Renata Boreham is a registered midwife with over 15 years of clinical practice and a former midwifery lecturer at Oxford Brookes University. She has been in Sri Lanka since 2019. Renata used Borton's (1970) model of reflection to explore her actions when attempting to enable health professionals to deliver a higher level of compassionate care through voluntary workshops. She chose this model for its generalisable framework, primarily designed to be used within education.
What?
I was invited to spend a shift on a labour ward in a semi-government/private maternity hospitals in Colombo to observe the health professionals on Monday 8 November 2021. My first impression was of a sterile, top-to-bottom white tiled rectangular room with two small windows. There were four birthing beds with curtains between them and one woman was lying on a bed with a monitoring machine (cardiotocography). The place looked clean, seemed organised and all equipment was labelled in metal cupboards. Approximately 10 staff members in full personal protective equipment were circulating, talking loudly and some were using their mobiles. Two medical students were present. There was a small table with four chairs. The radio was on quietly and there were bright lights. A door was open to the sluice, another door was closed and led straight into the corridor and the final door was open into the birthing room for patients who were COVID-19 positive. This room had two beds, no curtain and a plastic transparent divider between the room and the corridor.
A woman was brought into the labour ward for induction. I was with her during her birth, as she laboured quickly once her water was broken. I held her hands, massaged her gently, smiled at her and told her positive birthing affirmations to help her breathe through her strong contractions. She had very little understanding of English. She held me and afterwards, asked the nurses to translate to me that she was grateful for the support.
What did other people do?
There seemed to be little communication between women and staff. The staff members were busy with many tasks, people were walking around without any consideration for women's privacy, chatting and laughing with one other. Women's genitalia were exposed for all to see. I observed some discussion with women prior to tasks (from nursing or medical professionals). Infection control protocol prior to any aseptic procedure seemed to be followed. Birthing women were left mostly alone, without an explanation of the birth process or what will happen. Some nurses were using touch and talking to women. Food and drink were offered to some patients at intervals. A bed pan was given to each woman every 2–3 hours, with a complete absence of privacy while they used them. Examinations were performed by the senior registrar in front of everyone (with up to 10 people standing around the bed).
What was my reaction?
The labour room seemed clean and well organised. I was pleased to see that nurses and doctors followed infection control rules when doing tasks, using sterile instruments and clean materials. Aseptic techniques were adhered to and clean gloves were used appropriately.
All women were lying on their back or left lateral once they arrived, with their legs in lithotomy for the second stage. Women giving birth vaginally for the first and second time were given a compulsory episiotomy, using infiltration of local anaesthesia. This is different to UK practice, as the National Institute for Health and Care Excellence (2021) guidelines suggest no routine episiotomy unless clinically indicated. Perineal suturing was done by the registrar within 1 hour of birth if possible, following aseptic technique using local anaesthesia.
Both women present were on continuous cardiotocography monitoring, no Pinard or Sonicaid was seen being used, with a cannula in and fluids running.
I found it upsetting that staff showed little compassion, empathy and understanding to birthing women and lacked awareness of the physiology of normal birth. There was no privacy for labouring and birthing women.
What is the purpose of returning?
I wanted to use this observational shift as grounding knowledge for a workshop. I also intended to use it to identify points in practice that could be changed, using minimal resources to enhance patient care and women's birth experiences.
So what?
So what did I feel at that time?
I felt that nurses (institution midwives) had good knowledge of processes and were skilled nursing practitioners. However, they had minimal knowledge of holistic approaches and the normal birth process (the mechanism of labour, hormones and a woman's emotional wellbeing) and evidence-based practice was not always followed. All women were treated the same with no emphasis on privacy and dignity.
So what are my feelings after the day?
I strongly felt this labour ward had potential to improve patient care and professional satisfaction with minimal extra resources.
So what were the effects of what was or was not done?
The staff observed my interactions with women, including the soft voice and positive language I used, and the simple application of touch and massage.
So what positive aspects now surface?
Government midwives should have received basic midwifery knowledge after studying for 3 years. As individualised care and the importance of upholding respect and dignity is prioritised in midwifery globally, these changes should be discussed with staff, who should collaboratively create strategies to achieve this, to safeguard women and professionally develop their careers.
So what have I noticed about my teaching behaviour?
I tend to adapt the ‘role model’ leadership role; I demonstrated a simple intervention of touch, kindness and empathy to women. I felt staff were watching and eager to learn. However, knowing how some behaviours are culturally embedded, it may be a long and slow process of change.
So what observations do colleagues make of the way I acted?
A few nurses and midwives discussed with me the massage I gave to women and asked me to explain and demonstrate it. They seemed to be enthusiastic and keen to learn new skills and were curious how practice in England differs to their own.
So what is the purpose of returning to this lesson?
When mentoring a student or colleague in the UK, they are usually receptive and willing to change once they grasp that the new method of care will enhance women's birth experience and their satisfaction with the care provider. For the last 28 months, I have observed and interacted with practitioners in Asia, experienced Sri Lanka's systems and organisation and learnt about the strong and diverse culture here. I have realised that helping Sri Lankan care providers to make small changes that ‘they identify themselves’ will lead to changes that are more likely to be adopted by staff permanently, with greater flow on effects for women in their care.
Now what?
Now what are the implication for myself and others?
In Sri Lanka, I formed a bond with a consultant obstetrician who had worked in the UK and was flexible in her approach and receptive to change for better quality care in the government hospital. The obstetrician will be standing behind the movement for change at the facility. While I must take into account why nurses and doctors act the way that they do, it is key that they are gently made aware of the implication their behaviour has on women in their care.
Now what difference does it make if I choose to do nothing?
If I do nothing, I would feel that I was wasting an opportunity to make a positive difference to Sri Lankan women.
Now what is the main learning that I take from this reflection?
It was beneficial for me to spend a shift on the labour ward, observing staff interacting with their patients, their skills and attitudes. For me to understand why things are done the way that they are, I had numerous conversations with people of Sri Lanka. I feel that this is an ambitious nation of great cultural diversity, where religion pervades many aspects of life and rich tradition, historical impact and modern influences blend together in a unique melting pot.
Now what help do I need to help me ‘action’ the results of my reflection?
The 3.5 hour interactive workshop ‘empower to empower’ that I designed as a result of my reflection was received with interest. The agenda included back to basics, reinforcing the mechanism of labour, implications to physiology and practice, birth hormones and women's ability to cope. I highlighted how the behaviour of a healthcare professional can leave patients/women with lifelong consequences.
Now what aspects should be tackled first?
The workshop was delivered, and I tackled the key issues. First, I thanked the participants (nurses and doctors) for having me for my observational shift and welcoming me into their hospital to facilitate the interactive workshop. I congratulated them and acknowledged the important job they do, and how it makes a difference, putting them in the centre of the workshop.
I suggested the participants (health professionals) could do even better as science, physiology and evidence shows that with learning and an open mind, they can provide better experiences not only for the women in their care, but for the team and for themselves. I let them consider what changes/interventions they may like to explore and encouraged them to identify barriers and concentrate on ideas for how to overcome them. Surprisingly, most of the participants identified ‘privacy and dignity’ and ‘nurses' attitudes’ as two main barriers to not achieving quality and empathetic care. They also came up with some simple suggestions for how to change that, including limiting the number of medical students for each shift, being discrete when observing any practice, using screen dividers between women and open space and taking the time to explain tasks, procedures and the birth process to women.
‘I am thankful to you for showing us kindness and care which any medical book can't teach us…When medicine and drugs are given together with love and care, I think it will work like magic.’
(Written feedback from medical students who observed the author on the labour ward)
From what I witnessed and the examples of touching feedback that I am fortunate to have received, I believe that I am making a difference.