Midwifery leadership has been identified as an area of significant importance in government-level documents. As I described earlier, Maternity Matters (DH, 2007) highlights the value of strong and effective leadership in relation to placing the midwife at the centre of all women’s care. Meanwhile, ‘Midwifery 2020: delivering expectations’ (DH, 2010) emphasises the importance of timely and appropriate development for midwives choosing leadership and management career options. Such policy documents echo the wider public services literature identified earlier, relating to the ‘rise of leadership’ (Martin
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& Learmonth, 2012), and the complexities of a leadership rhetoric in the context of increased centralisation, governance and control (O’Reilly & Reed, 2010; Currie et al, 2009). While midwifery was not specifically identified as problematic within the Francis Report (2013), concerns have been raised about the profession in the aftermath of devastating events in other cases. The Healthcare Commission (2006) investigated a number of maternal deaths at Northwick Park Hospital, and found poor communication between midwives and obstetricians, as well as “deficiencies in the management structures” contributed to the poor quality of care the women received:
“For example, midwives were expected to manage a busy delivery suite that was reliant on agency and locum staff, with at times, little professional or managerial support” (p6).
Similarly, the Fielding Review (2010), an external review of University Hospitals of Morecambe Bay maternity services commissioned by the trust following five maternity serious untoward incidents during 2008, found a deficit of inter-professional and clinical- managerial communication. The review suggested there was:
“A requirement for staff of all disciplines to cooperate in working together harmoniously, and for management and staff to develop a greater sense of trust in their relationship” (p2-3).
A third case, based on several neonatal deaths and general public concern in relation to safety and quality of care at New Cross Hospital in Wolverhampton, prompted an investigation into maternity service provision by the Healthcare Commission in 2004. Their findings singled out leadership and management:
“The investigation also found problems around the leadership and management of the maternity services, team working and staffing. The leadership at all levels in
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the maternity services, and in the women’s and children’s division appears to have been weak and inconsistent for several years… The relationship between the Head of Midwifery, Clinical Director and Divisional Manager did not allow for effective leadership and management” (p6).
It is clear from these reports that midwifery leadership has been an area of concern for several years. A further issue within midwifery is the ageing workforce, highlighted in Midwifery 2020 (DH, 2010) and ‘Towards Better Births: a review of maternity services in England’ (Healthcare Commission, 2008). According to Midwifery 2020, 40-45% of the midwifery workforce is within ten years of retirement; two-thirds of the workforce is aged over 40; and one quarter of the workforce is aged over 50. In ‘Towards Better Births’, the Commission identified similar facts, adding that there was wide variation between maternity units in relation to age of staff, and suggesting that some units are not paying sufficient attention to forthcoming problems with senior midwives retiring. These figures give greater emphasis to the significance of developing the next generation of midwifery leaders, as the majority of the profession’s leaders are likely to be in the older age groups. At (former) strategic health authority level, there has been recognition of the need to develop the next cohort of midwifery leaders. NHS Midlands and East commissioned several leadership development programmes during 2007 to 2009, which were aimed at developing clinicians at various levels within the organisational hierarchy; meanwhile, the Royal College of Midwives runs a strategic leadership programme for senior clinical leaders. While midwifery has been identified as a profession in need of development at policy level, the profession is also of interest in relation to the study’s theoretical framework. For example, social identity theory would suggest challenges in terms of individuation, with midwives separating themselves at group level from obstetrics, nursing, and general management. From a de-individuation perspective, a continued professional identification
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among midwifery clinical leaders would echo the challenges of clinical leadership identities seen in published research among nurses and doctors. From a role identity perspective, the interaction between midwifery clinical leaders as agents and the wider organisational structure is of interest.
Given the concerns identified above, and echoing the experiences of doctors undertaking hybrid roles, it is to be expected that midwives will need to undertake significant identity work in their attempts to negotiate problematic discourses between professional group and organisational structure. The theme of narrative identity running through the study will enable analysis to include attention to this identity work, and strengthen the theoretical contribution the research may offer.
Finally, midwifery leadership is an under-researched area. While there have been studies of clinical leadership in nursing and medicine, as outlined earlier in this chapter, midwifery remains almost unmentioned. During the literature search for this study, only one empirical work within midwifery was discovered. That study (Byrom & Downe, 2008) does give some attention to midwifery leadership, but is focused on what characteristics make a ‘good’ midwifery leader, rather than examining the challenges facing those who move from clinical to leadership roles. Given the attention focused on midwifery leadership recently, as outlined above, the profession offers a rich field for exploration of identity construction and enactment in clinical leadership.
3.7 Chapter Conclusions
Leadership theory has evolved from ideas of traits, characteristics and behaviours to an approach which regards followers and organisational context and structure as equally important. Contemporary theory sees leadership as a fluid, adaptive process of attributed influence rather than as a fixed set of skills. Significantly, distributed models of leadership
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embrace ideas of leadership at every level of an organisation, based on contemporary organisational structures and a move away from dichotomous thinking more generally. The link between leadership and the study’s theoretical framework is clear: an individualistic focus is insufficient when considering identity construction within leadership, with evidence suggesting a powerful interaction between leaders, followers and organisational structures.
In the NHS, leadership thinking has recently been moving away from a managerial, top- down, hierarchical model of leadership development and enactment, evident in the advent of clinical leadership, with its principles of leadership at every level. However, clinical leadership has an added complexity of involving groups with strong professional identities, and literature in this area has identified a number of challenges. Alongside this complexity, there is the paradox described earlier in this chapter, where alongside a stated desire to increase the distribution of leadership across the organisation, NHS policy simultaneously appears to suppress the likelihood of distributed patterns of leadership due to an increasingly centrally driven programme of performance management and governance (Martin & Learmonth, 2012; Currie et al, 2009; O’Reilly & Reed, 2010).
Again, the link with the theoretical framework is clear: clinicians make the transition to a leadership role in the context of two significant factors:
1. An organisational structure that has traditionally employed a top-down approach to development and enactment of a managerial model of leadership, which is at odds with the principles of clinical practice;
2. The potential conflict inherent in enacting leadership in a hybrid professional- managerial capacity.
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Thus, in clinical leadership complexity exists at individual, professional group and organisational levels.
Finally, the case of midwives is interesting at two levels. First, as a professional group within the NHS organisational structure, midwifery can be explored in relation to a theoretical-level analysis of clinical leadership; and second, as a professional group with a problematic history and much recent attention in relation to future leadership, the study adds to an extremely sparse body of knowledge in this area. The literature review chapters have provided a justification for both of these elements of the study.
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