From relatively small initiatives in midwifery care, such as changes in shift rotas or new systems in record keeping, to major changes such as the introduction of midwifery-led beds or the “Team approach” continuous change has become an inherent part of professional lives. Whether it is liked or not, to some degree its ramifications affect every midwife and nurse, and the need to become aquainted and comfortable with change is vitally important for our professional progress With the introduction of Changing Childbirth Department of Health, (1993) which stressed informed choice for women and their partners, women centered care and more importantly continuity of care and carer, it is important that midwives have a “well person” mentality, ready to argue evidence-based practice and be true autonomous practitioners. The United Kingdom Central Council urges professionals to be pro-active, to continue their education and act as advocators for the women that they look after. To accompany this new stance, it may be time to radically review and challenge some of the long held clinical practices and organizational structures of midwifery care, Cross (1996). The aim of this assignment is to discuss the management of change relating to “Eating and drinking”, in labour. The history of Mendelson’s syndrome will be briefly discussed as will the strategy involved in implementing change, (bottom up, normative re-educative approach), management tools and managerial skills. Emphasis will be made on one process been Lewin’s (1958) however reference will be made to other processes regarding some alternatives. Communication styles in relationship to resistance and appropriate involvement of staff will be explored critically to illustrate and referral to various documents issued by the government and other statutory bodies that have influenced change will be made in supporting the assignment. Delivering quality in midwifery practice will be mentioned as will the application and importance of clinical supervision that coincide with leadership styles. The effects that change has on the role of the midwife bearing in mind the Code of Professional Conduct, resistance to change, ethics, accountability and autonomy will also be explored. In conclusion, a reiteration of the main points included within the discussion will be revisited.
Since the 1950`s women have been denied the privilege of eating and drinking freely in labour. This was due to the findings of Curtis Mendelson. He first described an “asthmatic type” syndrome in association with obstetric patients in his analysis of 66 cases of gastric aspiration occurring in 44,016 pregnancies in one US hospital between 1932 and 1945, Mendelsom (1946) He noted that this rare syndrome (0,15%) caused acute critical illness over 24-36 hours. A complete, uncomplicated recovery ensued in all cases of fluid aspiration. Following animal experimentation to determine the underlying pathology, Mendelson concluded that gastric liquid containing hydrochloric acid, when aspirated into the lungs, was responsible for the syndrome that today bears his name. On the basis of his findings Mendelson recommended that all parturients be starved of liquid and solid nourishment throughout Labour. This is still the case in a very small minority (3.6%) of maternity units in England and Wales, (Michael et al 1991).
Traditional change has been both being evolved and imposed into the profession with the driving force for change coming from managers, professional bodies such as the National boards, the UKCC, area and regional Health Authorities. Until fairly recently midwives have, in some instances being reactive rather than pro-active to change. However with the National Health Service culture driven by competitive market forces and the need for women-centred care and choice House of commons (1992), the emphasis is on each unit and practitioner to become increasingly involved in promoting change to develop excellence in practice. The Winterton Report, Department of Health (1992) and the subsequent Changing Childbirth report, Department of Health (1993) recommends a service that provides women-centred care facilitating choice, continuity and control. It firmly places midwives as the lead professionals working in partnership with women, which enables midwives to practice their full range of skills. Women have the right to know the advantages and disadvantages of eating and drinking in labour and through information from the midwife make an informed choice. In order for a change to be successfully implemented there needs to be some guidelines. It is considered important that midwives should be able to decide what guidelines they want to use and be actively involved in the development and implementation of them Kirkham (2000). In order to reduce resistance to change, staff meetings should commence focusing on the management of change; i.e. staff meeting in the formal setting at work (all grades), day and night duty. Multidisciplinary meetings, informal staff meetings, social events out of hours, staff meetings (single grade), documentation of the outcome, written agreement drawn up on philosophy, attitudes and practices, language choice simple precise, change ‘atmosphere’; staff should feel free to question, argue, debate and construct criticism, all of the above will help to prevent resistance and ensure that each process of change is properly adhered to. Change theories provide a theoretical basis for understanding the process involved in bringing about change. The problem facing health professionals is not the inevitability of change but the way in which the who, why, where, when and how of the process can be planned to achieve maximum benefits for individuals, groups and society as a whole. The need to select a strategy to guide practice which is deemed central to ensuring the success of the venture Wright (1998).
There are many different strategies for successful change as is there as many definitions for change. Lippitt (1973), argues that change is any planned or unplanned alteration in status quo of an organism, situation, or process. By contrast Lewin’s (1958) classic change theory defines ‘no change’ as a ‘quasi-stationary equilibrium; state comparable to that of a river which flows with a given velocity in a given direction during a certain time interval. He describes social changes as comparable to a change in the velocity and the direction of that river, and sees the change process as having three basic steps, firstly unfreezing, when the motivation to create some sort of change occurs i.e. realizing that a change is needed. Secondly moving, when change is planned and initiated, re-thinking over what is agreed if needed and finally refreezing, when change is integrated and established or stabilized into a new equilibrium. In the dynamic world of midwifery today, and in moving the change forward, there needs to be a steering force or a change agent. Wright (1998). Ottaway (1976, 1980) identifies a change strategy that can be incorporated in Lewin’s model where one works from the bottom up (normative-re-educative approach) see Appendix 1. This approach is demonstrated by Winterton (1992), with women and midwives calling upon those in authority, such as obstetricians and government to support and focus on changes needed in the provision of care. This could be that managers and educators work together thus supporting and facilitating each other and by combining their skills acting as the change agent. They in turn liaise through effective communication with the on-site staff to create the change. Wright (1998) states that using this approach it’s demonstrates the application of moving towards a more client-centred approach to care, as advocated within the principles of Changing Childbirth DOH (1993), he also indicates that the use of this strategy makes long term change more conceivable. The advantages in working through this particular change strategy is that it involves all grades of staff from the ‘shop floor’ gradually filtering through the rest of the organization rather than the reverse i.e. traditional change that was mentioned earlier. Current examples of the application of the normative-re-educative strategy for change are the moves towards a more patient-centred approach to care and education. The active involvement of the woman in identifying needs and selecting outcomes to achieve the desired outcomes of the plan of care and in evaluating the effectiveness of the care is another example of the bottom up approach to change Keyzer, (1985); Wright, (1986); Pearson, (1989). Other points could be introduced, Ottaway (1976) i.e. a pilot site where by the new norms are put into action in a controlled area i.e. delivery suite. Adequate training should follow on. Participators feel the need for new knowledge and skill which is then supplied for them rather than trying to change people for new skills. The staff decides when, where and how the change will come about. The change should be made to order to fit into the unit and not applied as a planned package, by this the staff are aware of what needs they feel are required rather than imposed by outsiders. This type of change strategy could be beneficial in the compilation of a new eating and drinking protocol on a delivery suite. The process is implemented there by involving people at all stages thus reducing the risks of resistance.
What is important is that change is not suddenly imposed upon practitioners but that each process is introduced in a constructed manor. In the above model the assessment of current practice, along with the need to change can be engaged by the change agent or steering group, which are selected to develop principles into practice. The previous influences on eating and drinking could be looked at i.e. Mendelson’s findings and what progress have they reached since 1946. The representation from the ‘shop floor’ ensures that there is an understanding of everyday problems that will help the smooth running of the process. This is also where the development of team work is important, getting commitment and involvement of groups of people within the service to utilize their energy and expertise to generate and sustain change Broome (1998). Another measure that could be used in the introduction of change would be a SWOT analysis meaning that one could look at the strengths, weaknesses, opportunities and threats within the organization. This is a good opportunity to examine the findings around eating and drinking in labour. Findings have shown from a Nottingham study in 1995 that women who could choose to eat and drink felt they had more control over their labour, Newton and Champion (1997). They didn’t suffer from the discomfort of fasting, which is known to increase anxiety. Fasting itself connot guarantee an empty stomach or a reduction in acidic gastric contents, Roberts and Shirly (1976). The confidential enquiry into maternal deaths, Department of Health (1990), shows the latest report where only 2 people was reported to have died from Mendelson’s syndrome. This causes threats that death has occurred and that it could happen again. In order to meet the objective of informed choice and giving women information, women need to be aware of the policy before they come into the labour ward. In order for women to be aware of the proposed policy it could be included in the antenatal information pack. This could detect any problems early in the planning phase. By evaluating the information obtained for these problem-solving approaches, managers and participants are able to re-adjust and if necessary re-plan the process. This also reduces the build up of problems and in turn prevents resistance. In the past there hasn’t been much resistance as the implementation for change or enforcement for change came from the top, i.e. senior midwives in conjunction with senior obstetricians and, as Rothman (1984) asserts midwives do not have a reciprocal right to determine medical practice. This is a good example of Mendelson’s findings that are still carried out today despite the research that is available. This is the power-coercive strategy where by the common assumption underlying it, is that persons with less power will always comply with their plans, directives and leadership of those with greater power. Professionals themselves need to conquer this tradition by been pro-active and applying the research and knowledge to evaluate practice. It must also be argued that policies should be flexible, based on current research and formulated by a group of professionals. Inflexible, obstetric and litigation fearing policies can but create a conflict between the midwives the obstetricians and the woman.
Within any large organization there will be people who are difficult or perceived as difficult. Change is often received as a threat and each department will have people who will ‘go with the flow and those that will resist and according to Ford and Walsh (1994), the reason why professionals resist change most of the time and yet be subject to overnight change is that usually it is imposed using the power-coercion top down model. This gives the appearance of change taking place quickly, but as Wright (1998) argues in reality little has changed as people generally resent such approaches to change and largely carry on as before. Resistance can be considered to be both good and bad: bad in terms of blocking or preventing something that may be essential; good in terms of tempering or balancing, thus preventing a headlong dash into a situation without prior planning Vaughan & Pillmoor (1989). Some of the reasons why resistance to change comes about is; lack of trust or confidence in managers, a dislike of how the change is been implemented, not feeling involved or a previous bad experience of change. Midwives are constantly working within the Code of Conduct, which may prevent midwives in tackling such changes or initiating changes. Conspiracy may help to overcome the resistance to change, but a more potent weapon is knowledge. Wright (1998) asserts that giving staff the knowledge of who they are, what goals they are aiming for, and how they can achieve them, is an important part of the process. Open dialogue and knowledge exchange may also reduce resistance, reassuring staff that the planned change will not bring redeployment or redundancies, for example, or, if this is likely, providing information about staff protection. The distress caused by change is real, and should not be overlooked by innovators whether they are managers, politicians or practitioners. A way of avoiding resistance and distress while initiating the change process is ensuring that it is functioning properly. Midwives and the designation of a change leader could help avoid this resistance. Midwives who process a sound knowledge of the system in which they work are often the most effective innovators of change. Pearson (1989) suggests that effective leadership does not rely on position alone. Successful change leadership is about utilizing a variety of personal attributes. Leadership styles can be identified within the different change strategies, Bennis et al. (1976) and Hersey and Blanchard (1982) i.e. Power coercive, telling, the change agent gives orders and defines the who, what, where, when and how. Rational-empirical, selling, the change agent provides information and convinces the group the need for change. Normative-re-educative involves participating, the change agent negotiates with the group in decision making when asked and delegating, self-directed change with minimal input from the change agent. In reality managers needs to utilize a mixture of leadership styles at different times. However the skill is being able to recognize, when and which style to use, Cross (1996). Poor clinical leadership results in poor standards of care, which are to be tackled by the introduction of clinical governance DOH (1999), this will ensure that clinical guidelines are properly produced and based on the beast available evidence to protect the mother, baby and the midwife. Change leaders are often clinical midwives or supervisors who through knowledge, experience, research-based practice and listening to women perceive the need to update and develop care. The supervisor of midwives is an ideal person to ensure that achieving women centred care or services due attention is given to policies and protocols required within the standards of the trust. The supervisor has an important role to the public in monitoring standards of midwifery practice and that policies been implemented are to achieve government set targets for women-centred care, do not increase the risk of litigation. Dineen, (1997) reports a lower incidence of disciplinary action when guidelines are used. Obstetric litigation cost runs into the millions of pounds, money which could be better spent on clinical care in a financial constrained health service. Midwifery supervision with its primary function of protecting the public from unsafe practice cannot be separated from risk management and the supervisor has an important role in developing and implementing guidelines for practice. The roots of risk management strategies adopted by trusts lie in insurance primarily to reduce the incidence of compensation claims. Supervision makes an important contribution to risk management, quality and audit strategies, as well as multi-professional development of protocols and guidelines for practice Kirkham, (1996).
Effective communication is another important factor in effective change. This involves considering both people and the way they take on change, and the methods used to communicate the change. Some people will work better than others, in a given situation. Effective communication is vital through the change process as a breakdown could create resistance; misunderstanding and if prolonged eventually chaos. It could be worth considering that women themselves are informed of the change i.e. (a new eating and drinking policy). This could be carried out at the first antenatal booking with the community midwife. Women should be given the information to enable them to make informed choice regarding all aspects of there labour including whether they eat or drink. Encouragement to ask questions will also help to avoid any confusion around the introduction of the new policy. Knowledge is power, and knowledge of change helps to give practitioners the power over change. Thus empowered professionals are not left merely to react, but may indeed be proactive in determining the course that health care takes. Midwives should help women to listen to their bodies through good communication skills and decide what is right for them in their labour; midwives have the ability to empower women by acting as their advocates. Rights theory strongly emphasizes patient autonomy and alongside this the right to have access to information and know all the risks Vaughan & Pillmoor (1998). Doing this it serves not only the interests of ourselves but also the interests of those we exist to help. An individual client or patient-centred approach to health care should rightfully acknowledge client autonomy, treating each individual with respect, dignity and privacy at all times. Client autonomy has been emphasized in the report of the Expert Maternity Group: Changing Childbirth DOH (1993): ‘the woman should be able to feel that she is in control of what is happening to her and able to make decisions about her care, based on her needs, having discussed matters fully with the professionals involved. The United Kingdom Central Clearing House Code of Professional Conduct (1992) and Guidelines for Professional Practice (1996), both advocate professional accountability. Choice and control are two essential ethical issues that are embodied within the principle of autonomy. The NHS Patient’s Charter in relation to maternity services implicitly refers to the principle of autonomy also, by stating the rights of women in relation to care they can expect DOH (1996a). In practice however it may be difficult to utilize professional autonomy to it’s full extent as a result of maternity unit policies and procedures, many of which can effect the woman’s freedom of choice and the midwife’s practice this is partly due to the statutory legislation defining the midwife’s practice. Cross (1996) identifies that autonomy for the midwife is hardly ever absolute because of the restrictions enforced by the local and government policies and protocols.
It can be suggested that one of the reasons why midwives have become more aware of the moral dilemmas faced in health care today is the recognition of people’s rights to some choice in how their health is managed. As in any change process there will be ethical issues to be addressed. Jones (1994) considers that ethics is the application of processes and theories of moral philosophy to the real situation. It is concerned with the basic principles and concepts that guide human beings in thought and action, and which underline their values. As stated in the International Code of Ethics for midwives, International confederation of Midwives (1993), midwives should participate in the development and the implementation of health policies that promote the health of all women and childbearing families. This is of great importance in relation to eating and drinking in labour, as there are severe consequences if things should go wrong. Midwives are been more pro-active i.e. using research-based practice it is clear that the awareness of moral issues are understood. The Code of Professional Conduct (UKCC 1992) is considered to be a framework for moral reasoning. It was formulated with regard to the broad ethical principles embraced by the profession Hussey (1996) and provides the standard expected for professional behaviour (ENB 1997). As professional practitioners this is the code that is adhered to and professionals need to be familiar with the code for guidance, regulation, discipline, protection, information, proclamation and negotiation. This enables professionals to resolve dilemmas in a consistent and legible manner.
Any change process needs evaluation. Evaluation is an integral and essential part of the change process, which should be utilized to increase the quality and efficiency of the care or service been provided. This may be viewed as the collection and the interpretation of information, by formal or informal means, to aid defensible decision making. New patterns of care should be designed to allow evaluation of both their effectiveness and their acceptability to women using the service. DOH (1993). An effective way of evaluating the change process could be achieved through delivering quality in practice and education and observing the effects. Quality is easy to understand, as it is one of the everyday needs. Everyone needs quality. Pirsig (1974) pp. 181 famously defined quality as what you like. The quality process can be demonstrated by the quality circle first described by Lang in 1976. It has also been represented as a ‘spiral’ Bucknall et al (1992) indicating that quality is a dynamic, ongoing process. See Appendix. 2.The process of quality assurance is simple whether applied to clinical practice or educational practice, or any service. It starts with a standard, an expectation, something to measure against. The standard is measured to see how far the actual practice conforms with the standard. Change is implemented in order to conform practice to the standard. The standard is then reviewed again and the process continues in a continuous spiral of improvement. Numerous delivery suites in the UK, have taken on to implement a new eating and drinking policy. Reassurance could be sought from these units to obtain information. This could be compared with the standards that are now been worked with and help resolve any discrepancies that may have arisen. Audit is the next stage in the cycle of quality. This refers to the process of measurement with the implicit meaning of systematic measurement with a view to evaluation Buckley (1997). All aspects of practice need to be audited and this should be audited against the existing standards. This could be achieved through observation of the change leader with the participants as a way of viewing what is happening where by qualitative information is gained. By observation this gives an up-close analysis of how the process is progressing. This also gives the opportunity for unforeseen or unintended consequences to be highlighted and hence the evaluation process to continue. The ability to justify one’s actions will lead to evaluation, which will enhance learning, Kirkham (1997).
This assignment has critically analyzed the process of change related to eating and drinking in labour and how the practice impacts the midwife. As mentioned in the assignment midwives need strategies to protect themselves from the outcomes of change and may wish to support changes of there own devising. Change as we can interpret from the assignment requires careful planning with those in authority having an in dept knowledge of change theories, management tools, managerial and leadership skills in order to plan and foresee any possible implications. The bottom up or normative re-educative approach is the strategy used as emphasis are on a client centered approach and has a major impact in midwifery care as women are demanding informed choice and continuity of care. If there is a good rationale for change and the proper process is adhered to there should be an uncomplicated transition to the “new”. Change, particularly a top down approach tends to damage the sense of control of one’s work but many people are uncomfortable with the idea of claiming control as a right, as this may be particularly true for midwives in the climate of changing childbirth, and the current slogan of choice, continuity and control for women. Sufficient training of staff, along with resource allocation requires consideration. Conflict will always be present, concerning the best use of resources, and the need to balance quality and quantity of care within budgetary constrains. It is sometimes frustrating for midwives involved in a change process, as rules and regulations from the government have to be of the utmost importance. This creates boundaries that midwives have to work within while bearing in mind the safety of the women and her rights. One of the most successful ways to accomplice the change process is to first and foremost accept that change is a natural process that occurs in everyone’s life. It is the word change that is the problem not the actual process of change.
Appendix 1.
Manager Educator
Change agent
Appendix 1. ‘Bottom up’ change strategy.
Ottaway (1976)
Appendix 2.
Implementing Change
Appendix 2. The quality cycle in context.
(Bucknall 1992)
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