School of Nursing & Midwifery, Griffith University, Gold Coast Campus, Gold Coast, Queensland, Australia.
School of Health, Edinburgh Napier University, Sighthill Campus, Edinburgh, Scotland.
BMC Health Serv Res. 2020 Apr 15;20(1):304. doi: 10.1186/s12913-020-05159-9.
Good quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan.
Participatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed context-mechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context.
Trusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women's care journey, which in turn changed their perspective of how they provided care and of women's care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed.
Leadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women's care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change.
高质量的助产护理可以拯救妇女和婴儿的生命。助产士连续护理（Continuity of Midwife Carer，CMC）是高质量助产护理的关键组成部分，它可以带来更好的临床结果、更高的护理满意度和增强护理人员的体验。然而，CMC 的采用往往规模较小或短暂。我们在苏格兰的一个卫生局使用真实评估来探索实施 CMC，作为苏格兰政府 2017 年生育计划的一部分。
采用参与式研究、质量改进和迭代数据收集方法，从各种来源收集数据，包括促进团队会议、地方和国家会议、质量改进和服务评估调查、审计、访谈和已发表的文献。数据分析开发了情境-机制-结果配置，以探索和为三个初始计划理论提供信息，这些理论被细化为一个总体理论，即什么对谁和在什么背景下有效。
在所有组织层面建立信任关系是 CMC 发挥作用的背景。然而，在实施过程中建立这些关系需要良好的领导力和有效的变革管理，以推动整个系统的变革，并在所有实践和组织边界上建立信任。助产士和妇女之间的信任关系受到重视，并促使她们提供高质量的护理；CMC 团队关系支持工作方式的改进和实践的持续，而不同护理模式中助产士和提供者之间的关系则维持或限制了实施。连续性使助产士能够充分发挥技能，并贯穿妇女的护理过程，这反过来又改变了他们提供护理的观点和妇女的护理需求。除了建立积极的关系外，可见的和支持性的领导鼓励参与，确保助产士感到安全、有价值和知情。
在所有实践和组织边界上建立信任关系的领导力为 CMC 的成功实施创造了背景。这些关系随后成为 CMC 成长和繁荣的背景。信任关系、充分发挥技能和贯穿妇女的护理过程触发了助产实践的变化。在 NHS 组织环境中实施和维持 CMC 需要在所有层面上对服务进行重大重新配置，这需要有效的领导力，不能仅仅依靠自下而上的变革。
