A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice
A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice
复制标题
DOI：
10.1016/j.midw.2008.07.008
复制
发表时间：
2010-06-01
期刊：
影响因子：
2.7
通讯作者：
Butt, Janice
中科院分区：
文献类型：
--
作者：
Hood, Laraine;Fenwick, Jennifer;Butt, Janice
目的：描述澳大利亚助产士对产科服务的外部审查，参与法律诉讼以及对助产士临床实践和个人福祉的影响的经验。背景：外部审查程序（通常称为“道格拉斯调查”）是由州政府发起的，针对医院工作人员和消费者的投诉，这些投诉集中在客户护理的异常情况以及不良后果和临床差错的高发生率上。这是在针对医务人员的一些法律诉讼的背景下发生的。因此，医院雇用的一些助产士被要求在各种法律论坛上提供证据。设计：使用探索性描述设计的定性研究。雪球抽样被用来邀请16名澳大利亚助产士参加录音采访。使用专题分析和与不断比较有关的技术来分析数据。地点：澳大利亚产科三级转诊中心。研究发现：分析确定了两个主要的主题，“一个关于审视的故事”和“一个关于恐惧的故事”，每个主题都有一些次要主题。《审视的故事》由三个副主题组成。“斗篷和匕首事件”反映了助产士的存在感和感觉“暴露”和“脆弱”，同时在分娩过程中“被蒙在无底”和不知情。副标题“被扔进狼群”描述了助产士作为证人参与医疗法律诉讼的经历。第三个副主题“调查跟随她们回家”概述了对助产士情绪健康和人际关系的影响。第二个主题“恐惧的故事”同样由若干次主题组成。“在工作中感到不安全：一种恐惧文化”描述了助产士在一个他们认为是由对诉讼的恐惧驱动的环境中工作的经历。为了保护自己和保持一种控制感，助产士采取了一些“感到安全”的策略，包括防御性决策和转向医疗护理哲学。这些概念都包含在“保护你的背部：设定界限”的副主题中。助产士、妇女和医生之间的关系受到的影响在“职业关系：受到恐惧的影响”这一次级主题中进行了描述。对助产士信心的影响以及由此引发的负面情绪构成了副标题“进退两难：助产士的痛苦困境”。最后，副主题“选择退出：专业工作实践的变化性质”描述了助产士在他们认为具有威胁性的环境中继续工作的能力所做出的具体专业决策和工作策略。结论：调查结果表明，参加这项小型研究的助产士在个人和专业方面完全没有准备和装备不足，无法处理在一个环境中工作的后果，这个环境是许多引人注目的法律诉讼和广泛的产科服务外部审查的中心。助产士对法律程序很幼稚，也没有准备好应对法律“游戏”和经常伴随法庭诉讼的媒体关注。尽管事实上没有助产士面临诉讼，但参与者称他们的工作环境变得越来越紧张，充满了恐惧文化。反过来，这种情况又使一些助产士更加需要采取一种“机构”的意识形态，这种意识形态强调分娩是一种需要医学管理的异常事件。这导致了专业和个人工作实践的变化。研究结果也对助产人员及其留任产生了影响。尽管研究结果是具体的，但这项研究为恐惧诉讼的现象及其对助产实践的影响提供了有价值的见解。鉴于其他一些西方国家在产科诉讼方面的相似之处，研究结果在国际助产领域具有相关性。(C) 2008 Elsevier Ltd版权所有。
Objectives: to describe Australian midwives' experiences of an external review of obstetric services, involvement in legal proceedings and the impact on midwives' clinical practice and personal wellbeing.Background: the external review process (commonly referred to as the 'Douglas Inquiry') was initiated by a state government and was in response to hospital staff and consumer complaints that focused on anomalies in client care and a significantly high rate of adverse outcomes and clinical errors. It took place within the context of a number of legal proceedings against medical practitioners. As a result, some midwives employed by the hospital were called to give evidence at a variety of legal forums.Design: a qualitative study using an explorative descriptive design. Snowball sampling was used to invite 16 Australian midwives to participate in a tape-recorded interview. Thematic analysis and the techniques associated with constant comparison were used to analyse the data.Setting: Australian maternity tertiary referral centre.Findings: the analysis identified two over arching themes, 'A story of scrutiny' and 'A story of fear', each with a number of subthemes. 'A story of scrutiny' consists of three subthemes. 'A cloak and dagger affair' reflects the midwives' sense of being and feeling 'exposed' and 'vulnerable' whilst simultaneously being 'kept in the dark' and uninformed during there view process. The subtheme 'Being thrown to the wolves' describes the midwives' experiences of being involved, as witnesses, in medico-legal proceedings. The third subtheme, 'The Inquiry followed them home' outlines the effect on midwives' emotional wellbeing and personal relationships. The second major theme, 'A story of fear' again consists of a number of subthemes. 'Feeling unsafe at work: a culture of fear' describes the midwives' experiences of working within an environment they perceive as driven by the fear of litigation. In order to protect themselves and maintain a sense of control, the midwives adopted a number of strategies to 'feel safe' including defensive decision making and moving towards a medical philosophy of care. These concepts are captured within the subtheme 'Covering your back: setting boundaries'. The impact on relationships between midwives, women and medical practitioners is described within the subtheme 'Professional relationship: coloured by fear'. The effect on midwives' confidence and the resultant negative emotions elicited make up the subtheme 'Between a rock and a hard place: the midwives' distressing dilemma'. Finally the subtheme, 'Opting out: the changing nature of professional work practices' describes the specific professional decisions and work strategies that midwives made about their ability to continue working in an environment that they perceived as threatening.Conclusion: the findings suggest that the midwife participants in this small study were totally unprepared and ill equipped, both personally and professionally, to deal with the consequences of working within an environment that was the centre of a number of high profile legal proceedings and an extensive external review of obstetric services. The midwives were naive about legal processes and unprepared for the legal 'game playing' and media attention that often accompanies court proceedings. Despite the fact that no midwife faced litigation, the participants described their work environment as becoming increasingly stressful and permeated by a culture of fear. In turn, this situation has reinforced the need for some midwives to adopt an 'institution' ideology which reinforces birth as an abnormal event that needs to be medically managed. This has led to changes in professional and personal work practices. The findings also have implications for the midwifery workforce and retention. Although the findings are context specific, this study provides valuable insight into the phenomena of fear of litigation and its impact on midwifery practice. Given the similarities concerning obstetric litigation in some other Western nations, the findings have relevance in the international midwifery arena. (C) 2008 Elsevier Ltd. All rights reserved.