5 Effective collaboration with medical colleagues: making it happen 
Introduction
This chapter describes and explores ways that midwives and obstetricians can successfully work together to ensure women receive care that is appropriate and leads to the best possible outcomes. We have come together to write this chapter and share insights and experiences from our different perspectives and professional positions—as midwives and obstetrician. We will present practical examples as well as some of the theory on collaboration, and believe that it is not enough to just ‘do’—it is important to understand ‘why’ and to look at these issues from a range of perspectives.
We will concentrate on professional collaboration and the process to ensure that midwives and doctors can work together effectively to bring about and sustain midwifery continuity of care. We start by telling our story and giving you our views on what works in ensuring that effective collaborative relationships are developed and sustained. You may draw on some of our experiences to help you think through your own processes of effective collaboration. Later we provide a more theoretical understanding on collaboration, including theories of collaboration, inter-professional working relationships and trust. We hope this theory might help those who want to explore these issues in more depth. We believe that understanding the principles behind what we think and do can help us be truly effective collaborators. Our focus is the professional relationships between midwives and obstetricians. This is not to say that the women are not an important and integral part of the partnership and of midwifery continuity of care, but here we focus more on the professions than the woman.
We know that collaboration is often challenging, and sometimes environments are so hostile that even the best theories and approaches in relation to effective collaboration will not work. If this is your environment, we encourage you to continue to strive towards the vision that is supported by evidence and increasingly by government policy. The road is long, however, and often full of obstacles. Small changes can be made often and with each small change the possibility of building better services for women will become more likely and, hopefully, possible. We hope that some of the strategies outlined will be helpful even in the most difficult situations and settings.
Bringing about change through collaboration: our story
We started working together in 1996 in an urban teaching hospital in the southern suburbs of Sydney, Australia. The hospital had begun a process of change to its organisational culture and was committed to introducing innovations in service provision that included the introduction of models enabling midwifery continuity of care. We will use our experience of working to transform the maternity service at our hospital (St George Hospital in Sydney) from a traditional model of care to one that is flexible, woman-centred and has successfully implemented and sustained midwifery continuity of care. All three of us were involved in this change: Pat as the Clinical Midwifery Consultant; Caroline as a midwife researcher who undertook her doctorate on the research attached to the implementation of the first new model of care; and Greg as the obstetrician who supported the models and provided obstetric care alongside the midwives. This process of collaboration, organisational change and leadership has taken us, and others who have worked with us, the best part of 10 years and continues today with ongoing new challenges. We have detailed this leadership process and the story in a chapter in another book that readers may also like to read (Brodie & Homer 2008).
Implementing midwifery continuity of care was challenging in this hospital in the mid to late 1990s. As in most Australian maternity services, at St George Hospital women were being provided with fragmented, hospital-based care that was generally directed by obstetricians. In Australia at this time most midwives worked in hospitals, often in one clinical area, for example in antenatal, birthing or the postnatal ward. The exceptions to this were a small number of privately practising independent midwives and a few birth centres. Ten years ago very few midwives employed in the public hospital system (where most women receive care and give birth) worked anything but shift work. On-call work, where midwives were at home with a pager if they were needed, was rare, especially in major metropolitan hospitals. Some midwives provided community-based postnatal care in the form of a few home visits. These were generally midwives who had not provided the care during the antenatal or birthing periods. Many midwives and a few forward thinking obstetricians realised that this system was not fully utilising midwives’ skills or meeting the needs of women. There was also evidence from research as well as government reports and policy documents recommending that substantial change to the system was needed. This was the environment and then impetus for our collaboration to bring about a change to our services and develop midwifery continuity of care.
We knew that, in order to bring about change in maternity services so that midwifery continuity of care can flourish, a nexus or an impetus is usually needed. In our case, this started with an external review of maternity services in our region in 1994. The review recommended widespread reform and reorganisation to the area’s three maternity services, including the appointment of a Professor and Director of Obstetrics. Professor Michael Chapman was appointed to this role soon after. St George Hospital had already commenced a process of change to its organisational structures and had begun introducing innovations in service provision. A maternity service consumer survey was completed around this time and recommendations based on the findings were beginning to be implemented (Everitt et al. 1995). The recommendations included moving antenatal care into community-based settings and implementing midwifery continuity of care programs. The senior midwifery manager, Jo Wills, was personally committed to changing the system to improve care for women and babies. She was widely respected in the maternity unit and had provided many years of leadership during this early time and subsequently. A previous government report (NSW Health Department 1989) had recommended that birth centres be established to cater for women of low risk in a ‘homely’ environment. Jo had led the establishment of the Birth Centre at St George despite active opposition. A Professor of Family Health (who was also a midwife), Lesley Barclay, was appointed around this time to lead research and practice development in midwifery in the Area Health Service where the hospital was located. Many others also worked together in leadership roles to ensure the models of care that were developed would be sustainable.
The first model we developed, the ‘St George Outreach Maternity Project’ (STOMP) was set up with a deliberate focus on collaboration between midwives and obstetricians as part of a community-based maternity service, available to women of all risk. We evaluated this new project through a randomised controlled trial involving 1089 women, comparing maternity care in STOMP to routine maternity care at St George. The study demonstrated a significant difference in the caesarean section rate between the groups: 13.3% in the STOMP group and 17.8% in the control group. This difference was maintained after controlling for known factors contributing to caesarean section rates. Women receiving STOMP care were more satisfied and costs associated with the new model were less than for standard care (Homer et al. 2000, 2001a, 2001b).
Over the next 10 years a number of models of care were established, the primary component of all being midwifery continuity of care. These include the risk associated pregnancy (RAP) team (Farrell et al. 2000, Homer et al. 2002) and a caseload model for newly graduated midwives in the birth centre called TANGO—Towards a New Group Practice Option (Passant et al. 2003). There are elements common to all these models which we feel are integral to successful collaboration.
Why collaborate in maternity care?
The concept and experience of collaboration holds different connotations for each of us. Many midwives and doctors would report that they collaborate as a matter of course in their day-to-day practice. Whether they are collaborating, consulting, referring or simply cooperating is rarely explored and as such the potential benefits that might ensue from more positive and effective relationships cannot be fully realised. It is a reasonable assumption that through collaboration, teamwork and sharing of clinical information and skills, midwives and obstetricians have a greater chance to improve the outcomes for women and babies. The relationship between midwives and obstetricians is an integral part of providing maternity care, in particular the right service, at the right time and in the right place (Guilliland 2007).
Despite the potential benefits of enhanced collaboration there is little evidence of models of care designed to increase collaboration as an ‘intervention’ aimed at improving experiences for both women and health professionals. The concept has, however, been highlighted in the United Kingdom. For example, ‘The Confidential Enquiry into Maternal and Child Health’ recommended greater collaboration, communication and consensus decision making as central to reducing negative outcomes in care (CEMACH 2004).
It is our view from over 20 years of practice that historically midwives have had relationships with doctors that were enabling for the doctors. It is now time to develop relationships that are enabling for midwives. When midwives and doctors collaborate effectively there are exchanges of essential ideas and information. This exchange can only occur if there is a sharing of responsibility and power, along with recognition of the need for occupational autonomy. In contemporary maternity services, provision of such ‘sharing’ of power in essence means that doctors must give up some of their power. Equally, it also means that midwives must accept full responsibility for their clinical decision making. Understanding of the need for recognition of, and respect for, the differences between the identities of midwife and obstetrician will be integral to the success of collaboration in maternity care (Hardy et al. 1999). This step will assist later in the collaborative process when there is the inevitable exploration of various competing and conflicting interests.
What is collaboration?
When we started writing we sat together (over coffee as many of our meetings are) and mulled over what we really meant by collaboration. We decided collaboration takes work and commitment and that it develops over time. We liken collaboration to marriage, which also takes time, needs work and attention from time to time, is predicated on a commitment, and needs mutual understanding and respect. Collaboration in maternity care also means having a shared vision and philosophy and being committed to working together, which at times means that everyone has to make compromises. Collaboration also means understanding and respecting one another’s skills, talents and scope of practice (Brodie 2003).
According to the Oxford English Dictionary (1997) the meaning of the term ‘collaboration’ may mean to ‘work jointly on a project, especially a literary, artistic or scientific project’, or ‘to cooperate traitorously with an enemy’! For our purposes collaboration in maternity care means: ‘the exercising of effort by midwives and doctors towards each other for the purposes of shared functions, namely the provision of safe, rewarding and effective care to women and their families’. This meaning is adopted for the purposes of explaining the writers’ shared perspectives on collaboration. Later it will be acknowledged that, in practice, quite often the term is confused with ‘cooperation’, which may or may not be experienced ‘traitorously’ between enemies.
Theorist Schrage (1990) conceives of collaboration as being like ‘romance’ and, like romance, it is difficult to define. According to Schrage, romance ‘embraces a continuum of interaction from the simple flirtation to a deep and abiding love, as well as every single possible permutation in between’. The collaborative continuum is similar in that it:
… stretches over vast possibilities of interaction: from the serendipitous stranger saying the right thing at the right time to the decades long mutual obsession of two scientists to tap out the secrets of molecular biology. (Schrage 1990, p 46)
Schrage suggests that collaborations have their own brand of simple ‘flirtations’ and deep, abiding commitments. Passivity is not a feature of collaboration. Like a romantic couple, collaborators are constantly reacting and responding to each other. Frequency of contact becomes almost as important as the nature of the contact. The collaboration becomes an entity unto itself.
The critical difference, in Schrage’s (1990) view, is that unlike romance, collaboration is supposed to produce something. Collaboration is a purposive relationship. At the very heart of collaboration is a desire or need to either solve a problem or create something, usually within a set of constraints. These constraints include:
Given these constraints, collaboration cannot be routine or necessarily predictable. People collaborate precisely because they don’t know how to—or cannot—deal effectively with the challenges facing them as individuals. There is uncertainty because they genuinely don’t know how they will get from ‘here’ to ‘there’ and they require others to work with them in an interdependent way to achieve results. In contemporary maternity care this gets played out in a myriad of ways according to existing relationships of trust or otherwise, the agreed protocols and practices, and the particular demands and pressures of the clinical situation.
This interdependence is one of the key features of collaboration critical to the process. In the initial phase of any collaboration it is important that each of the parties becomes aware of how all of their concerns are intertwined and the reasons why they need each other to reach an outcome (Gray 1989). Parties in conflict can easily lose sight of this so reminding each other of this critical ingredient often kindles renewed willingness to search for the particular trade-offs that could produce a mutually beneficial outcome. Within hospital-based maternity care settings it is often stated that ‘midwives and doctors cannot survive without each other’. Gray suggests that clear understanding of exactly what each other’s concerns are and ‘why’ each group needs each other is more often assumed rather than explicated or agreed upon. We recommend some discussion within your particular service as a strategy to build understanding and clarity about the relationships that are necessary if effective collaboration is to be achieved. You may like to use parts of this chapter to promote this discussion.
Other dynamics of collaboration described by Gray (1989) and others that are useful in the arguments built in this chapter are summarised below.
Gray’s work portrays the dynamic and forever changing domain of collaboration that is a part of the everyday relationships and organisational culture of maternity care. Thus, envisioning collaboration as a process rather than an outcome in which stakeholders assume responsibility for decisions made enables investigation of how innovation and change in currently unsatisfactory relationships can occur. If collaboration is successful, new solutions emerge that no single party could have envisaged or created (Gray 1999). Applied to maternity service provision and effective care, such a process requires deliberate focus, articulation, understanding and the leadership of professionals. While ever collaboration is not made explicit as part of routine care, its powerful potential for improved decision making and better outcomes cannot be realised. Moreover, the term may hide what may simply be ‘cooperation’ by midwives who are in a subservient and subordinate position within the inter-professional relationship.
One of our aims in working together was to make our collaboration explicit. This meant that we were overt in designing models of care that were collaborative, but also in the way that we worked together and with others. The next section outlines some of our essential elements of collaboration.
Essential elements of effective collaboration
Effective collaboration does not happen overnight nor does it happen by accident. In our view, there are a number of essential elements that need to be in place to ensure the collaboration is actually effective. These are drawn from our experience in practice over many years. A theoretical explanation of some of these elements follows this section.
Collaboration takes time
Accepting that effective collaboration takes time is probably the most important first step. Getting some innovations up and running can be quicker in some environments than others, but that is usually because a lot of work has gone into an area previously. Successful implementation of innovations, including midwifery continuity of care, is unlikely to occur if the hard work has not been done. By hard work we mean having the right people in the right leadership positions at the right time, developing the shared vision and ensuring that everyone is committed to it. In our context, this meant the presence of leaders committed to change, who brought about our employment in the hospital.
Sharing the vision and philosophy
Having a shared vision and believing in that vision is essential for effective collaboration. This also is true for a shared philosophy. There is no point in each professional group developing and having largely different ideals: it is likely that none will flourish. Using a farming metaphor, we do not believe in planting two different crops and only giving each half the amount of care they need. Both will fail. We want one crop that thrives and is sustained by the elements.
An important aspect of this shared vision and philosophy is ensuring that any model of care is fundamentally about women and woman-centred care. The importance of this philosophical foundation is discussed further in Chapter 8. Informed care of pregnant women must be at the centre of service innovation and care provision. The needs of the practitioners, midwifery or obstetrics, cannot be the main focus of the model of care.
A shared commitment to continuity of care and effective relationships is an important element. While this seems obvious and is well expressed in much of the writings around midwifery continuity of care, we believe it is fundamental to understand and articulate. By relationships, we do not only mean the relationship between the woman and her caregiver, we also mean the relationship between midwives and obstetricians and with other care providers. Having continuity of relationship between care providers over time builds trust and enables successful communication.
Trust, respect and fun
Trust is an essential element of effective collaboration. Working closely together, especially when the challenges are many, means that you need to trust one another. Trusting one another also means having an understanding of where each person is coming from and that all of you share a common understanding of where you are going. Trust is also about respecting one another’s skills and knowledge. We describe more about the theories of trust in maternity care later.
Working to bring about organisational change is always challenging. If it were easy, it would be done already and you would not be reading this book. In our view, collaboration also means making sure that you have some fun along the way as well. We may not always wish to socialise together or be close friends, but appreciating one another’s contributions and ensuring there is time to chat, network and support one another are also important components of effective collaboration.
Having different roles and respecting these differences
Another aspect to our capacity to collaborate and bring about change was the multi-levelled nature of the organisation. The three of us were on the operational level—we actually needed to make things happen. Above us were the Senior Midwifery Manager and the Director and Professor of Obstetrics and Gynaecology who provided a ‘shield’ from opposing forces. For example, initially at meetings with other obstetricians, who were opposing midwifery continuity of care models, the Director of Obstetrics engaged with the opposition to ensure that we could continue with our development work. Equally, the Senior Midwifery Manager ensured the other midwifery managers were aware of the changes that were taking place, and she mentored us and provided strategic advice.
Box 1 provides some insights on the essential elements of effective collaboration from another obstetrician, Rineke Schram, who works with women from disadvantaged communities in England. She presents her views on what obstetricians can do to support midwives to provide continuity of care to vulnerable women (pers. comm. 2007).
Box 1 Essential elements of collaboration
We propose that these suggestions work both ways—they also reflect what midwives can do to support obstetricians in a collaboration with a common aim: to provide women with continuity of care.
Being committed to organisational change
In designing and implementing midwifery continuity of care, another essential element to collaboration is having a shared commitment to organisational change. Designing and implementing midwifery continuity of care usually requires organisational change. The degree of organisational change required depends upon your context, your existing environment and culture, and your history. For some, little change may be required as the organisation has a culture that is supportive of midwifery continuity of care and can easily be moulded to accommodate new models of care. We guess that, since you are reading this book, you may require more significant organisational change to occur to implement and sustain these models of care.
Leadership is integral to effective collaboration and organisational change. As we described earlier, having the right people in the right positions at the right time is vital. However, this is not enough. Leadership means fostering mutual respect and trust as we described in previous sections. This is essential if models are to be sustainable. This is discussed further in Chapter 9. In Box 2 we outline the leadership factors that are needed to sustain collaboration and organisational change (Brodie & Homer 2008).
Using evidence to support organisational change
We used evidence to design, implement and sustain midwifery continuity of care. It was also important to recognise that in order to foster effective collaboration, we needed to be well informed about the evidence and could debate the merits or otherwise of it. Again, this is part of understanding and respecting one another’s strengths and knowledge. Sometimes we would read the evidence with different disciplinary ‘eyes’ and this altered how we interpreted it. This commonly happens when obstetricians and midwives debate evidence—the important part is that you must be able to do this from a sound knowledge base in a mutually respectful way. We frequently argued and critiqued information and our understandings of it.
We used the evidence on a number of levels. On one level, we used the evidence from numerous research projects as well as government reports to justify change in the organisation, and to counteract common arguments against introducing midwifery continuity of care. The next level was to use research as a tool to bring about change. One of the most frequently voiced arguments against any proposed change is that it will impact adversely on clinical outcomes. What better way to monitor this than in a well-designed clinical trial where outcomes are closely monitored and reported? For example, as described earlier, the first midwifery continuity of care model, the St George Outreach Maternity Project (STOMP), was implemented as a randomised controlled trial. When the trial finished in 1999, the findings justified the continuation of the project. STOMP has just celebrated its tenth birthday.
The next level was to use evidence to develop policies and protocols for high quality care and to ensure professionalism. The models of care were always established within clear boundaries that recognised the scope of practice of the midwife and ensured consultation and referral were built in. We had a multidisciplinary committee that developed literally hundreds of evidence-based protocols that were used to guide care in the maternity unit. We were all involved in the process of protocol development and could ensure these were implemented within the models of care as well as across the entire service. The protocols were woman-centred and aimed at ensuring that midwives took responsibility for their care and decisions.
Being creative
Bringing about organisational change also means you have to be collectively creative and think laterally to solve problems. Often the solution to your problem will not be in a book or an article. Problems and challenges are often unique because each model of care is slightly different as it caters for local contexts. Being creative is a challenge within itself. Many of us have been brought up through fairly conventional systems that have lots of rules and historical ways of doing things. Being creative means that you have to think on your feet, and explore new and uncertain approaches.
For example, when we found we had vacancies in a caseload model of care in the Birth Centre, we chose to recruit new graduate midwives and appointed an experienced midwife as their mentor. The experienced midwife worked alongside the midwives in the birth centre as they took on their own caseloads. Mentoring in this model was not always face-to-face; lots of phone conversations took place, especially during antenatal care and during labours. This approach was counter to the usual practice of the time. Historically, newly graduated midwives spent a year rotating through the unit or worked in one area (antenatal, labour or postnatal). Equally, it was very rare for new graduates to be considered ‘experienced’ enough to work in a birth centre. We showed that with the appropriate mentoring and support, new graduate midwives were an excellent group to work in the birth centre straight from graduation (Passant et al. 2003), and their enthusiasm and energy is rejuvenating for the unit as a whole.
Different ways of collaborating
There are a number of different ways of collaborating. We have described our way of collaborating with one another to bring about change. We also recognise we need to collaborate within organisations and even more broadly across disciplines.
Collaboration within organisations
In reviewing the research on inter-organisational collaboration, Hardy and others explored the complex role that collective identity has on an organisation’s capacity to generate collaborative relationships (Hardy et al. 1999). They refer to problems with collaboration related to a blurring of boundaries and professional identities, and suggest collaboration involves a particular struggle for individuals related to maintaining their own identity while engaging in a process that aims to create a new group identity—the collaboration itself. If participants do not engage with the collaboration they are likely to limit its potential, but in so doing they may also engender differences and conflicts that contradict with or challenge their own individual roles and professional boundaries. An exploration of the competing and conflicting interests, as well as understanding the separate identities, is needed before pursuing the collective identity that is successful collaboration (Hardy et al. 1999). An example of this in practice was the regular information sessions we provided when introducing our STOMP model of care. By engaging everybody in the maternity unit, individuals’ concerns over their role in the future organisation could be addressed and, usually, their fears allayed. This ensured a feeling of common ownership of the change and a sense of pride in the organisation’s willingness to undertake these difficult changes for the benefit of the women.
Appreciating our professional boundaries
The different roles of the midwife and obstetrician are not always clearly understood (Deery & Kirkham 2000, Stafford 2001). In many contemporary maternity services, midwifery autonomy is not acknowledged or supported, and very often the scope and boundaries of midwifery practice are blurred and confused (Ball et al. 2002, Kirkham & Stapleton 1999, 2000, Robinson 1989, Watson et al. 1999). Models of midwifery care that support autonomy and recognise the full potential role of the midwife are still rare in Australia (Brodie & Homer 2008) and in many other countries.
The inter-occupational boundaries between midwifery and medical practice have been explored by sociologist Witz (1992). She examined the way in which the male power (of obstetricians) has been used to limit the employment aspirations of women (as midwives) since the seventeenth century. The resulting demarcation lines of practice that were established, particularly in the nineteenth century, were based on sexually segregated spheres of competence in the medical division of labour. In our view, these continue to influence the nature and organisation of contemporary maternity service provision (Carpenter 1993, Pringle 1998). To this day, and to varying degrees, patriarchal structures remain and continue to impact and constrain the professional role and scope of practice of midwives. Clearly, it is essential that they be considered in any attempt to improve inter-professional relationships or to challenge the existing systems of maternity care.
Purpose and effect of collaboration
Sometimes we think of collaboration as being synonymous with teamwork. In a critique of teamwork, Schrage (1990) points out that collaboration is a far richer process with the issue being not simply one of communication or teamwork, but rather the ‘creation of value’. He describes a necessary process of value creation that the traditional structures of teamwork and communication cannot achieve. He defines collaboration as:
a process of shared creation: two or more individuals with complementary skills interacting to create shared understanding that none had previously possessed or could have come to on their own. (Schrage 1990, p 40)
Collaboration creates a shared meaning about a process, a product or an event, which, in the context of this book, is the desire for ‘best’ outcomes of maternity care for women. The actual process of collaboration is hard to measure with its many levels of conversations, interactions and communications. Collaboration, Schrage suggests, is not described in terms of the relationships it may create but in terms of the objective to be achieved. In support of this, Schofield (1992) suggests that the main reason for collaboration is to improve the quality of professional decision making, which in turn has the potential to make care safer and more cost effective with less duplication. Even when parties are unable to reach agreement, some benefits from collaborating are still possible according to Schofield (1992). The process of collaborating usually leaves parties with a clearer understanding of their differences and an improved working relationship.
Hardy and colleagues, in examining various organisational theories of collaboration, conclude that the basis of effective collaboration is collective identity and that the foundation of collective identity is conversation. Collaboration and the beneficial changes it brings about are bound up with a struggle between competing conversations, identities and influences, and the key is to manage and sustain that struggle through the maintenance of a connected identity (Hardy et al. 1999). In doing so, these authors argue, collaboration that recognises the individual identities and positions as well as the collective identity will more likely enable new solutions, practices or better outcomes to emerge that no single party could have envisaged or enacted (Gray 1999).
Applied to maternity care, women as recipients of care stand to benefit greatly if the carers are able to reflect on the processes of communication, examining how shared or unilateral decision making by either party affects outcomes. This is most obvious in the care of women who are experiencing complications of pregnancy or who have known risk factors. Effective communication, focussing on the individual needs of the woman and recognising the complementary but unique roles and boundaries of practice that exist between health professionals, is at the centre of risk management, harm reduction and improving birthing experiences for women (CESDI 1998). This is a critical interpretation of collaborative relationships in maternity care. The challenge of maintaining one’s individual role and identity while engaging in a process of creating a productive and effective collective identity will be a confronting experience requiring skills, confidence, self esteem and support. We suggest that this is at the core of building effective relationships in practice.
There are a number of environmental, practical, procedural and inter-personal attributes that are necessary for true collaboration to occur. These are important when considering the effect that collaboration between the professions might have in the development of maternity services. These are detailed in Box 3.
Collaboration and interdependence
Recognition of mutual interdependence by the stakeholders is important early in the process. This may be initiated because each person recognises the potential advantages of working together on the problem or because they need each other in order to solve it. Without this recognition collaboration will not occur.
The potential to advance the ‘collective good’ of all of the stakeholders through the pooling of resources or, alternatively, the cost of doing nothing being too high, also requires recognition. Collaborative initiatives offer a decided advantage over other methods of decision making in that they guarantee everybody gets heard. If collaboration is successful, new solutions emerge that no single party could have envisioned or enacted.
Seeing collaboration as an ongoing process, rather than an outcome, in which stakeholders assume responsibility, assists in gaining understanding of how innovation and change might occur. Once initiated, collaboration creates a forum in which mutually agreeable solutions can be invented and collective actions to implement the solutions can be taken. Viewing collaboration as a process also enables description of its origins and development, as well as knowledge that it may change over time. For these reasons, attention to the process of setting up and supporting the collaboration becomes critical to its success, and to the capacity for the work and experiences gained to benefit others who wish to undertake a similar process.
The importance of trust
In any relationship, the defining element is trust between individuals and a reciprocity that assumes trust will be both given and expected. Trust is a critical success element for successful business, professional and employment relationships as well as its more obvious part in satisfying personal and romantic connections.
The development and maintenance of trusting and collaborative partnerships between maternity care providers is a critical factor in the successful implementation of new models of care that improve experiences and outcomes for women (Homer et al. 2001a). In our experience, the development of trust between midwives and obstetricians was a crucial element in both the development and the subsequent sustainability of a model of care such as STOMP (mentioned earlier in this chapter). In this model, midwives were required to work as autonomous practitioners based in a community setting, separate from the mainstream hospital services and personnel but with ready access to obstetricians. They made clinical decisions under their own responsibility and scope of practice, and referred and consulted with obstetricians and others as necessary. While the nature of the study made it impossible to measure a cause and effect, we believe the collaboration itself was an important factor in the improved outcomes for the women experiencing this care. This collaborative professional relationship was based on a clear understanding of roles and boundaries of practice, and a growing level of respect and trust that developed between midwives and obstetricians, which continues to the present day.
Well-functioning maternity units suggest the reasons for their successes are that they have well-defined roles and responsibilities between midwives and obstetricians, and there is a high level of trust and mutual respect between the professions (Howat & Scherman 2005). It seems evident that when trust between the professionals is low, the relationship between midwives and obstetricians is threatened by ‘turf war’—obstetricians then fear midwives will exclude them and midwives think they don’t need obstetricians (Howat & Scherman 2005). Neither of these polarised positions is helpful.
Trust is also about understanding where one another comes from and respecting why we each think and act the way we do. Midwives need to stop and think what it must be like to be an obstetrician who is faced with a situation where it is too late to help, and where they know that if there had been consultation or referral earlier, they could have made a difference. Similarly, midwives need to consider their own ‘distrust’ of obstetricians who perhaps do not always seem to respect women’s rights or try to facilitate normal birth. Until both parties are up-front in explicating the assumptions they carry into the relationship, then the assumptions will linger.
Theories on trust
It is important to examine the concept of trust as it applies to the development and maintenance of collaborative relationships in contemporary maternity care. There is a growing body of literature that assists in explaining why and how trust is an essential element of collaborative relationships and organisational effectiveness. Much of this is useful in gaining understanding of collaboration and leadership in midwifery and maternity care. Limerick and Cunnington’s (1993) work effectively highlights changes in the contemporary organisation and the increased emphasis on interpersonal skills and communication, particularly trust, in the workplace. Much social science literature has given attention to the concept of trust including psychology, sociology, political science, history and economics, each with its individual and different lens and approach. Various perspectives have emerged that propose different explanations and theories. There is very little literature, however, that attempts to integrate these different perspectives or articulate the role that different perspectives might play in critical social processes involving human interactions and relationships; for example, cooperation, coordination or collaboration in the provision of health care.
The social–psychological perspective emphasises the nature of trust in interpersonal transactions, which has relevance and applicability to this examination of how trust develops in collaborative relationships. Application of how trust develops in the context of romantic relationships as described by Boon and Holmes (1991) also allows extrapolation to inter-professional working relationships. This links appropriately with our earlier use of Schrage’s work when describing collaboration as being like romance that ‘embraces a continuum of interaction from the simple flirtation to a deep and abiding love, as well as every single possible permutation in between’ (Schrage 1990, p 46).
Trust in collaborative relationships has been cited as also being similar to romance in that it moves through three stages: the romantic love stage, the evaluative stage and the accommodative stage (Boon & Holmes 1991). According to these authors, in the romantic love stage, the parties experience a surge of positive feelings towards each other and at this stage love and trust are indistinguishable. As sustained contact continues, each of the parties will reveal imperfections and weaknesses that will require the other to step back and evaluate the relationship more broadly. During this phase, as the ‘pros and cons’ of the relationship are debated and the players learn to trust each other, these authors assert that this is when ‘real’ trust takes root. Finally, in the accommodative stage, negotiations of conflicting needs and expectations take place and the parties solidify the necessary trust to sustain the relationship (Boon & Holmes 1991). What is most useful in this description of romantic relationship building is the element of evolution, with the dynamics of building trust being different at each stage of its developmental processes. Trust takes on different characteristics according to what stage of its maturity has been reached. Clearly this is highly relevant to the gaining of an understanding of trust in the workplace generally, and in maternity care in particular. The dynamic and forever changing membership of health care teams and organisations presents a particular challenge to the creation of trust.
In professional business relationships, trust has been described as having three forms:
These descriptions are readily extrapolated to many clinical settings of maternity care. Traditionally, many midwives have experienced a sense of being trusted by other midwives, their supervisor or an obstetrician colleague through being credited with certain knowledge or behaviour that will be applied in particular situations. The predictability of clinical decision making based on an individual’s knowledge of practice and protocol, coupled with their presumed competence and ability, is, for the most part, assumed and expected and forms the basis of effective care of women. Trust is also an essential element for midwives to have between one another when working in group practices or in small teams. Without trust, the group practice will struggle as you cannot negotiate times, hours, the care of women and flexibility.
Knowledge-based trust in maternity care requires a level of familiarity and understanding of the other person and their capacity to perform in practice, which can only occur over time. The better people communicate and know each other the more accurately they will be able to predict what the other will do. Importantly, this predictability enhances trust, even if the person is predictably unreliable because the ways they can violate trust can be predicted (Boon & Holmes 1991). In midwifery continuity of care we know that trust takes time to develop and again needs commitment—team building days, social events, celebrations are strategies that can bring all the players together so they can develop an understanding of one another’s way of thinking and acting.
Identification-based trust involves both parties appreciating and understanding each other’s skills, values, actions and preferences such that each can effectively act for the other (Boon & Holmes 1991). Clearly this form of trust could emerge between two midwives or obstetricians who wish to represent each other or to substitute for each other in a clinical sense as in the case of a practice partnership. In mainstream contemporary clinical practice settings this is more applicable in regard to actual tasks or specific skills rather than complete roles, for example the midwife completing a clinical procedure that is more usually the domain of the obstetrician.
In any relationship, trust evolves and changes over time. Not all relationships develop fully and many professional relationships in health care services do not advance beyond a very preliminary and superficial perception of trust. Putnam (1993) has demonstrated that social capital is indispensable to the responsiveness and smooth functioning of civic institutions with low levels of interpersonal trust, correlating well with low levels of confidence in institutions. What emerges from this understanding of trust is that without it, relationships cannot develop. Without a relationship there is no possibility of collaboration. Critically, without collaborative trusting relationships the potential to improve health care and maternity care in particular is severely limited. This is important to grasp as we move ahead with introducing and embedding sustainable models of improved maternity care.
Conclusion
We have explored the reasons for collaboration and the essential elements to ensure that effective collaboration can actually work. We hope that some of the theories around collaboration and trust will be helpful as it is important to understand the ‘why’ as well as be able to apply the ‘how’. Mutual respect, flexibility and trust are essential parts of effective collaboration. In addition, teams have to be creative, open to change and prepared to listen as well as act in order to collaborate successfully.
The next chapter presents the story of the Women’s and Children’s Hospital in South Australia where a Midwifery Group Practice was designed and implemented in a tertiary setting.
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