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Table 3 Refined CMO configurations

From: Implementing continuity of midwife carer – just a friendly face? A realist evaluation

CMO1: Good leadership builds trusting relationships which make staff feel safe, able to engage and practise autonomously thus supporting on-going implementation
CONTEXTMECHANISMOUTCOME
Leaders (organisation & policy) enact their vision & belief in CMC by:
• Visible leadership
• Congruence between vision and action
• Appropriate resourcing of new model, including time, support
• Trusting staff to be responsible / autonomous
Organisation Leaders (MACRO)
• Direct resources to enable CMC
• Challenge attitudes or behaviours that don’t support high quality care
Midwives (MESO)
• Feel safe, supported and reassured
• Are motivated and empowered to engage
• Trust the process of change will be well managed and properly resourced
• Trust each other
• Feel heard and understood
MACRO
• Positive work place culture
• Retention of staff
• Sustained implementation of CMC
MESO/MICRO
• Role satisfaction
• Wellbeing
CMO2: In the context of effective leadership CMC provides opportunities to build more trusting relationships between midwives & women, at all levels of the organisation, which trigger changes in behaviours and practice.
CONTEXTMECHANISMPROXIMAL OUTCOMES
MICRO (woman-midwife) regular and repeated contact across the childbearing enable a relationship where:
• Trust develops
• Women don’t have to repeat their story so provide more information at care appointment
• Midwives more informed and familiar with woman’s context
• Women better informed about their care
Women
• Feel known, understood & accepted rather than watched or judged,
• Feel confident in their midwife’s abilities
• Disclose more personal information & seek more information
• Believe in/trust their midwife
• Engage with health services and health advice
• Feel empowered, confident in own abilities to birth & nurture their infant
• Women & midwives feel relaxed and less anxious;
Midwives
• More informed about women’s circumstance, plan woman-centred, appropriate care, timely detection of changes requiring treatment or referral
• Develop flexible communication/ keeping in touch so women feel safe and cared for
• Hormonal regulation optimises biopsychosocial processes
• Health service engagement and healthy lifestyle choices
• Woman centred care
DISTAL OUTCOMES
• Improved maternal & foetal wellbeing
• Reduced clinical intervention
• Increased breastfeeding
• Increased satisfaction with care
• Midwife role satisfaction and better emotional wellbeing
MESO: Prioritising space & time for team meetings. Collaborative working across organisation:
• Builds trust
• Shared philosophies & values
• Open supportive communication
• Shared understanding of roles
• Feel accepted rather than watched or judged
• Feel confident, relaxed & less anxious about practice
• Are able to ask for help or support, particularly in challenging situations
• Communicate openly & honestly about personal & professional challenges (make CMC work for all midwives)
• Value and care for each other
• Supported and empowered to provide high quality care
• Midwife role satisfaction
• Good work life balance
• Reduced stress and anxiety
• Safe high-quality care
• Implementation of CMC
MACRO: shared meetings, genuine listening and addressing concerns:
• Trust develops
• Shared philosophies & values
• Open supportive communication
• Shared understanding of roles
• Feel valued, cared for, supported and empowered
• Trusted to be in control of diary, workload and so able to provide flexible woman centred care
• Motivated to engage with and support new model
• Safe high-quality care
• Woman centred care
• Autonomous practice
• Implementation of CMC
• Positive workplace culture
• Retention of staff
CMO3: in the context of good leadership, trusting relationships and autonomous practice midwives use the full scope of midwifery practice to provide flexible, woman-centred evidence-based care.
CONTEXTMECHANISMOUTCOME
Shared belief in the values and philosophies of CMC across organisation ensuring:
• Relationship based care across the childbearing journey
• Autonomous, responsible midwives practicing to full scope of midwifery
• Choice of role / location
• High quality evidence based care.
• Motivated to engage with CMC
• Seek out best quality evidence to inform care
• Reflect on consequences of care decisions & experiences to inform future care
• In control of diaries, planning & flexible working
• Provide home based care: empowering for women, build relationships
• Provide expert, information & emotional support to women, midwives & MDT
• Direct resources to enable CMC
• Challenge attitudes or behaviours that don’t support high quality care
• High quality evidence-based care
• Good clinical outcomes
• Role satisfaction
• Wellbeing
• Positive work place culture
• Retention of staff
• Sustained implementation of CMC