The experiences of midwives and nurses collaborating to provide birthing care: a systematic review protocol

Review question/objective The objective of this review is to identify, appraise, and synthesize the qualitative evidence about the experiences of midwives and nurses collaborating to provide birthing care. This qualitative review aims to answer the following question: What are the experiences of midwives and nurses collaborating to provide birthing care? Background The focus of this systematic review is upon collaboration between midwives and nurses for the provision of birthing care. Collaboration is defined as: Collaborative woman‐centered practice designed to promote the active participation of each discipline in providing quality care. It enhances goals and values for women and their families, provides mechanisms for continuous communication among caregivers, optimizes caregiver participation in clinical decision‐making (within and across disciplines), and fosters respect for the contributions of all disciplines.1 (p.15) Interest in collaboration and the provision of health care, as a means to meet the growing complexity and diversity of patient needs is increasing for clinicians, administrators, politicians and decision makers. Specific to the provision of maternity care, several professional provider organizations in North America have released joint statements indicating their commitment to collaborative maternity care.2,3 Commitment to collaborative practice in maternity care, through joint statements, by national provider groups is commendable. However, the complexities involved in implementing and in sustaining collaborative practice require an understanding of current collaborative experiences.4 Facilitators for and barriers to collaboration have been commonly identified in the literature. Examples of facilitators for collaboration include; communication,5‐12 clarity of roles,6‐9,11,12 respect,5,6,8,10,12 trust,5,7,8,10,12 supportive institutions/organizations/culture,5‐7,10,13,14 shared values or shared vision,9,12,13 and a willingness to collaborate.5,6,10 Examples of barriers include: poor communication,13,15‐17 resistance to change,6,16 different philosophies,17,18 perceived threat to professional role,19,20 insurance and liability,18,20 lack of respect,17,20 lack of clearly defined roles,15,19 and lack of knowledge of other health disciplines.13,19 The interdependency of the facilitators and barriers is apparent, where the presence of one facilitator such as a willingness to collaborate often supports the presence of other facilitators such as communication and trust. Similarly, the presence of one barrier, such as poor communication, becomes a challenge to collaboration as a whole. Although these lists are not exhaustive, they do provide insight into the kinds of support and challenges that maternity health care providers may be experiencing in the establishment and maintenance of collaborative practice. Access to maternity care providers is influenced by geography for women around the world. For example, in New Zealand, midwives are chosen as primary care providers by 75% of women requiring perinatal care,21 and in The Netherlands, midwives provide care to 50% of women at the beginning of delivery.9 However, in Canada, midwives in 2010 attended less than 5% of births.22 The different approaches to maternity care are reflected by the global variations in access to maternity care providers. These global variations of maternity care provision provide an opportunity to explore multiple models of collaborative maternity practice and to understand collaborative experiences from the perspective of numerous maternity care providers. Collaboration in primary care, of which birthing care is a part, has become a focus for the improvement of the quality and efficiency of health care provided to individuals and families worldwide.13 Improved health outcomes identified as a result of collaborative care have included: lower caesarean section rates,5,23‐25 reduction in the use of epidural anesthesia for pain management,6,23,24 reduced rates of episiotomies,24,25 increased breastfeeding rates,23,24 and improved patient satisfaction.5,26 The positive impact of collaboration on health outcomes in maternity care supports the need to explore the collaborative experiences of the professionals providing the care. Such an exploration can inform how best to support collaborative practice with the aim of achieving the best possible health outcomes. There has been a focus on the collaborative relationships and attitudes between midwives and physicians in the literature.24‐32 Midwives will be defined using the definition of a midwife from the International Confederation of Midwives, “A midwife is a person who has successfully completed a midwifery education programme that is duly recognized in the country where it is located and that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery. ”34 However, apart from midwives and physicians, other care providers also contribute to collaborative maternity care. For example, nurses work with both midwives and physicians in the provision of birthing care. Nurses will be defined as, “…self‐regulated health‐care professionals who work autonomously and in collaboration with others”. 35(p.6) The International Council of Nurses recognizes that nursing is more broadly defined, Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.36 Nurses, like midwives, provide direct care to women and families during labour and delivery. However, despite the similarity of their roles, differences exist.2 In Canada, for example, nurses have a history of providing maternity care within the health care system and midwives have not. The first introduction to regulated midwifery occurred in Canada in the province of Ontario in 1993.37 Health care providers and administrators continue to adjust to the integration of midwives into maternity care teams differently in each province.38 Challenges with collaborative practices amongst midwives and nurses have been identified by several Canadian researchers using qualitative methodology.8,14,39‐42 An example of a common theme that was identified was the role confusion experienced by nurses working with recently integrated midwives.8,15,40‐42 Despite these similarities and challenges, no comprehensive synthesis of the current evidence related to the experiences of collaboration among midwives and nurses has been conducted. Such a review would provide invaluable information to care providers and families providing or receiving birthing care. This systematic review of existing qualitative data will contribute to a comprehensive understanding about the collaborative experiences of midwives and nurses, and help to identify future directions for researchers and policy makers. A preliminary search of the Joanna Briggs Database of Systematic Reviews and Implementation Reports, CINAHL and PubMed has revealed that there is currently no systematic review published about this topic.