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 | ||
CONTEXT | MECHANISM | OUTCOME |
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. | ||
CONTEXT | MECHANISM | PROXIMAL 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. | ||
CONTEXT | MECHANISM | OUTCOME |
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 |