Engaging with clinical supervision in a community midwifery setting: an action research study

The main aim of this research study was to explore midwives’ views and experiences of their support needs in clinical practice and then to identify how they would wish to receive such support. There was much literature to support the existence of stress and burnout in midwifery but no research that addressed ways of alleviating this. Further aims were to redress that imbalance by planning and facilitating a model of clinical supervision devised by the participating midwives.

The study took an action research approach that involved working with a group of eight National Health Service (NHS) community midwives in a collaborative, non-hierarchical and democratic way in order to achieve change. This accorded with a woman-centred approach to working with clients that was being encouraged within midwifery. The midwives were typical of many community-based midwives in the United Kingdom (UK) who were working in increasingly stressful, complex and changing environments.

Wider organisational and cultural issues are considered that affect working relationships. The nature of the way the midwives worked when they were offered and received support, and how they reacted and coped when their work team and work situation was threatened, was also explored.

Each midwife was interviewed twice; before and after the experience of clinical supervision. They also participated in two focus groups before clinical supervision. In-depth individual interviews lasted up to two hours, as did the focus groups. The interviews and the focus groups were taped, transcribed and then analysed using a relational voice-centred methodology.

The main findings were that recent and ongoing change plus the organisational demands placed on the midwives by the NHS and their managers were detrimental to working relationships with their colleagues and clients. This also inhibited the process of change. A discourse of denigration became apparent within the interviews and the midwives behaviour and coping strategies revealed some well developed defence mechanisms, as well as an apparent lack of understanding on their part and that of their midwifery managers in relation to emotion work. Resistance to change was a key defence mechanism used by the midwives.

Strong messages emerge about certain ‘performances’ being available to midwives and the use of defence mechanisms as a way of ‘getting the work done’. There are also messages about the cultural legacy of midwifery and how this can inhibit autonomous behaviour by midwives. Developing and increasing self awareness is still not viewed as being intrinsic to the work of the midwife and midwives are being asked to undertake a level of work that they have not been adequately prepared for. Neither do there appear to be effective role models for midwives. The bureaucratic pressures of working in a large maternity unit are also addressed where the system is seen as more important than the midwives.