Sub-theme: Defining Professional Boundaries

This theme focused on the importance of setting expectations with women from the beginning of contact to establish boundaries on work life for the midwives (Table 14). Expectation setting featured in nine of the studies and included the working practices of the midwives and when and how to contact midwives (Hunter et al. 2016; Newton et al. 2016; Gilkison et al. 2015; Browne et al. 2014; Edmondson and Walker 2014; McAra-Couper et al. 2014; Fereday and Oster 2010; Engel 2003). Expectations about contact included the reasons women should call midwives out of hours and the mode that they could contact them on. Setting of expectations around contact for women helped to protect the midwives work life balance. In one study the midwives discussed their decision to use pagers not phone to further control their work-life boundaries (Gilkison et al. 2015). Agreement of expectations with colleagues was also important for the midwives to maintain professional boundaries they set with women (Newton et al. 2016; Gilkison et al. 2015; Browne et al. 2014; Fereday and Oster 2010; Moore 2009; Engel 2003). This meant that women and their named midwife could trust they would be cared for by someone who shared the philosophy and structure of working.

Table 14: Thematic Framework for Strategies to Sustain: Counting the Personal Costs

STUDY NO.

STUDY AUTHOR THEME THEME DESCRIPTION SUPPORTING EVIDENCE

1 BROWNE ET AL. Into the future Continuity experience for student midwives was perceived as contributing to the development of midwives who were woman rather than institution- centred; a positive attribute regardless of the future workplace setting of the midwife.

…my understanding is that, there is a lot of interest in continuity models and that they’re actively trying to promote those…they’ve got that experience, they’re got that in their head as, as I guess the ideal form of midwifery, and so when you want to resource those, you will get a whole bunch of girls who then say ‘yes that’s the model I want to work in’. (p577)

4 DONALD ET AL. Changing

assumptions about commitments

The second theme showed that for successful change to occur the midwife needed to gain awareness of her own needs and change assumptions surrounding her commitments to the woman and herself.

We actually need to say, no, I’m looking after myself, or no, I’m being a mum today. And there’s nothing wrong with that. (p125)

You might be very involved with people, but don’t forget you’re not indispensable and you can’t be everything to everybody all the time. (p132)

5 EDMONDSON AND WALKER

Good work-life balance: Setting Boundaries

Participants set boundaries with the women, themselves and their midwifery partners in order to establish and maintain work–life balance. Through the establishment of these boundaries participants had a break from work and did not feel guilty for not being available for the women.

. . .let your women know as well that there are times that you might not be available. (p34)

6 ENGEL Setting boundaries on practice

Setting boundaries with woman was important to maintain work life balance for the midwives. This differed between midwives according to the way they liked to work and their philosophy but had to be shared between colleagues working together.

I am sorry but I do that type of care within regular hours. (p14)

…the women don’t mind. I have explained it to them beforehand, I make it clear. (p14)

7 FEREDAY AND OSTER

Establishing realistic expectations with women

It was important that boundaries were set with women to ensure the midwives maintained a balance between work and life. Flexibility for these midwives was interpreted as needing to be of benefit for their own lives, as well as offering an individualised service for women.

But we don’t promise anything that we’re not prepared to give and recognise that we may have a little bit less continuity [with women] but that we really need that balance between our personal life and working life. (p315)

8 GILKISON ET AL. Sharing arrangements with women

The sharing of practice arrangements with women helped the sustainability of the model. The sharing of these practice arrangements of colleagues

underpinned the concept of partnership.

…we offer information about the practice

philosophy, how we work, the back-up midwife, the time off… (p13)

10 HUNTER ET AL. Negotiating boundaries

For the midwives to remain generous of spirit, certain strategies are required to support and sustain this quality. These strategies appear to be around negotiating and maintaining professional boundaries that support generosity of spirit, and invariably come as an evolution of practice.

After 10 years of feeling guilty for everything that I didn’t do and every text that I told off or every phone call that I didn’t answer….[then] that guilt actually went away…when I made my boundaries clear to me… (p53).

12 MACARA-COUPER ET AL.

Negotiating and keeping boundaries

An important part of the reciprocity of the

partnership is about negotiating boundaries with the women. This underpins the concept of partnership, sustaining the midwives and the model.

As long as you tell the women when you book them, ‘this is how I work…

these are my boundaries. This is when I work’. (p30)

15 NEWTON ET AL. A different way of working:

Working on call

Over time, caseload midwives also became more protective of their off duty time as a component of self-care.

…if its urgent ring me, anytime. But if it can wait ‘til morning just ring in business hours only. (p227).

A different way of working:

Avoiding burnout

This study did not find any increase in burnout for the caseloading midwives however there was an increased sense of awareness and understanding that there needed to be personal and group strategies in place to avoid this.

So I think a lot of midwives who’ve left blamed the model, that it has not worked, that its not fun, but it might be more about how you handle it. (p227)