2.3 Bases Teóricas
2.3.4 Modelo SERVQUAL
The midwives valued the autonomy that they now experienced and unlike the previous interviews, the language that the midwives used in relation to women in labour had altered:
I suppose it is very autonomous . . . because you have the one room privacy and it is the relationship that you build up with the woman all day. So I love
that part of it . . . Mary (1, 12-23)
As mentioned previously and will be seen further in the next chapter, the words midwives used were much more positive and indicated a different experience. In contrast to the activity outside the labour room, here a paradox was apparent in the dialogue of the midwives. Within the individual rooms of this large maternity unit, midwives experienced less surveillance than in their previous hospitals. They thus experienced greater freedom in their work. Midwives had previously felt that ‘midwifery’ was not valued; in this new setting the midwives seemed to have strengthened their identity:
. . . it's the same work but I think you have got a bit more autonomy here actually, when you go into the room and you are the midwife there . . .
Amelia (3, 30-33)
The midwives in Hospital A had been almost interchangeable, with the possibility of doctors or other midwives intervening and making decisions about care. The size of the new unit had brought about a change in the way all staff worked. Doctors focused their attention on women having their labour induced or experiencing complications, and midwifery managers were busy managing the unit. This left the midwife alone, particularly with those women whose labour seemed to be unproblematic. The midwife was trusted to provide appropriate and safe care:
once there is any intervention . . . they (doctors) pop in and out whereas if you have someone . . . in spontaneous labour . . . they don't see that as a
problem Ann (8; 8-11)
Susan, who had frequently been in charge of the labour ward in Hospital A, enjoyed providing more direct care:
you have your own lady you look after in your own four walls . . . and unless I feel that I have a problem . . . I am quite happy to relate to the woman and work to whatever her requirements are, her needs or her wants are . . . I
suppose it is a slightly different scenario in Hospital A . . . The one to one is fine by me, absolutely; I have no problem with that. Susan (7, 3-15)
Midwives enjoyed their autonomy and, as mentioned before, if there were no particular concerns, they used affirmative language when they spoke of caring for women in labour. Midwives from Hospital A, were particularly positive about this aspect of their work. Lucy expressed the heightened sense of responsibility that came with this autonomy:
. . . you have to make up your own mind on how you are going to do it. But to me that is good because it is keeping to your professionalism, your accountability and making you think and making you aware of ‘how am I going to account for this woman's care’ . . . Lucy (3, 30-34)
The privacy was valued by all. Midwives from Hospital B, who expressed greater regrets, than Hospital A midwives, at leaving their old unit, also used positive words when they described their experiences in the room. This was expressed by Claire as:
You are cocooned in some ways . . . it is good, the doors do close, (there is) a curtain just inside the door . . . and people a lot of the time respect it.
Claire (4, 11-14)
Amelia, who previously spoke about the technocratic skills required by labour ward midwives, now informed me how this freedom from surveillance enabled her to use various strategies to support women, without anticipating the censure she had previously experienced:
I find that you are able to conduct your midwifery care very well . . . if you want to do intermittent monitoring or if they want to mobilise and they have their birthing balls or Pilates balls and what have you, you can just do that if you are happy. But sometimes in Hospital A, I remember X (a midwife in charge) making a comment . . . ‘to do a trace (CTG) every hour’ but there is no point in doing a trace every hour if you are doing intermittent (monitoring) . . . it is great for those women who go into labour naturally . . . because they can do whatever they want, they can go on all-fours or ‘on the
ground’ or whatever they want . . . It actually leads to better deliveries. Amelia (3, 16-28)
In Hospital A, the birthing balls had not been used and when I had interviewed Amelia there, she told me that discontinuing a CTG invited adverse comments from midwifery managers. Now, there was no one to oversee activities and midwives had the confidence to implement their own decisions about care.
This lack of surveillance and acceptance of responsibility had facilitated junior midwives to gain confidence and Claire informed me that sometimes, even junior midwives now encouraged doctors not to interfere:
(Doctors) sometimes think they need to be in on everything and really a lot of the junior midwives realise that the doctors don't need to be in on a lot of
these situations. Claire (4, 15-20)
This will be explored further in the next chapter. Midwives had more confidence in articulating their views and this was now considered acceptable:
The midwives themselves have a bit more say. It is good yes. Susan (2, 28)
The old structures where a midwifery manager or doctor could oversee and influence the practices of labour ward midwives no longer occurred. As will be seen, this gave midwives confidence to incorporate new practices.
Conclusion
This chapter has explored the midwives experiences of working within the individual labour rooms. The title of this chapter, ‘Any port in the Storm’ reflects the midwives’ new freedom and potential vulnerability as they entered individual labour rooms to take responsibility for a woman’s care. The subthemes are, ‘island in the storm’, ‘sink or swim’, ‘cast up on the rocks’ and ‘your own lady in your own four walls’ which also reflected a new autonomy. This new setting was larger and had greater throughput of women than previously experienced by any of the midwives. The size of the unit meant that doctors and senior midwives were caught up in the workload and were not involved in individual women unless a problem was identified. The midwives no longer had opportunities to discuss aspects of care with
their colleagues and would be told to contact a doctor directly if they had any concerns. There was an assumption that assistance was always available but on occasion this did not occur. A junior midwife described this as ‘to sink or swim’. Though all midwives felt isolated in the room they did not admit to feeling vulnerable and even junior midwives rose to the challenge of the setting and reported positively on their experience. As will be explored further in the next chapter, the confidence the midwives expressed in the very positive language that they used such as being ‘cocooned’ in the room, reflected a new experience. The isolation had led to increased autonomy, decisions were no longer challenged and no one interfered with their care. As will be seen in the next chapter, when a birth went well, the midwives gained confidence from the women themselves. Judgements about the care they provided was reflected back to the midwives by the feedback they received from the women.
Autonomy is not usually associated with midwives working in an obstetric led unit and was not a feature of the midwives experience prior to the move. How this impacted on the midwives’ practice will be explored in the next chapter.