Impacts of Clinical Risk Management on Midwifery Practice - Literature review Example

Impacts of Clinical Risk Management on Midwifery Practice Introduction Risk assessment and management is one of the highest featured agenda in maternity care (Bryers & Teijlingen, 2010).This is majorly because of the heightened dangers of dealing with women in labour and the nature of the current society where the only action for negligence seems to be through the courts in quest for financial recompense. Establishing potential risk factors and tailoring care to guard against risk is vital in achieving safe outcomes for the mother and the baby (Kenyon, 2009). This essay explores the process of Clinical Risk Management (CRM) in the maternity setting to demonstrate how CRM impacts on midwifery practice. In addition, the essay offers woman-centred strategies that midwives can employ to promote safety and manage risk for the childbearing woman. Impact of CRM on Midwifery Practice One of the most important issues in CRM is addressing the issue of fear. Grayling (2002) says that, “What we fear comes to pass more rapidly than we hope – mainly because we make it so” (cited in Dahlen 2010, p. 156). Cain (2007) observes that we live in a world in which McDonalds have to place a warning on a coffee cup that it may contain hot liquid. No wonder that clinical governance requires contemporary midwifery to be governed by risk assessments and systems (Bryers & Teijlingen, 2010). The current world is plagued by a triumphing obsession with safety and risk. This alludes to the fact that, to effectively address the safety and risk management in midwifery, we must address the fears surrounding pregnancy and birthing. It is important to understand the beliefs people hold about birth and where they come from and how they shape maternity care delivery. Pairman et al. (2009) observe that risks in childbirth should be understood not only in their physical terms but they should also be understood in their cultural and societal contexts. One of the cultural and societal areas that has majorly affected risk control in midwifery is modernity and globalization in which people have lost faith in technology and professionals and are more risk conscious, becoming a ‘risky society’. This creates a desire to avoid all risks which is a problem on its own (Beck, 1999). Apart from the risky society, other societal forms affect the way in which decisions regarding risks are made in healthcare thereby affecting how midwifery decisions are made in regards to risk management. Dahlen (2010) argues that that, “basing ones practice on evidence is an entirely different thing to having one’s practice rules by one randomised control trial” (p. 157). Perceptions on risk management and risk management are some of the debates plaguing maternity care (Bryers & Teijlingen, 2010). The belief system around birth and around the notion of safety and risk reflect on language and language definitely impacts on the choices that women make. In most instances, as Dahlen (2010) notes, perceptions on risk are educated into people; this means that they can be educated out. In most instances, perceived risk may not always reflect on actual risk. There are three dimensions regarding risk; assessment, communication and risk management. Rightly assessing the risk, effectively communicating it without raising anxiety and managing the risk effectively builds confidence is one of the competencies every midwife should have. Risk may not be eliminated entirely, however, it should be assessed, acknowledged and addressed so that it can be minimised both for the staff and the client (Kenyon, 2009). Risk management in midwifery involves three main areas; risk identification, risk analysis and risk control (Irwin 2010). Midwives are required to use their knowledge and skills to identify and control risks during pregnancy and after pregnancy. Identifying risk means identifying the problems which is the key factor in finding solutions thereby reducing risks. According to Williams (2002) identification of risks can be through; observation, interviews, inspection, clinical incident reporting, use of questionnaires and auditing. In addition, using Root Cause Analysis (RCA) of the perceived problem helps in identifying the underlying cause of risk which could lead to women’s risky incidents (Irwin 2010). Early identification of risks helps in finding the solutions early enough and coming up with control measures. This is especially important for high-risk women. Risks should be identified and controlled in time to avoid adverse effects (Lees 2014). In addition, communication should be done in time to allow women to make decisions about their care. Lindgren et al (2010) name three categories of perceived risks that women identify for hospitals that make them opt for home births. First, the risk of being in the hands of a stranger where the woman and her baby are taken care of by a person she does not know. Secondly, the women feel that they are in the hands of routines and unnecessary interventions. Women feel that hospitals are full of routines which are compulsory for everyone. They feel that every birth is unique to the mother and baby and should be treated as so. Sandin Bojo et al (2006) argue that there are routines and interventions in the hospital settings which add no benefit and could even be harmful. Finally, women perceive risk they are in the hands of structural conditions such as transport to hospital after labour onset, change of environment and making decisions. Midwives are required to assess women and assign them according to evidence-based categories. Consequently, this influences the choices that women have during their pregnancy period and around birth. In risk assessment midwives are required to identify those women who are at high or low obstetric risk in order to minimise maternal and neonatal risk. However, Stahl and Hundley (2003) question the effectiveness of this strategy. Their study established that labelling women as ‘at risk’ negatively affect their psychosocial state. Similarly, Hawson (2001) say that for a woman who considers herself as healthy to be classified as ‘at high risk’ increases the risk for complications. Proper documentation of patient information plays a big role in risk management. This involves properly documenting comprehensive history as well as the physical examination reports (Jomeen, 2012). This will help other collaborate with you in the line of care and in effect improve risk management. Safety is an important component of risk management. The physical environment should be kept safe at all times. The clinical equipment should also be safe for the patient’s use in order to prevent infections. Strategies to Promote Safety and Manage Risk As discussed earlier, midwives should examine their own fears and recognise their roles in contributing to women’s fears – which influences their choices of maternity care. Maternity care providers have the responsibility of reducing manufactured fear and build trust from women. It is impossible to negate the importance of risk management in maternity care. All staff should ensure that they protect both mothers and babies from avoidable harm, support patients and family in cases of adverse events and build trust with the patients. Arulkumaran (2010) rightly observes that maternity care should be anchored on the principles of availability, accessibility and acceptability. Safety should be observed because it is the back bone of quality. First midwives maternity care should be given from an accredited workplace which has all the required equipment. Care should be given by adequately trained staff who are able to assess, communicate and manage risk. There should be a framework for incident reporting and identification of risk based on severity and frequency of occurrence. This will help in minimizing such incidents in future. Improving the safety culture; having a positive culture in an organization and having management commitment with safety as its key priority. This is in the organizational level, environmental level and team and staff levels. According to Allen et al (2010), safety culture entails; competence, management and supervision, risk, safety systems, communication, work pressure, beliefs about cause of errors, feedback and communication, overall perception of safety and job satisfaction among others. The Nursing and Midwifery Board of Australia (NMBA) has provided midwives with competency standards and professional conduct which is expected for every midwife. Working in accordance to these standards will improve risk management and improve care which will impact positively on midwifery practice. One of the areas specified in the competency standards is practising legal and professional practice. In risk management, the standards requires the midwife to be responsible and accountable for his/her actions and work, identify complications and carry out appropriate and timely consultations and carry out referrals where needed. The midwife is also required to delegate where necessary and ensure appropriate supervision (ANMC, 2006). The other strategy is using the birth stool model proposed by Pairman et al. (2010). The birth stool is for the midwife rather than the woman giving birth and applying it in practice makes the midwife to be safe and effective. The seat of the stool is called ‘being with women’. It is the centrality of the relationship between the midwife and the woman. This seat is the quality of the relationship and it is also the quality of communication which form a vital factor in maintaining safe and appropriate care. ‘Being with women’ gives the midwife time to know the woman, understand her and anticipate her needs (Pairman et al, 2010). From the seat (Being with women) is the first leg of the stool – ‘being a professional’. This means that a midwife should be both a skilled and accountable practitioner. This means that a midwife has the necessary skills to assess risk. The midwife should be accountable to her decisions and her actions as well as accept responsibilities for adverse outcomes. The next leg in the stool is ‘working the system. This means that the midwife continues to connect with the woman and her experiences while working in the system. As Pairman et al (2010) note, midwives do not work in isolation; they work in a system and are required to understand the working of the system and participate in it. Working in the system requires three major things: developing and maintain collaborative relationships with those in the system, understanding the processes put in place and working within them, and acknowledging the power relationships within the system and managing disparities. The third leg is ‘working with complexity’. Risk management in midwifery is complex and midwives are faced with unknowing and uncertainty (Pairman et al, 2010). This means that a midwife should be able to weigh options and trade-off values while making decisions on risk and safety. ‘Storytelling’ is the Struts of the stool. This is the part that holds the stool together connecting the legs with the seat. Storytelling to women, the authorities and colleagues help midwives to stay connected to each other, understand the complexities of midwifery and understand what is expected. Conclusion Midwives should ensure that they practice safe, evidence-based practice. In addition, they should carry out accurate risk assessment. They should also practice high quality record keeping and endeavour to learn from every situation. Finally, responding to complaints and discontent can address misconstrue risks on the part of the women and build trust on the midwives and the models of care. Employing risk management strategies coupled with adherence to the local and national governance and policies will improve risk management. References Allen, S., Chiarella, M., Homer, C. S. (2010). Lessons learned from measuring safety culture: An Australian case study. Midwifery, 26, 497-503. Arulkumaran, S. (2010). Clinical governance and standards in UK maternity care to improve quality and safety, Midwifery, 26, pp. 485-487. Beck, U. (1999). World risk society. Polity Press, Malden. Cain, K.G. (2007). And now, the rest of the story y About the McDonald’s Coffee Lawsuit. Journal of Consumer & Commercial Law, 11, 14–19 Cooper, M. & Fraser, D. (2009) Myles Textbook for Midwives. Edinburgh. Churchill Livingstone. Dahlen (2010). Undone by fear? Deluded by trust. Midwifery, 26, pp. 156-162. Dahlen, H., Barclay, L., Homer, C. (2010). The novice birthing: theorising first-time mothers’ experiences of birth at home and in hospital in Australia. Midwifery, 26, 53–63 Declercq, E., Sakala, C., Corry, M., Applebaum, S. (2006). Listening to mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. Childbirth Connection, New York. Grayling, A.C. (2002). The Meaning of Things: Applying Philosophy to Life. Phoenix, London. Irwin, J 2010, 'Obesity, risk and the challenges ahead for midwives', British Journal Of Midwifery, 18, 1, pp. 18-23 Jomeen, J. (2012). The Paradox choice in maternity care. Journal of Neonatal Nursing, 18, 60-62. Kenyon, C. (2009). Risk management standards in midwifery are no substitute for personal knowledge. Complementary therapies in clinical practice, 15, 209-211. Lee, S 2014, 'Risk perception in women with high-risk pregnancies', British Journal Of Midwifery, 22, 1, pp. 8-13. Lindgren, H. E., Jadestad I. J., Christensson, K., Wally-Bystron, K. & Hildingsson, I. M. (2010). Perspectives of risk and risk management among 735 women who opted for a home, Midwifery, 26, 163-172. Pairman, T., Sally, K.T., Thorogood, J. P. (2010). Midwifery: Preparation for Practice, (2 Eds). Elsevier Health Sciences, Australia. Sandin Bojo A. K., Wilde Larsson, B., Axelsson, O., Hall Lord, M. L. (2006). Intrapartal care documented in a Swedish maternity unit and considered in relation to World Health Organization recommendations for care in normal birth. Midwifery 22, 207–217 Stahl, K. & Hundley, V. (2003). Risk and risk assessment in pregnancy – do we scare because we care? Midwifery, 19, 298-309. Van Tiggelen, J. (2009). Birth Rights. Good Weekend, September 5, 14–19. Williams J (2002) The tools of risk management and their application to midwifery practice. In: Wilson J, Symon A, eds. (2002) Clinical Risk Management In Midwifery The Right To Have A Perfect Baby? Books for Midwives Press, Oxford Read More