Improving a Care Delivery Environment

Introduction

The training of a midwife calls for the use for methods that can help improve learning and service delivery. One of the Invaluable tools for medical practitioners in the improvement of their practice is the use of reflection. This has brought about a boom in research as to the possible applications of reflection to improve service delivery in nursing and midwifery (Bulman & Schutz, 2004). Reflection makes available the feelings and thoughts of practitioners to enable them to improve on service delivery (Lloyd et al., 2009). A person can reflect either on their actions or in their actions (Yvonne, 2010). In the first case, this takes place after an event has taken place. However, in the second situation, someone takes conscious effort to check their thoughts and feelings in the process of doing their job. These two areas underlie the motivation to undertake this project. An additional use of reflective practice is supervision, which is also an essential component of service delivery (Todd, 2005).

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There is a recognized need to improve services at the maternity wing and there is evidence that this will be possible after identifying the critical issues through a process of reflection. In this project, using an established reflective model, various issues regarding midwifery and the delivery environment come into focus. The goal is to develop a thorough theoretical understanding of the process of reflection and afterwards to use this understanding to identify areas that are available for improvement. Reflection is indeed a form of research with its own rules and leads to actionable outcomes (Rolfe, 1998).

The paper begins by a critical analysis of the existing delivery environment and then proceeds to look at literature on various models of reflection. An actual reflective exercise based on one of the models is the tool of choice for uncovering opportunities to improve service delivery in the hospital.

Critical Analysis of Current System

The hospital that forms the basis for this project has a maternity wing that offers antenatal, postnatal, and labor room services. The facility has sixteen beds for mothers. It has two delivery beds, which are at least ten years old. Thirteen nurses work on three eight-hour shifts. At any one time, one nurse is off duty. On average, there are ten mothers per day within the facility with a delivery rate of about three babies per shift. There are a few problems bedeviling service provision at the facility. They include staff stress, complaints from mothers about inadequate attention from nursing staff, and inadequacy of the facilities.

Stress Among Staff

Stress among the facility’s staff comes from various sources (House & Wells, 2002). There is stress from home and other personal issues (Fahlbusch & Bromiley, 2005). In addition, there is a significant amount of stress on the nurses because of their hectic workload (Wallis & de Wolff, 1988). On any shift, there are only four members of staff. These have to handle the entire number of mothers at the facility. It means that they are involved in providing support for an average of three deliveries per shift, and at the same time provide support for those requiring postnatal and antenatal care. It is impossible to provide the mothers with sustained support beyond the medical attention they need. While the nurses recognize that the mothers also need emotional support, they simply do not have the time to offer it.

Complaints from Expectant Mothers

This situation leads to a reasonable degree of complaints by mothers that they do not receive adequate attention from the nurses (Lashley & Morrison, 2001). Childbearing is a unique moment for mothers and as such, they have a wide array of needs, which the nurses are simply unable to offer. They need counseling, they need emotional support, they need physical support, and most importantly, they need to feel comfortable in order to develop trust, which is a key determinant of the quality of their experience during childbearing (Glover, 2003). Lack of these may result in unintended consequences such as the delivery of pre-term babies (Schott & Henley, 1996).

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Inadequacy of Facilities

To make matters worse, the facility lacks in state-of-the-art equipment. Some of the equipment is old making service provision more difficult (Hall, 2006). A case in point is the beds, which have been in use for the last ten years. They have depreciated considerably because of constant use and have become uncomfortable for use by the mothers.

Supporting Evidence

There are three reasons why the current situation is unacceptable. The first reason is that the effect of insufficient staffing in a maternity facility is a well- documented fact. A mother requires continuing care beyond the biological event of giving birth. This care is not just medical in nature; it includes psychological and emotional care (Lauwers & Swisher, 2010). In addition, she needs all the medical attention she may need at the time she is in labor. Low staff numbers mean that the mother may develop complications without the nurses noticing because of their preoccupation with more urgent occurrences in the delivery room.

The second reason is that there is need to keep workplace stress at a minimum to ensure that the nurses are able to offer optimal services. The strain is higher on administrators because in addition to the normal work related stresses, they double up as caregivers to both mothers and the nurses themselves (Mander, 2009). This pressure makes the situation dangerous for the mother and very discomforting to the relatives of the mother especially the husband (Mander, 2004).

The third issue, arising out of poor facilities contributes to the overall discomfort of the mother. Having poor facilities or old ones makes the mother suffer from crumbs more easily and leads to painful labor. This is because a mother is best prepared to give birth when she is relaxed and is without any worries (Phillips, 2003). Physical discomfort considerably increases the stress a mother is under and leads to contractions that are more painful. Such equipment may create a barrier between the mother and the caregiver, which could result in a less than ideal birth experience (Neilson, 1998). The role of every institution providing maternity services is to provide the highest possible standards of care for mothers to ensure the experience is pleasant and as trouble free as possible

Literature Review

Chapter Introduction

This chapter presents the findings from literature reviewed in line with the objectives of the project. The literature relates to three areas. The first are is the delivery environment. This refers to the totality of the physical and environmental issues surrounding a mother during the process of childbirth. The second area is the midwife’s scope of duties. The medical field values specialization. There is no room for ambiguity in as far as job descriptions are concerned. This calls for a clarification of the duties of the midwife. The third section is a comparison of three reflection models. The models covered include Johns’ model, Gibb’s model and Kolb’s model.

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Delivery Environment

In the context of delivery, the term environment elicits debate with a preference for the term birth territory (Fahy, 2008). This is because territory includes architectural and geographical boundaries of the environment and includes the people within it (Fahy, 2008). There is a tendency to treat childbirth as a sickness and not a natural occurrence. This leads to the reversion of control of the birth environment to medical service providers and not the women giving birth (Rogers, 2010). The kind of environment that a woman gives birth in influences her degree of control over it (Rogers, 2010). She has more choice and scope at home, compared to a health facility (Rogers, 2010). The debate here seems to be between the home environment and health facilities. One of the characteristics of a health facility is that it provides a bed for a woman in labor, while what she needs most at that time is mobility (Gould, 2002). Walsh (2006) noted the importance of women to feel safe to nest like other mammals during childbirth. He alluded to the need for an environment where a woman feels safe to give birth (Walsh, 2006). One of the issues that every midwife deals with when making these choices is risk and safety (Pairman et al., 2006). The capacity to handle any safety issues diminishes in the home setting away from a hospital, and should there be an emergency then the situation becomes difficult. In addition to the physical space, a midwife’s philosophy and skills also play a significant part in creating the ideal birth environment (Downe & Simpson, 2011). The environment is critical in the delivery process because it can influence the amount of pain that a woman feels during childbirth (Simkin, 2001). A woman who is afraid of the environment and receives care from strangers may feel anxious. This leads to an increase in labor pains. There is evidence that there are long-term positive effects to a woman’s health associated with a supportive birth environment (Mander, 2001).

Midwives Scope of Duty

Midwifery predates modern medicine (Enhenreich & English, 2010). Records of this profession exist in ancient texts such as the Egyptian heliographs, the Bible and even in Hindu and Chinese writings (Singingtree, 2000). This age-old profession suffered immensely in the hands of a patriarchal medical system brought about by modernization in the nineteenth century. In addition, formal medical training in medicine relegated women to the role of nurse, and with the increasing training expenses to attain certification in medicine; women did not attend medical school because of lack of resources (Leung & Furth, 2010). Many countries have legislation barring anyone from offering medical service without licensing, which requires prior formal education. This is despite the fact that midwives never trained formally but learnt their trade through years of experience as apprentices of an older midwife (Marland, 1994).

Defining the role of midwives remains a work in progress (Raynor, 2009). This comes from the fact that many of the duties they previously held now fall into the hands of many different professionals such as obstetricians and gynecologists (Lane, 2005).

The duties performed by a midwife vary from country to country depending on legislation, cultural factors, and the degree of accessibility to health facilities by expectant mothers. The laws aim at getting rid of negligence, malpractice, and misconduct (Drury & Staples, 2000). In the Midwives Code of Practice, the duties listed for a midwife to perform include supervising, caring for, and advising women who are pregnant, during labor, and after childbirth (Cronk & Flint, 2001). In addition, it is the responsibility of the midwife to conduct delivery and to provide care for the baby (Cronk & Flint, 2001).

Professional midwives hold multiple roles including the provision of direct care, childbirth educator, hospital manager, midwifery and nursing instructor, and administrator among others (Foster & Lasser, 2010). According to a study by Askham and Barbour (2004) on the role of midwives in scotland, there seems to be a wide array of roles for midwives in various settings such as in antenatal clinics where they may examine pregnant women or provide support to the General Practitioner when examining the pregnant women. In labor wards, they detect complications and report these to the medical staff for correction (Askham & Barbour, 2004). In postnatal clinics, midwives influence considerably the decision to discharge a mother and a baby (Askham & Barbour, 2004).

Finally, in the community, midwives visit the mother and baby for the first ten days and report any anomalies to the doctor in charge to take a decision on whether to readmit the mother and baby into the hospital, or to prescribe medication (Askham & Barbour, 2004). In the context of labor and childbirth, the midwife plays a crucial role in the general well being of the mother during childbirth (Odent, 1996). The mother-midwife relationship achieves the most result when there is an atmosphere of trust between them (Russel, 2008). It is up to the midwife to build this trust and to connect to the mother at an emotional level. A midwife also acts to protect the birth space to ensure that external stimuli do not distract the mother, and to ensure that she does not receive unwanted attention (Crabtree, 2004). One of the emerging roles of midwives is to provide critical care for pregnant women who have prevailing medical conditions with the potential of complicating pregnancy and childbirth (Billington & Stevenson, 2007).

Models of Reflection

Reflection is the means of linking learning and service experiences to derive meaning from those experiences (Cress et al., 2005). As an education strategy, it enables individuals to grow both academically and professionally because it imparts skills to students that they carry on to practice (Gidman, 2007). It encourages students to learn and to have a structured plan for career growth (Zuzelo, 2009). This is because learning does occur when individuals make sense out of the experiences they go through (Padmore, 2007). As a learning method, it augments the knowledge gained from lectures and serves to reinforce the material ensuring long-term retention of content. More importantly, it makes it easy for them to apply the lesson in the (Murphy, 2007).

There are several models used for reflective learning. Three that are particularly relevant for consideration in this context are John’s model, Gibb’s model, and Kolb’s model. They form part of the reflective cycle models (Ellis et al., 2003). Reflection is the source of information for certain work requirements for a nurse such as critical incident analysis (O’Carroll & Park, 2007). It also provides a favorable record useful for clinical supervision (Driscoll, 2000). In addition, it assists reflective practitioners greatly in enquiry-based-learning because they have to ask questions and find answers to those questions (Rolfe, 2003). Self-awareness stands out as the key skill upon which the practice of reflection stands (Atkins, 2004). This is because it makes it possible for people to see themselves and to investigate how their actions affect others, and how other people actions affect them.

Johns’ Model

The proponent of this reflective model, Christopher Johns, came up with a series of questions to provide some direction for a reflective practitioner to apply in the course of reflection (Griffiths, 2008).The six stages in Johns’ model are; description, feelings, evaluation, analysis, conclusion and action plan (Smith & Sherwin, 2009). The model is useful for inexperienced reflective practitioners (Griffiths, 2008). During the description stage, practitioners ask themselves questions relating to the facts surrounding the events under reflections. In the second stage, the questions relate to feeling. Through these questions, the reflective practitioner describes what their initial feelings were in relation to the events that happened. In the third stage, the reflective practitioner evaluates the situation. The key questions here relate to the good and the bad things that happened. The questions also check on what made the practitioner happy or unhappy. In the analysis stage, the practitioner asks whether they can make any sense out of the situation. In the fifth stage, the reflective practitioner asks what that they can do to improve the outcome of the situation in the future. In the final stage, the reflective practitioner develops an action plan to enable them to take advantage of their lessons for future occurrences. This model works well for novices because it offers a structured way of handling reflection to improve the process of learning (Linsley, 2009). However, along with other models it should give way to the reflective practitioner’s own instincts to allow them to develop their own style based on the individual experiences (Johns, 2005). Reflection after all is a subjective exercise (Johns, 2009).

Gibb’s Model

While Johns’ model is linear, Gibbs model is cyclic (Robotham, 2005). Gibb’s model, like Johns’ follows six steps. Gibbs developed his model with the thinking that it would help students develop the reflective skill and in the process develop a means of learning anew from experiences (Rita, 2009). Reflective practitioners go through description in the first two steps, evaluation in the next two steps, and thinking and planning in the final two steps (Delany & Molloy, 2009). These steps compare well with Johns’ model (Ely & Scott, 2006). The use of a diary greatly aids the reflective practitioner to get the best out of the exercise and works equally well with both the Gibb’s and the Johns’ models (Spouse et al., 2008).

Kolb’s Model

David Kolb published a proposed model for use in learning and research. Earlier, in 1975, Kolb, together with Fry, had chosen a cyclic model as the basis for learning because of its consistence with cognition, and with growth and development (Kolb & Fry, 1975). Kolb advanced the work in an attempt to improve the understanding of the learning process (Powell, 1998). Scholars refer to this model as Kolb’s Learning cycle (Rolfe, 1998). Kolb’s model assumes certain conditions as preexistent in a learning situation. These include the active participation and interest of the learner in the learning process, the ability of the learner to reflect on experiences selectively, the learner‘s sufficient independence from the instructor, and the instructor’s provision of support and direction for the learner (Woodall & Winstanley, 1998).

The cycle has four distinct stages. They include, concrete experience, observations and reflections, formation of abstract concepts and generalizations, and finally, testing implications of concepts in new situations (Kolb, 1984). During the first stage, a learner relies on their day-to-day encounter with other people, with their feelings and perceptions of situations acting as the main medium of learning (Jerling, 1996). In the second stage, a learner uses careful observation patience and objectivity to derive lessons from experiences, looking at the situation from different points of view (Jerling, 1996). In the third stage, the learner develops abstract concepts based on the experience they have had by using logic and ideas rather than relying on feeling or intuition (Jerling, 1996). In the final stage of active experimentation, these learners now seek to take action be preparing themselves to act differently if a similar situation arose (Jerling, 1996).

The common thread among these theories is that they rely on the construction of a personal theory based on personal experience (Rolfe, 1998). As with all theories in all other fields, there are always weaknesses and strengths of each theory. The important thing is to apply a theory based on the conditions that dictate the need for one, since one theory might fit a situation better than another might.

Reflection

Chapter introduction

Having identified the three critical issues surrounding the provision of service at the facility, and having developed a working understanding of the role of reflection in midwifery, this chapter applies those lessons through an actual reflection exercise based on the issues identified. It applies the issues to one of the reflection models. The first section deals with the choice of a model. This is a critical part because each of the models has its strengths and weaknesses. Not all of them fit for every situation. This makes it necessary to identify a suitable model to apply in the situation (Ryan, 2010). The second section is the actual reflection exercise based on the issues identified. This is in fact the first part of all the reflection models (Calabrese & Zepeda, 1997). However, there is a deeper treatment of the issues here. The final section presents the recommendations derived from the reflection exercise.

Choosing a model

Reflection is not a new skill to many reflective practitioners. However, its practice before structured training does not follow a traceable pattern and often may not end up in resolutions and an action plan to follow (Noveletsky, 2007). This is why new reflective practitioners undergo training in reflection to make it possible for them to learn reflection as a disciplined application and tool in career development. Over time, they learn to use reflection based on their own style but each time meeting the core objectives of the exercise. The models provided offer some kind of structure for use especially by the novice reflective practitioner (Potter & Frisch, 2008). In this project, the review covered three models. There are other models not covered in the scope of research because of the feeling that these three were representative (Hakim, 2000).

However there was need to settle on one of the models for the actual reflective exercise. The nature of this exercise was such that it was a one-time project seeking clear resolutions on the issues raised. In addition, it required to be comprehensive and clear-cut. Amongst the three models considered, Johns’ model provided the best fit for these conditions. The model is not cyclic (Dexter, 2011). It provides a consecutive system of reflection because it starts at a definite point and ends on another definite point. The series of questions it presents leads a reflective practitioner along a non-return path to the conclusions. Gibb’s model and Kolb’s models are cyclic, requiring the reflective practitioner to revert to the starting point.

On the second count of comprehensiveness, Johns’ model stands tall compared to the other two. Gibb’s model combines some of the steps in Johns’ model reducing its value as a learning tool. On the other hand, one of the issues raised against Kolb’s model is that it is rather simplistic and fails to take full account of learning by logical derivation (Illeris, 2007). These reasons made Johns’ model more appropriate for this project in order to appreciate the full cycle of the reflective exercise. It not only leads the reflective practitioner along a clear path, but it also provides sufficient opportunity for reflection because of its comprehensiveness and therefore fits best as a model for reflection suitable for novice reflective practitioners.

Reflection Using Johns’ Model

Outline of Steps in Johns’ Model

The version of Johns’ model used for the reflection exercise was as follows. It has a description stage, a reflection stage, an influencing factors stage, an alternative strategies stage, a learning stage and finally, an action plan stage.

Description

Working at the maternity facility came with some negative issues (Barrows & Powers, 2008). The staffing was too lean for the demand, with three nurses available at any shift to care for about the mothers. The nurses work in shifts and one of them gets an off at any one time. The key issues are that the pressure on the nurses is high leading to conditions of stress. The mothers therefore complain of inadequate attention from the nurses who must keep up with all their demands. In addition, the beds the patients use are old and uncomfortable leading to aggravation of the issues they have.

Reflection

As a midwife, I tried to offer the best services I could within this context of low staffing and high workplace pressure. I did this because according to my training, my foremost duty as a midwife is to create the best environment possible for mothers to give birth (Choi et al., 2007). I however was unable to offer consistent services because of the heavy workload. The consequences of my actions included complaints from mothers who demanded more attention, feelings of guilt and inadequacy on my part because I could not offer the best services possible, and tension with my colleagues because we were working under pressure with no room for rest or mistakes. I felt depressed most of the time, praying and hoping that nothing goes wrong because I feared we could not handle any emergencies satisfactorily. The mothers always felt angry with my colleagues and me because of the limited attention we gave them. Their anger showed because some of them spoke out harshly and shouted at us for attention (Gregory, 2000).

Influencing Factors

Internally, I felt the need to do my best because my training prepared me for that. In addition, it is only human to be available for people in need. A mother in labor is one such person. Externally, several factors influenced my actions. One of them was the high demand for my attention at all times. The delivery process is a very sensitive on for mothers and requires full attention. However, the need for this attention is not limited to the time of delivery, but spans the entire duration of labor and after childbirth. I had to keep evaluation, which among the mothers in the facility needed my attention most at any one time. I also understood that the beds were not comfortable for the mothers, which made me empathize with them. My actions and decisions should always come from the best practices training I have as a midwife to ensure that I do not compromise the quality of services rendered. Allowing the tough situation to cause me to lower the standards of service is a bad idea (Dell & Michael, 1993).

Alternative Strategies

The use of alternative strategies to solve internal problems holds the key to improved service provision (Abrams & Kleiner, 2003). The maternity facility allows very few people into the delivery room because they can be a source of distraction for the mother. On our own as midwives, we are doing our best, which I am afraid is not good enough. The choice we have is to find ways of making the facility more conducive for mothers at the least cost possible because there is a staff shortfall regionally. We need to encourage the mothers to come along with a friend or relative who can provide them companionship for the entire duration of their stay so that they feel more relaxed. There is also need to replace the old beds. For now, unless we get them from well-wishers, it will be hard for the facility to replace them. The consequence of allowing people into the delivery room means that there is a higher risk of infection for them, the mothers and the newborn babies.

Learning

I learn that I should not feel guilty about my limitations as a midwife working in these conditions, but I should strive to do all I can to improve the situation by sharing these ideas with my supervisor. I now feel relieved because it is not my fault that the facility is understaffed. In fact, I feel like I am making a difference because things would be tougher without me. Since I have not talked with my colleagues about this experience, I have not taken effective action to help sort out this issue. By taking time to reflect on these issues, I feel better prepared to deal with the situation (Irving, 1982). I have seen the situation in new light with a possible way out.

Action Plan

From here, I plan to do the following things. I will talk to my supervisor about the possibility of allowing a mother to come with a friend or relative to support them throughout the process of labor and childbirth to ensure that no mother feels neglected. This will relieve the pressure from the nursing staff. I will also make an effort to talk to my colleagues about their feelings concerning the pressures we deal with on a daily basis to share ideas and to see if they may have better ideas for managing this situation (Williams & Green, 1997). The third issue I will think further on is how we can replace the facilities beds. Even though the facility has a tight budget, with some though, it may be possible to raise the money needed. I will check with my supervisor whether we can appoint a fundraising committee to bring together well-wishers to sponsor new beds if it is impossible to raise the required resources internally.

Knowledge Gaps

The two key issues that are clear from the reflection exercise on need to improve the service delivery to the mothers are; there is need to increase the amount of social and emotional support accorded to the expectant mothers, and that there is a dire need to acquire new delivery beds for them (Armstrong & Kotler, 2011). On the issue of increasing support, the unclear issues are the potential consequences of having third parties in the delivery rooms. There is the risk of infection to the mother and the newborn but the severity is unclear. Another possible way of providing this support is by enlisting the help of volunteers. It is unclear whether there is any such help available for the facility to take advantage.

On the issue of replacing the beds, there are several unclear issues. First, we need to establish the cost of replacement of the beds. There are many suppliers of medical equipment and as such, there is need to contact them to find out what it will cost the facility to replace the existing beds. It may be possible to renovate the existing beds to make them more comfortable. This option is limited to the areas of the bed that do not form part of its basic structural design. If the option of acquiring new beds is the most feasible, then financing of the beds will be the main issue. It is unclear how long it might take the facility to raise the money internally, or even if it has the capacity to save any money in the first place (Boyatzis, 2008). If the option of approaching financiers becomes the most feasible one, then the facility will need to establish whom the potential sponsors are in order to engage them.

Conflict Resolution

There are several opportunities for conflict in this kind of work environment. The actors in it include the institution’s management, the medical officer, the staff, and patients in the facility and the society. Conflict areas with the hospitals administration are in the areas of financing and staffing. Since it is their responsibility to ensure that there are adequate levels of service, they bear the ultimate responsibility regarding the quality of service offered. Therefore, it is very easy to pass the blame to them for the work conditions that exist in the facility (Armstrong, 2002). This can make a person resentful and unresponsive to the management. The medical officer runs the facility on a day-to-day basis. Therefore, the chances of conflict are very high. The officer takes decisions on matters like who will work on which shift, how long the shift will be and when a particular staff member will be off duty. In addition, the medical officer enforces the decisions of the board and ensures that the facility keeps the regulations from the government and other regulatory authorities. This scope of responsibility requires firmness and consistence. It also calls for a lot of patience with various stakeholders who may not have a full appreciation of the extent of responsibility bestowed on that office.

The hospital staff members are the executing officers in the hospital. They handle patients directly and ensure that they get their treatment. This means that they will be the first to hear about any problem or query from the patients. It also means that they will be the ones to receive criticism (Dye et al., 2005). After a long days work, it is usual for someone working in a stress filled environment to become irritable (Adair, 2006). The patients are another important source of potential conflict in the facility. As the clients, they notice very quickly when the services rendered do not meet their expectations. They therefore have the potential of creating a lot of conflict. The final category of people who are a source of conflict for the facility is the general society. The society has expectations on the services the facility should offer. Any discrepancy between these expectations and the actual services rendered manifests as conflict. They may make it harder for the staff and the hospital to operate if the staff members do not feel appreciated for their hard work (Griffin & Moorhead, 2009).

Based on the reflection, I realize that I may have fallen into conflict with some of the parties discussed above. In addition, from the resolutions developed, it is possible to fall into conflict with some of them in the future. I will make sure that in all my actions I appreciate the constraints within which the hospital’s management is operating. I will approach them from a non-confrontational perspective and in case they turn down my ideas, I will not allow myself to become resentful because that will only harm my morale. The medical officer prepares rules governing the activities of the midwives. In the past I did not appreciate the degree of constraints that the officer works under but now I realize that the best way to avoid future conflict with the medical officer is to be as understanding as possible.

The hospital employees also form a crucial part of the system. I have felt that the patients did not get sufficient attention in the hospital but I realize that it is not because the staff members are negligent. The reason is that they have a huge workload. When it comes to the community, I can act as an advocate and ambassador for the hospital to improve community relations. I should not allow myself to get into negative criticism on the running of the hospital. This will only poison my attitude making my work harder (Chopra, 2002).

Recommendations

The exercise brings to mind three possible actions that will make life easier for patients, midwives, and nurses alike at the hospital. There is need to have a strategic approach in dealing with emergent issues in any work environment (Daughtry & Casselman, 2009). The first one is to encourage a family member or a close friend to the expectant mother to accompany her to the maternity to provide consistent support for her during the childbearing process. It is clear that a nurse cannot provide all the care that a childbearing mother needs. From the literature reviewed and from the insights gleaned from the reflection exercise, nurses provide medical support and then leave out the rest of the social and emotional support that a mother needs. The role of the relative will be to help create a relaxed and familiar environment for the mother so that she does not suffer from anxiety.

The second one is the engagement of the community to help in the acquisition of new delivery beds for the maternity (Harvard Business School, 2005). This recommendation stems from the fact that the community is the primary beneficiary of the hospital’s services. Within it, there exists sufficient goodwill to make it possible to seek the support of community members to sort out the stubborn issue of uncomfortable delivery beds (Bensoussan & Fleisher, 2008). The hospital must be constrained financially to make the purchase on its own; otherwise, it would have bought the beds by now. If this option cannot work for any reason, then there is always the option of renovating the existing beds to improve their degree of comfort for the mothers (Bronzino, 2000).

The third one is the treatment of all the stakeholders with respect and understanding in light of the fact that they all work under very stressful conditions. There is a huge potential for conflict between the various categories of stakeholders. Each class of stakeholders has expectations and feels dissatisfied whenever there is a lapse in the provision of services. In this situation, the best thing to do is to keep calm and communicate clearly with patience and understanding. It will reduce the tension that may accompany discourse in the stressful environment within the hospital.

These recommendations summarize the key issues that the reflection exercise prompted as the process of reflection took place using Johns’ model.

Conclusions

Major Conclusions

There is value in reflection as a learning strategy

After undertaking the reflective exercise, I saw things in a new light and felt much better because of putting things in perspective. The process called for an analytical process geared towards discovering my motivations and providing me with an understanding of my emotional condition (Bennis, 2009). Looking back, I used my own experience in the reflection exercise to learn from the situation I worked in. since I was the one involved in these issues I reflected on, I had a good idea of both the internal and external issues at play. While these issues may not have been obvious initially, the reflection exercise provided me with an invaluable aid to make sense out of the situation and to see it from a different angle. Since I was not looking at it in the heat of the moment, I had a better chance of remaining objective, thereby making the lessons relevant, not just for similar situations but also for other situations (Brown & Armstrong, 1999).

The best model for reflective practice is Johns’ model because it is comprehensive

Among the models chosen for consideration in this project, Johns’ model proved to be the most useful. The objective of a reflective exercise for a novice reflective practitioner is to get the reflective skills they need. They can develop their own unique style with time (Bruce, 2002). However, for the first exercise, it makes sense to use a comprehensive model with clear-cut beginning and ending to guide the mental and emotional process relating to the reflection. The other models presented reflection as a cycle. This may confuse the novice reflective practitioner and therefore they are not very useful for learning purposes. After getting into the rigor of reflection, it makes sense to use them because the practitioner is clear about their benefits and limitations.

The role of midwives is still evolving and varies from society to society

One of the issues that came through in the literature search was the evolving nature of the roles of the midwife. For many years, the midwife role was a settled office. However, with the introduction of formal training in medicine, their role has ended up in the hands of various professionals such as nurses, gynecologists, and obstetricians (Dalic, 2007). While these professionals have advanced training in the medical aspects of their roles, the do not effectively, replace the midwife because of the reason that a midwife traditionally provided more than just medical help for a mother in labor. In different societies, midwives play different roles depending on the availability of specialized services. However, they still exist in all societies with their work either regulated or unregulated, depending on the country.

The chief responsibility of a midwife is to create the best conditions for childbearing

From literature and from practice, there is a key role of any midwife regardless of geographical location and the cultural context. The role is to create a comfortable delivery environment for the expectant mother. Very many hurdles have come up to regulate midwifery because of quality control (Goel, 2008). These hurdles include laws and the need for certificates to prove one’s trade (Chuang & Liao, 2010). An expectant mother has a wide array of needs beyond the biological action of childbirth. There are emotional and social needs. In some cases there are also cultural and religious issues surrounding childbearing. In those societies, the midwife has the added duty of ensuring the observance of rites, customs, and ceremonies that accompany the childbearing experience. This means that the role of a midwife is varied, but the main purpose is to ensure that the delivery environment is safe and comfortable for the mother.

Self-development Initiatives/Strategy

Adoption of the use of a note book to assist in reflection

I have noted that I will become better at reflection if I use a notebook to record my experiences on real time basis as fodder for reflection. Recording my feelings and thoughts on the move will make it very easy to remember how I felt or what I found interesting in every situation. I learnt a lot about journaling while reviewing literature and I plan to put it into practice (Hopkins & Bilimora, 2008). This will greatly increase my learning.

Maintenance of reflective practice as a means of continuing learning and personal development

I also plan to continue using reflective practice as a means of personal growth and development. What I find fascinating about it is the fact that I rely on my own authentic feelings based on experiences to determine the significance of each experience. This mode of learning will definitely lead to great personal growth and improvement (Kusluvan, 2003). It will help me to reduce the mistakes I make in life because I will be able to pinpoint the areas I am weak at and the patterns my life follows.

Discussion of the issues with colleagues, seniors and other caregivers from different disciplines to keep on expanding my view of childbearing.

Finally, I have made a commitment to myself to keep on learning from other professionals such as nurses and obstetricians in the course of carrying out midwifery (Kuvaas & Dysvik, 2009). This is because these professionals have a great deal of information regarding the medical aspects of pregnancy and birth. An appreciation of what they know will improve my effectiveness as a midwife and it will make it easier for me to render proper advice to expectant mothers (Green, 1992).

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