Fundamentals of Midwifery: A Textbook for Students (16 page)

Effective communication is an essential component of high quality care and good team working.28 This is particularly important when the team includes multiprofessional disciplines and chang-ing shift patterns. Two key points where communication is paramount are at handover and when there is a request for review of the patient’s care.There are tools and frameworks which can be used to assist in the process of effective hando- ver and review, although the robustness of some of these has not been tested (Mayor et al. 2011; Staggers and Blaz 2012). Examples of communication tools used in midwifery practice are Situation, Background, Assessment and Recommendation (SBAR) (Raynor et al. 2012; NHS Insti- tute for Innovation and Improvement 2008) and Reason, Story, Vital Signs and Plan (RSVP) (Featherstone et al. 2008). These have been designed in response to poor communication, affecting patient care and team working, with the intention of standardising elements of the handover to improve consistency in the approach and therefore less likelihood of missing important information. Johnson et al. (2012) also suggest the use of ICCCO for handovers, which relates to Identification of patient, Clinical risks, Clinical history/presentation, Clinical status, Care plan and Outcomes/goals of care. This was developed from their analysis of 126 handovers. This could also be a useful tool for teaching students and new staff the key issues required at handover.Handover or transfer of care should be an opportunity to enhance consistent and effective care, but if not handled well can in fact compromise safety (Thomas et al. 2013). Staggers and Blaz (2012) identify the different types and context for handovers and how these differences are important. They identify that focusing on any one type of handover ignores the specific needs of different units and patients. Conversely, they recommend having some structure in the process, acknowledging that this can be a time when mistakes are made, leading to signifi- cant harm or near misses. The Australian Medical Association (2006) and British Medical Associa- tion (2004) give specific guidance on effective handovers and how these can protect the patient and staff. Structured handovers can also save time as information does not have to be repeated and assists in interprofessional or multidisciplinary working. There is also the opportunity to include the patient in the handover, giving attention to the place handover is carried out, to ensure confidentiality and privacy is respected.A crucial element for success is identifying which tool works best for a particular team, taking into consideration the view and opinions of the members of the team as Johnson and Cowin (2013) found. Their research identified elements that can hamper effective handovers, including: a lack of focus; too many people involved; environment being too noisy and distracting; differ- ences between handover information and records; and a lack of understanding of others roles. It also identified positive features around effective handovers of care in the information sharing between the team and patient, as well as a clear point at which the care moves from one team to another. Johnson et al. (2012) suggest that written handovers, eboards and other computer models may also help with this process.
Activity 2.7 Reflect on an effective and ineffective handover you have experienced and identify what thedifferences were between the two, in relation to both the handover and ongoing care.
Communication tools can also be used when reviewing patient’s ongoing care. It is good practice to ensure that over a period of care, there is regular review of the situation to ensure that any developing risk factors or problems are identified in a timely manner. One review ofcare communication tool‘RSVP’ already mentioned, relates to Reason, Story, Vital Signs and Plan
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when requesting action and advice related to a client; particularly useful when there has been deterioration in the patient’s condition (Featherstone et al. 2008). Another tool widely used in maternity settings is ‘SBAR’ which stands for Situation, Background, Assessment and Recom- mendation; this has been developed to work with different disciplines and in other environ- ments such as the military and aviation (Johnson, Jefferies and Nicholls 2012; Street et al. 2011). Whichever framework is being used, it must be remembered that whilst it is there to provide structure, it should not constrain communication by missing out important questions and extrainformation which is specific to that particular patient or situation (Mayor et al. 2011).The key elements around successful handovers and transfer of care are that they should:

focus on the purpose of handovers

focus on key elements

not be overly long

be objective

be in an environment which facilitates listening

involve the patient wherever possible

not include jargon and abbreviations

pay particular attention to structure and organisation

be confidential.
Activity 2.8 Next time you attend a handover or transfer of care think about using a tool, or if one is usedthink about its effectiveness.Whilst there are many different methods of communicating today, such as telephone; text; written records; verbal handovers and email, the key principles of the information that needs to be handed over is generally the same. Practitioners must however be mindful of information governance to ensure that if information is being passed electronically or in a form that could be accessed by someone other than the intended recipient; it is protected to ensure confiden- tiality (NMC 2008; NHS England 2013).The NMC has clear standards relating to record keeping within the Code (NMC 2008). All midwives and student midwives must be aware of what the Code says and adhere to these standards.
Clinical consideration Remember that listening is an important skill in communication. Never forget that the woman is more in tune with herself than anyone else is, and her voice must be heard, her views respected and her contribution acknowledged and valued. This can be particularly challenging where women are hesitant or reluctant to participate in decision-making.
Collaboration
Downe and Finlayson (2011) argue that in order to facilitate effective interprofessional work,the focus should be on collaboration, rather than team working. Their view is that the act of
trying to mould different groups into a team can be counterproductive and lead to the develop- ment of factions and hierarchies. These they argue hinder rather than foster team working. Downe and Finlayson (2011) discuss how this can happen in maternity services with doctors30 and midwives working in opposition to each other, rather than together. This conflict can occurdue to misunderstandings around the aims of each discipline and justification for the plan of care. This distrust is well documented with maternity services worldwide (Gould 2008; McIntyre et al. 2012). By shifting the focus to collaborative working, for those involved in the care of a woman and her family, conflict and ineffective care can be reduced and women-centred, quality care facilitated. Through collaboration, practitioners put aside their differences and possible power struggles, with a direct correlation between high levels of collaboration and improved standards of care (Goodman and Clemow 2010). Collaborative working has been identified as being ‘
characterised by a shared vision, collective goal setting and a mutual understanding of roles
’ with an ‘
ethos of power-sharing
’ (Hutchings et al. 2003, p 35).From clinical practice experience, it is crucial that this collaboration includes the woman and her family. The woman is a key team member and communication with her is vital. Relating to the rights of the woman, there should be a signing up to ‘
no decision about me, without me
’ (DH 2012a). Power struggles between professionals have been discussed, but there may also be a power struggle between the professionals and the woman. Many women have confidence in their ability to give birth and have strong views on how they will achieve this. The woman’s view of how she will achieve her goal can be in conflict with that of the professionals involved in her care and can conflict within teams where there exists a lack of consensus. It is important to recognise that in some instances the woman may actually be the team leader. Hall (2013) puts forward the case for identifying an extra‘C’ in compassionate care, which stands for‘
central- ity of the service user
’ and for the other C’s to work around the user.During emergency situations the dynamics and collaboration within teams is crucial, with each member of the team knowing their role during the event and working together seamlessly. There is a limited amount of time in which to make decisions and consult the woman and her partner about the necessary actions. Regular interprofessional training for all the members of the team can facilitate this. Gaining consent from a woman in such situations is a challenge, but with experience staff can develop methods of giving key information quickly and effectively. Any decisions made in such situations must take into account what is the best course of action and this will need to be justifiable and based on current evidence. It is essential that the woman and her partner are given the opportunity to debrief after the event, so that they can develop an understanding of the events and the thinking behind the decisions made. Depending on the nature of the event, other members of the team may also need some form of debriefing. It can be difficult for students to know what is happening and what their role is during these events. Therefore students should seek help from their mentor, Supervisor of Midwives or a midwifery lecturer to discuss situations they have been involved in.
Activity 2.9 Think about a woman and her family where you have participated in their care; identify howmany people have been involved in this care. It may be useful to compare patients who are labelled as low and high risk.What challenges does the number of people involved bring for collaborative working?
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Figure 2.2
Unequal power and hierarchy. Source: Reproduced with permission from J. Green.
Power dynamics
As previously mentioned, one of the difficulties identified in team and collaborative working isunequal power within teams and hierarchies (Caldwell and Atwal 2003; see Figure 2.2). In order to fully collaborate, all members of the team must be treated as equal, particularly during decision-making processes. Hierarchies and lack of understanding of the roles of different team members can lead to misunderstanding around accountability. All professionals must remem- ber that they are accountable for all their own acts and omissions. For all midwives it is essential to have a good working knowledge of the NMC Rules and Standards (NMC 2012) and the Code (NMC 2008) (see Chapter 1: ‘To be a midwife’, where this is discussed in more detail). Brown et al. (2011) recommend that leadership and good use of conflict resolution techniques can assist in effective team working and development of partnerships and collaboration within a team, so preventing the negative impact disempowerment can have on team working.Team dynamics are related to power: who has the power and how is it used. The organisation of the NHS and other large institutions tends to involve hierarchy and an individual’s position within this hierarchy tends to influence how much power a person will have. Power can be related to profession, experience and amount of time within the team.There is a view that in the maternity setting doctors tend to see themselves as at the top of any hierarchy, with midwives below them and then the women (Downe and Finlayson 2011). Some midwives may also see themselves as lower down in a hierarchy, but others feel they are at the same level as the doctors. Downe and Finlayson (2011, p. 165) call this the ‘
polarised culture of maternity care
’ and Gould (2008) identifies ‘professional dominance’ as a threat to safe care and good team working. Since the woman knows herself better than anyone else does, it could be argued that she is in fact at the top of the hierarchy. Nothing can be done for her or to her without her consent. The power the professionals then wield is the manner in which they communicate with the woman to influence her decisions. This can be illustrated in the work of McCormack and McCance (2006) on person-centred nursing, which could just as easily be seenas person-centred midwifery. This would identify the woman in the centre of the framework, with the process radiating out from there.‌