Interprofessional team trust in maternity services: a service evaluation

The importance of leadership in developing and maintaining a climate of trust is well documented (Chartered Institute of Personnel and Development (CIPD), 2012; Mahon, 2013; Drescher et al, 2014; Frith et al, 2014;West and Coia, 2019;West, 2021). The literature identifies trust as ‘central to any relationship’, allied with quality (Berwick, 2003; O’Brien et al, 2021), and a highly prized value of the NHS (King’s Fund, 2014). The complexity of trust in healthcare is highlighted through different authors’ accounts in the literature. Mahon (2013) describes it as in transition; it is influenced by power dynamics (Tanco et al, 2016) and gender, ethnicity, age and education (Meyer and Ward, 2008).

Trust has been described as involving vulnerability and uncertainty, a willingness to risk the other party will act in the best interest of the trustee (CIPD, 2012). Arguably, in organisations, trust extends beyond individual vulnerability to team and organisational vulnerability. This interconnection of trust on the micro, meso and macro levels was explored by Mahon (2013), who discussed the importance of connecting interpersonal and organisational trust, facilitating collaboration between clinicians and consideration of how mechanisms for training are developed.

The CIPD’s (2012) report examined organisational trust across private and public organisations and found it promoted co-operation, facilitated partnerships and reduced risk. Greenhalgh and Papoutsi (2019) proposed the idea that laying the foundations for building and maintaining trust and learning involves a participatory culture, distributed leadership and shared decision making.

Reports into maternity service failure (Kirkup, 2015; 2022; Ockenden, 2022) have repeatedly presented a service that lacks transparency, governance and compassion, where poor interprofessional relationships (typically between midwives and doctors) result in tribes, silos and fear, with catastrophic outcomes. Ockenden (2022) emphasised the importance of leadership and Kirkup’s (2022) report into maternity service failures at East Kent hospitals identified four areas of action, one of which was teamwork with a common purpose.

Effective teamwork in healthcare between teams, organisations and systems is critical (Kirkup, 2015). The literature highlights relational leadership styles, such as distributive, collaborative and compassionate styles, as those that foster trust and effective teamwork (West, 1996;West et al, 2003; Drescher et al, 2014; King’s Fund, 2014). They create psychological safety, helping staff to feel empowered and in control and facilitate effective teamwork (West and Coia, 2019; West et al, 2020; West, 2021) and ultimately lead to better outcomes in care.

Interprofessional learning is not without its challenges, particularly in maternity where, historically, tensions between midwives and obstetricians have existed and been exacerbated by what has been seen as the medical domination of birth (Oakley, 1981) and differing professional philosophies (Davidson, 2020). By understanding differences in interprofessional value perspectives and respecting different team members’ decision making, the team can function in a critical friend capacity (Wiles et al, 2016). This needs to go beyond the established emergency skill drills currently in place and establish a common purpose across and within professional disciplines to enable teams to work in a mutually supportive way, which is critical to providing high-quality, safe maternity care (Kirkup, 2022).

During the COVID-19 pandemic, Steward et al (2021) demonstrated how bringing the maternity multidisciplinary team together to share and learn provided much-needed support to clinicians and led to learning in unprecedented circumstances. These huddles have proven to be a sustainable platform that facilitate trust, reflexivity and effective teamwork.

Methods

By adopting a critical feminist stance, this study aimed to illuminate women’s voices in what is described as a predominantly male-orientated NHS organisational culture (Davies, 2003). Despite feminism’s perceived relevance to midwifery study (Yuill, 2012; Walsh, 2016; Hawke, 2021) there is a paucity of research using this method, particularly in the UK.

A feminist research ethic is attentive to the power of knowledge, boundaries, relationships and ‘situatedness’. Attending to the feminist ethic of situatedness and critically evaluating one’s standpoint may also help to reduce bias through transparency of the researcher (Ackerly and True, 2008). Thus, the author’s own socio-political location required attention throughout the research process.

Sample

There were six female participants, three doctors and three midwives, chosen to represent each of the six trusts in a selected local maternity and neonatal system. Members of the multidisciplinary team huddles were invited to participate via email; details of the study were sent via email by the local maternity and neonatal system and/or given to huddle members in a Teams chat following a description of the study by the author.

The aim was to have staff of different grades to enable a diversity of perspective. However, as a result of time constraints and time commitments of participants, only the more senior members of staff were able to take part. From a midwifery perspective, senior management and those working clinically were included; medical participants were consultant obstetricians or obstetric physicians. Table 1 outlines participant demographics.

Data collection

Semi-structured interviews were used for data collection. The interview schedule (Table 2) was tested with peers and the author’s supervisor, and leading questions were removed. A pilot interview was also performed. The interviews were conducted via Microsoft Teams and recorded. All took place at a time and place chosen by the participant, and lasted between 15 and 60 minutes. Five of the participants were in their own home, and one was in their work environment.

The social construction of research interviews may be seen as a ‘malestream’ method, presenting a hierarchal relationship between interviewer and interviewee (Oakley, 1981). To alleviate this, emphasis on the participant’s role as contributor to gathering knowledge and fostering a relationship of collaboration is advocated. Oakley (1981) discussed the importance of the relationship for reciprocity and made the decision to give information asked for by participants. This approach was used in the present study, where participants’ questions during the course of the interviews were answered. This had the benefit of bringing different ideas to the interview; for example, it raised how to involve midwives in huddle presentations.

Data analysis

Thematic analysis was used to analyse the data collected from the interviews. Each interview was transcribed and the transcripts were read and reread. Repeated reading to familiarise oneself with the data prior to beginning to code is recommended (Braun and Clarke, 2006). The steps described by Maguire and Delahunt (2017) were followed. This process was repeatedly reviewed and refined and led to three thematic maps. An audit trail of interviews and interview transcripts was kept. Member checking, where the transcripts of two participants were reviewed by them for accuracy, was used, and this process also involved testing findings and themes.

Ethical considerations

Ethics committee approval was not required for this study as it was a service evaluation. The head of research for the national maternity team gave advice on the ethical considerations for the study, and permission to approach participants was obtained from the head of maternity and senior responsible officer for the local maternity system.

All participants received an information sheet about the study. The author confirmed consent for the study at each stage with participants, ensuring their confidentiality and anonymity. All participants where made aware they could withdraw at any time, with the consent form explicitly stating this. The data collected were electronic and password protected, only accessible to the author.

A formal risk assessment was not carried out; however, the local maternity and neonatal system had good links with psychologists who were running psychological safety sessions and it was decided to signpost participants to these should they ask. None did.

Results

The participants’ demographics are outlined in Table 1. Three of the participants were midwives, and three were obstetricians. Three themes were extracted from the data: learning to trust, influencing organisational culture and women’s experiences of care.

Learning to trust

Participants highlighted feelings of vulnerability and how relationships developed. Enhanced relationships led to increased understanding of each other’s situation. Consequently, communication across the local maternity and neonatal system between the hospital site and clinicians improved, resulting in sharing of experiences and learning.

Relationships

The use of Microsoft Teams as a virtual platform during the pandemic created a new way of communicating across systems, which was valued by the participants.

‘We’re thrown in a position where we know nothing…Certainly you were more likely to pick up the phone and talk to your neighbouring unit and actually make an effort to understand how things were in other units’. MW2

‘I would say now more than the past 10 years, the right people talk at the right time…and that is the strength of this huddle. I don’t think that had happened before.’ DR5

‘Now having teams I think people are able to dip in more...I’d never heard of Teams...Teams has enabled… more people access’. MW1

‘It’s a good thing because on Teams it’s easier for people to attend the meeting’. DR4

One participant felt that the huddles contributed to psychological safety, which facilitated learning.

‘I think attending the huddles...for me personally, it’s about engagement and that psychological safety of us all having a voice and discussing what’s happening.’ DR5

Teamwork

Participants spoke about the huddles’ value in bringing the multidisciplinary team together for joint decision making.

‘We need to work to a collective of how we’re going to manage this scenario and actually putting more heads together. We came up with some good things’. MW1

‘But I think the network and the huddles, there’s so much sharing and understanding…you know it’s all right for the top people to know but actually, how do you get it to the shop floor…And I think that’s where we are.’ DR5

‘It does improve team working. It does improve your knowledge. It does bring an easy transfer…because you know each other’. DR6

Despite positive relationship building and effective communication, professional tensions were also present. Participants expressed tensions between professional groups and organisations, for example between district general hospitals and teaching hospitals. Some participants felt the midwife voice was missing from the huddles and while acknowledging difficulties, also talked about how that may be heard.

‘But often the doctors don’t want to hear the other side, but we should be drip feeding it where we can… Plus, we tend to say “oh and how did we support the staff in this situation?” It’s the midwives bringing them the broader bits, so I would say some joint presentations might help’. MW1

‘I think people are bit more sympathetic in tertiary units to the hospital...which is [a district general hospital], and need resources, and [are] more willing to help and accept our complicated women’. MW3

‘You’ve got to somehow make sure everybody has a voice…I’m already apprehensive about how do we make sure everybody has got a voice…because if you don’t get the midwife, if you don’t get that bit right, nothing that I do makes a difference’. DR5

Influencing organisational culture

As healthcare is increasingly delivered on a systems footprint, navigating the physical boundaries of geography and metaphorical boundaries of culture was felt to be more critical.

System awareness

Some participants acknowledged that the huddles facilitated system awareness and the importance of this for coordinating care.

‘It was getting used to the fact you’ve got to think bigger than your trust. So it was adjusting our way of thinking....It did help, the [local maternity and neonatal system]…you can be quite insular in your own trust, this opens up your eyes that maternity is a network’. MW1

‘The fact that they were [local maternity and neonatal system]-led was good, to understand how the [local maternity and neonatal system] works, because that’s…not something that you get really involved. You get very focused on your own environment...From my perspective at [the hospital], we are always very insular…I think it’s easier to understand the pressures and to be more collaborative, more compassionate...If they’re struggling on how to look after a woman, you could understand, maybe because you already built that connection’. MW2

Leadership styles

Participants commented on the leadership of huddles and evolving a more distributive leadership between organisations, while recognising different leadership styles are required for different situations.

‘I’ve noticed I’ve attended the last few and it’s more OK, you’re bringing good cases and expertise from [the hospital], so that’s quite good. It balances a little bit that leadership…I think at the time was just the right thing…especially in a crisis. You do need people to take control and to lead in a particular way…I think the leadership is more collaborative and more inclusive now’. MW2

‘I think it’s great to see that leadership and when the huddles actually occur has evolved…recognise that actually it’s probably best to let everyone take part’. MW3

However, one participant identified tensions between leadership ownership, organisations and systems and the problems of a more distributive leadership style.

‘When [leadership] belongs to everybody, who takes responsibility for it?’ DR5

Women’s experience of care

The participants highlighted increases in knowledge and their perception of their effect on women’s experience of care.

Clinical knowledge

Some participants felt that women’s experiences of care were impacted by improved management following the huddles, and the ability to provide recommendations based on case studies.

‘It did help us manage women, especially those critically ill women…before they tipped over into critical care you were able to manage them a bit better’. MW1

‘I’m on the shop floor a lot…so the information I get on the huddle, I can then translate that to staff, whether it’s on a one to one because we’re seeing a woman presenting in a particular manner or whether it’s at handover when we discuss a case. And you can say “this is what was recommended on the huddles case…and this was the recommendation”, so it’s definitely affected practice’. MW3

‘But I really think that it’ll make such a difference to the way we care for the patients…we are discussing cases…and the woman lived… all the units benefited from it…everyone got to learn’. DR4

One participant talked about the difference between an impact on care and an impact on women’s experiences.

‘It would have impacted indirectly because our knowledge is improving…I’m not sure experience was affected… definitely safety and care did…which indirectly does impact patient experience, if the doctors are more knowledgeable, more confident’ DR6

Inequities

The participants were aware of current inequities in access to care and how the huddles could help address this.

‘It will be like any woman, whether she’s cared for at [the hospital] or whether she is at [a different hospital], you know she’ll be looked after equally well’. DR4

‘For me, the huddles have impacted on how do we get it right for every woman? And the inequity it’s… about what can we do to change the process and how do we change it together’. DR5

‘I see eventually the whole [geographical area] will be one big trust…these huddles are the start of that. It feels like we are getting closer towards all women get similar treatment and we work with each other’. DR6

Discussion

Developing trust and teamwork: influence on organisational culture

Trust involves the trustee accepting a degree of vulnerability and uncertainty and a willingness to take risks (Langharne et al, 2013; O’Brien et al, 2021), trusting the other party to act positively (CIPD, 2012). In the present study, participants had the dual role of ‘trustee’ and ‘trusted other party’ that is suggestive of reciprocity, an important component of effective team working (West, 2021). The participant’s comments conveyed a feeling of uncertainty that the pandemic created, reflecting vulnerability. It was felt that the huddles brought people together, allowing relationships to develop and individuals and organisations across the system to communicate.

A supportive psychological environment is critical for guarding against burnout when working in high-stress, high-emotion environments (Smith, 2021). Psychological safety has been allied with a trusting team climate that positively affects workplace culture and innovation, and is a determinate of care quality (West, 2021). Although the concept of psychological safety was only mentioned by one participant, feelings of support and value were evident in other responses. The Ockenden (2022) report states ‘staff who work together must train together’, with a mandate that this should include the principles of psychological safety.

Delivery of maternity services has evolved to be coordinated over a systems footprint rather than among individual trusts. Arguably, the use of a virtual platform reduces relationship building (Penarroja et al, 2015); however, the present study’s participants suggested that the virtual model was an enabler of these relationships.

Despite the positive comments about the effects of team working, tensions were also apparent. These were present interprofessionally between midwives and doctors, organisationally between the district general hospital and teaching hospitals, and at the system level between organisations and the local maternity and neonatal system, echoing Mahon’s (2013) reference to micro, macro and meso levels of trust.

Participants’ comments on the lack of consideration of the midwife’s voice, together with what may be seen as an inability to overtly challenge medical colleagues, are reflective of this complexity. Muting of the midwifery voice as a result of an overly biomedical model of maternity is not new (Kirkham, 1999; Kirkham and Stapleton, 2000). These issues are of great importance for maternity services. Ockenden (2022) and Kirkup (2022) made clear how poor relationships, collaboration and teamwork can have catastrophic long-term consequences for all involved.

Leadership impact and influence

Participants recognised the need for different leadership styles at different times. The skill for a leader is being able to transition across different leadership styles, balancing service delivery priorities, system-wide collective responsibility and compassionate and inclusive values (King’s Fund, 2014). Nevertheless, problems associated with more collective styles of leadership were highlighted in the present study. For example, there was confusion over the focus of responsibility. Participant remarks regarding improving interprofessional collaboration and reducing inequities are suggestive of increasing trust and an improving organisational culture. The sustainability of the huddles is dependent on leaders facilitating open dialogue between members of the multidisciplinary team and shaping systems that support mutual recognition and respect between professions.

Improving women’s experiences of care

All participants felt that the huddles had improved women’s experience of care. While most assumed impact on care and on women’s experiences were synonymous, one participant alluded to these not being the same. Although the participants’ examples showed a link between increased clinical knowledge and safe care, the reality of a woman’s experience may be different, and is an area that would benefit from further study.

However, inequities in care across the local maternity and neonatal system were noted during the huddles, with participants reporting a strong desire to address them. The importance of reflexive groups has been highlighted, as they can often go beyond operational decisions to making strategic decisions (West, 1996; 2021) and this would appear to be a strength of the huddle.

Limitations

There were several limitations to the present study. The author is a novice researcher and the sample size is small. An increased timeframe and larger study would give voice to a wider range of opinions from a broader section of the workforce. Another potential criticism is that it neglects the significance of intersectionality. It is important to recognise the limitations of presenting gender as a collective that transcends, for example, race and class.

The necessity of virtual interviews for research projects, which were time-limited during the pandemic, have been highlighted (Sah et al, 2020), while acknowledging the limitations that this can cause. For example, as a result of technical difficulties, there may be a time-lag in responses, both verbal and non-verbal, resulting in difficulties with the researcher being reflexive. While accepting these difficulties, it is important to note that the pandemic has normalised the virtual platform. The present study’s participants were familiar with this mode of communication and there were no restrictions imposed by poor or non-functioning computers or connectivity. However, the interviews with the two participants that the author had not previously met face to face were significantly shorter, lasting 15 and 20 minutes respectively, where the other interviews lasted between 40 and 60 minutes.

Conclusions

Maternal medicine huddles during the COVID-19 pandemic provided a unique opportunity to explore the development of trust in the maternity multidisciplinary team. The findings highlighted the importance of developing trust for promoting teamwork and the significance of leadership styles and behaviours in influencing a positive organisational culture. The huddles have proved a sustainable initiative, facilitating service improvement and high-quality effective care.

By adopting a critical feminist stance, the present study attempted to offer an alternative viewpoint to current available literature. The reasons for the paucity of feminist research in maternity remain unexplored; however, an area of interesting further study would be considering the feminist paradigm as deviant in the hierarchical, gendered institution of the NHS, into which midwives are situated.

It is recommended that the huddles form part of the local maternity and neonatal system trust’s learning and development of maternity staff. It is hoped that this would involve the inclusion of more junior staff and influence mutual respect and professional recognition, which the huddles have suggested would positively impact practice.

The present study highlighted the value of a climate of trust for a positive organisational culture and complexities of interprofessional teamwork. For quality care outcomes that are equitable and sustainable, leaders need to navigate these complexities and build reflexive teams. The importance of leadership, teamwork, interprofessional mutual respect and shared learning cannot be underestimated when faced with the multidimensional and dynamic challenges of maternity services.

Key points

• Trust and a positive workplace culture are critical for safe maternity care.
• Leaders have a critical role to engage and provide a learning environment.
• Increased trust results in increased reflexivity in the multidisciplinary team, which enhances strategic decision making.
• There is a paucity of feminist research in midwifery; reasons for this require further exploration.

CPD reflective questions

• How do you think you positively influence organisational culture in your maternity unit?
• Do you think feminism has relevance for midwifery practice?
• Is the way you lead promoting trust in the workplace?