicate mostly by phone, we do not really see the midwives. They phone us when they need to transfer a patient; we do not phone them because we do not have patients to send to them! (Nurse5)
Culture
Culture of team work
This hospital has a culture of collaboration: people do work together and get along more than other hospitals. It is a special environment. So, I think the corporate culture of this place is to work together in a collaborative way. (OB3)
In this birth center, the accent is on real teamwork, and each team helping others. (MidA)
We are quite informal with each other, so I think that sometimes there is a slippery slope because we can be too informal and then people may feel disrespected. I think that there can be a fine line between being buddies with a doctor or with a midwife, and then slipping into “Oh! That was actually disrespectful that comment that was made”. (Nurse 4)
Culture of interventionism vs. non-interventionism
Because it is a high-risk center, I find we are very prone to interventions, inductions, C-sections and things like that, then yes in a certain way it could influence the role of the midwives here, because we are so interventionist. There are a lot of interventions being done whereas in regards to midwife’s environment, there are usually no interventions. (Nurse 3)
When you are in a hospital, the epidural is just in place. You know, almost every mom when they hit transition phase, will ask for something for pain, an epidural like “I can’t do this… I need pain medication, you're torturing me”. When you are at a birth center, you know that, that option requires a transfer to another institution and is more complicated. So you’re going to be more likely to pull up your boot-straps and do what you need to do to get through the delivery. (Adm4)
We will maybe accelerate the labor more; maybe break her water a little bit faster because we need to get patients moving. You have to manage the whole case room, you want to do what's best for the patient but you need to move patients…you don't want them to be dragging on too long … there’s more patients that keep coming, so you need to get patients delivered. (OB2)
We do not believe that high-tech is better than low-tech, and so that is why say, we are kind of hybrids between the midwives and the obstetricians; we can do the high-tech, but we know that it is actually destructive to use high-tech when low-tech will do them same. (PH1)
The nurses are never told, “Why don’t you go and support a woman”, they’ve always being told “why didn’t you chart this, why did you stop the Syntocinon?” No one even explains to nurses the value of supporting a woman, no one tells them that if you're with the woman in the room, you can avoid the epidural, and avoid the intervention, so you can see how it can be a little bit of a clash sometimes, the culture of midwives with their supporting to avoid the interventions, and nurses who are trained to do interventions and not to avoid them. (PH1)
Even if we would like to support the patient we cannot, because we do not only have one patient; we have two or three patients at one time. So when we have a patient in labour – the patient who doesn’t want an epidural – and you have another patient… it's hard for us, in the sense that we have to be running around going… so the one- to- one caring – as a nurse – doesn’t exist. (Nurse 8)
In birth center, there is a culture of non-intervention. It is fair to say that pregnancy for us is normal, but it is not at all costs! (Mid3)
Structure
Organizational rules and regulations
Nurses end-up taking doctors’ orders. We can negotiate or say that we do not agree but at the end of the day, what the doctor says goes. You know the nurse can refuse to do something that she does not feel is safe or comfortable doing, sure, but she cannot change what was prescribed... Of course, there is hierarchy there... Whereas the way the system is set-up, midwives do not take orders from doctors… Once you bring midwives into hospitals, who is at the top of hierarchy? Doctors! (Adm4)
Systemic factors
Power status
I am involved in lobbying government to provide more support to nurses, and I think that government needs to be influenced to meet the needs. If the government is going to issue a policy, saying that midwives are going to deliver ten percent of the babies in the province of Quebec, then there needs to be lobbying of the government to provide the resources to improve that interprofessional collaboration. (Adm2)
In Ontario, a midwife is in charge of the whole department of midwifery at the ministry of health level. That would be helpful if you have somebody who is sitting on the top level and understands midwifery. (MidA)
Managing care
An obstetrician follows three hundred pregnancies in a year! The obstetrician should prioritize the difficult pregnancies; and say to the woman: “I could suggest to you to find a midwife or to find a family doctor” and say that “I work in collaboration with those professionals, and if you develop a complication in your pregnancy, they will call me”. (Adm4)
The CLSCs have a big role to play because they see the woman in the early stage of the pregnancy. Some of women do not even have a physician or someone to follow their pregnancy, and if the CLSCs could explain clearly the role of each one and the choices that are available for the woman, I think that would be a nice help. (Adm2)
I think obstetricians should handle more high-risks patients and I think family practice doctors and midwives should be handling more low-risks patients. (Adm4)