Clinical leadership on the labour ward

Introduction
Clinical Leadership is a way of facilitating change and increasing the quality of care
at the front line of practice. However, the failure of midwifery leadership and being
designated an oppressed group questions the ability of midwives to practice as
clinical leaders in the labour ward environment. Whilst there is some research
relating to clinical leadership in nursing, no research exists that investigates the
clinical leadership of midwives who are directly involved in giving care to women.

Aim
The aim of this research was to explore clinical leadership on the labour ward and to
develop an understanding of the associated characteristics of clinical leadership. The
attributes that delineated effective clinical leadership were examined in addition to
associated professional discourses and relationships of power that existed on the
labour ward.

Methods
A critical ethnographic approach was undertaken on the labour ward of a district
general hospital and a teaching hospital in the North of England, using participant
observation and semi-structured interviews. A total of sixty-nine hours of participant
observation was undertaken. A purposive sample of 30 midwives were interviewed
in the first instance and further interviews were undertaken with 18 midwives who
were nominated as effective clinical leaders by the midwives in the initial interviews.
Data were examined through the lens of Bourdieu’s Theory of Practice.

Findings
Clinical leadership existed at different levels on the labour ward, however, midwives
mostly identified LWCs in this role. LWCs’ clinical leadership was necessary,
contradictory, gendered, socialised and unsupported within the hierarchical, high-risk
and fearful labour ward. A combination of heroic and values-based clinical leadership
was required to maintain safety and facilitate productivity. Heroic leadership, the high
level of accountability and symbolic capital invested in the LWC led to a loss of
autonomy for other midwives, a lack of dissent and difficulty initiating changes in
practice. The contradictory nature of the LWCs’ work and a lack of support led to
them experiencing both emotional and physical stress. Within an increasingly highrisk
labour ward environment the LWC clinical leaders experienced professional
misrecognition and discrimination that resulted in dysfunctional inter-professional
relationships and keeping the obstetricians away from women.

Conclusion
A high level of responsibility invested in the LWC combined with socialisation led to
heroic leadership which fostered dependency prevented change and innovation.
Inequalities of power and dysfunctional relationships were symptoms of a system
failure that does not support midwifery practice or woman-centred care.
Recommendations are made for policy, education, practice and future research.