The collaborated data from the Positives and Challenges exercise and the Action Worksheet from Phase One were revisited as the next stage in co-creating solutions for MCoCer. The next part
Figure 25. Theme 'Meaningful Relationships'
The midwives identified knowing women better through MCoCer practice would provide a better environment to support Individualised Woman-centred care (Figure 26).
Figure 26. Theme 'Individualised Woman-centred care
Relational Joy
Family feels
included
Women will
know their
midwives
Better for women
and family
Individualised care
plan agreed in
partnership with
woman and midwife
Personalised care
Care for women in a
unique way,
personal to them
Flow of care and
conversations
Woman centred
Easier to be
advocate. Ease of
The midwives felt that MCoCer would improve Safety for women and babies, in comparison with current fragmented practice in which midwives felt key components of care could inadvertently be overlooked (Figure 27).
Figure 27. Theme 'Safety'
The midwives felt MCoCer models would enable more cohesive teams and Shared Philosophy of Care with colleagues which is something they expressed was lacking in their current workplace experiences (Figure 28).
Figure 28. Theme 'Shared philosophy of care'
Know the women and
family you're looking
after less likely to miss
something important
Safer for women
Women we care for
feel safer
Shared
Values
More Team
Cohesion
Figure 29. Theme 'Improved job satisfaction'
Improved Work-Life Balance was identified as a benefit of working as a continuity of carer midwife. This was associated with the reality of smaller caseloads and being more likely to be able to complete working tasks in a timely way was key to this as well as the ability to work flexibly around personal commitments (Figure 30).
Figure 30. Theme 'Improved work-life balance'
Job satisfaction
Full set of skills used.
Confident in all areas.
Relaxed midwives
because they know
their women and are
not meeting new
women all the time
Better work-life
balance
Flexible working
hours
More time to do
what you need to
do (smaller
caseload)
The collaborated themes from the challenges exercise were defined as; Conflicting Ideologies, Increased Expectations, Work-Life Balance and Logistical Concerns.
The midwives expressed concerns about Conflicting Ideologies and philosophy of other colleagues within the wider maternity environment. This included selecting immediate midwife colleagues to work with, differences in personalities and beliefs and understanding and trust between core and caseload working and from management (Figure 31). They clarified that as a caseloading midwife you must be supported to be autonomous, but that this would require a significant change to the organisation of maternity services from the current situation to facilitate this.
Figure 31. Theme 'Conflicting Ideologies'
Justifying midwifery
care when liasing
with other staff
Trust of management
in your
capabilities/work
ethic
Attitudes of other
staff
Medical staff (not)
trusting midwives
Lack of trusting
relationships
between staff
members
Not a shared
philosophies with
medicalised staff
Situational awareness
between
core/community
Lack of protocol for
care package-not
working the same
way
Inability to choose
team members
Clash in personality
Resistance to change
Mutual Respect (lack
of)
The midwives perceived that MCoCer would mean Increased Expectations on them in their professional role (Figure 32). This incorporated ideas about women expecting them to ‘know everything’ and be available at all times and management creating an extended role that was out with their comfort and skill level, while not being supported or trained to provide this type of care.
Figure 32. Theme 'Increased expectations'
Time
management-
stress!
Unrealistic
expectations of
women
Woman's
expectations-
needs to remain
professional
Increased pressure
to know
everything
No choice in skill
set
Staff (midwife)
commitments
increasing
Although flexible ways of working were identified by the midwives as a positive, the midwives also raised concerns that working in MCoCer models could erode the definition between work and personal life and could threaten their Work-Life Balance (Figure 33).
Figure 33. Theme 'Work-life balance'
The midwives voiced concerns about how continuity of carer would be provided with a lack of midwives and the associated cost of increased on call and extended midwife roles for the NHS. Continuity of medical care was also perceived as an important element of MCoCer which they did not feel was addressed in the current model and would be overlooked in the future design and implementation of new maternity care. This theme was collectively titled Logistical Concerns (Figure 34).
Figure 34. Theme 'Logistical concerns'
Lack of life-
balance
Impact on
personal life
On call stress-
restrictiveness of
this
How are women
allocated?
Caseload
size/caseload
cap? (no choice)
Feeling
overwhelmed by
women/caseload
How do midwife
students
learn/shadow?
Continuity of carer
with medical staff?
Finances-cost of on
call?
Overall the midwives noted more perceived challenges than positives of working in a MCoCer model, which reflected the uncertainty the midwives felt for practice change. Each of the midwives often participated in both the view of positive and the reflecting challenge of the same theme, highlighting personal conflict with the concept of MCoCer, rather than conflicting ideas between members of the group. Through discussions the midwives identified that the proposed practice change caused them to feel a great deal of uncertainty and lack of control about their own working practice and the future;
I’ve had a few of those moments when I’ve thought, how is it going to work? Is it actually going to change things in the way they say it’s going to? [Gayle]
As such it was a difficult exercise for the midwives to separate and identify specific positives and challenges. Many of the Positives and Challenges themes reflected the same topics, depicting the opposite aspect of each key factor. As such the themes identified were simultaneously convergent, as they addressed the same topics, and divergent as opposite elements of the same key factors were raised by the midwives. Figure 35 depicts the relationships between these themes that developed from themes in Figures 25-34.
Figure 35. Summary of Positives/Challenges themes
While we did not specifically return to the Positives and Challenges exercise again during the inquiry, the exercise did help inform the development of relevant co-created solutions as reported in the following two sections.