Sometimes when you start a research project you have a fair sense of what you will find. With ethnographic research, there is the possibility that you will stumble across something that will take you quite by surprise. Today’s post is about something that was a real revelation to me that came to light in my doctoral research. The paper that I wrote about it with my co-authors Associate Professor Mary Sidebotham, Professor Jennifer Fenwick, and Professor Emeritus Jenny Gamble had just been published and I’m pleased to be able to share what I learned with you all at last (Small et al., 2021).
As a clinician I have been surrounded by professional guidelines – I read them, teach about them, undertake clinical care in relation to the recommendations in them, am held to account by what is in them, and have been involved in writing them. Learning about Institutional Ethnography gave me new ways to look at guidelines that generated some major AHA! Moments along the way. One of those ways involves putting people back into the picture.
What do I mean by putting people back?
Institutional Ethnography reminds us that work is done by actual people, in their bodies, in a particular time and place. When we generate official documents about the work that people do, much of this information is stripped out. Putting the hidden information back in can reveal insights about what is really going on. In the paper, I looked at three examples, here I will focus on just the first one of these: escalation of care.
Escalation of care refers to the practice of asking someone else to be involved in the delivery of care. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) fetal surveillance guideline (RRANZCOG, 2014) says
In clinical situations where the fetal heart rate pattern is considered abnormal, immediate management should include escalation of care if necessary to a more experienced practitioner.p. 17
Who is it that would be the person who is doing the work of escalating care? There is a clue in the wording of the recommendation that the guideline writers consider that this is not a task for the “more experienced practitioner” to whom care is to be escalated. As a senior obstetrician, it is clear to me that this recommendation was not written for me. Knowing what I know about the roles taken by other people who work in the birth environment, the role of escalating care primarily is the responsibility of a midwife (at least it is here in Australia where the research was conducted).
When you put people back, assumptions become visible
It is interesting that the guideline writers chose the specific language that they did in writing this recommendation. I have no way of knowing whether this was a conscious choice or reflects habitual use of language that is typical in obstetric discourse. The recommendation shows the assumption that midwifery experience is different to obstetric experience, with obstetricians remaining the “more experienced practitioner” at all times. A very experienced senior midwife would be expected to escalate care to a junior consultant obstetrician (who had less experience of working with women having CTG monitoring) if that obstetrician were the person who was on call for the birth suite that day.
What is required for quality care is that a person whose scope of practice includes tasks such as fetal blood sampling and operative birth (obstetric tasks) should become involved when the CTG is considered abnormal. Escalation of care here is about expanding the skill set of the care team. The experience required is different in nature, rather than in amount – something the guideline doesn’t accurately capture. This seems to imply that the guideline writers consider midwives to perpetually be less experienced “obstetricians” rather than members of a complementary profession.
Two other recommendations about escalation of care were also relevant to practice at the hospital. The first came from the state guideline about fetal monitoring, saying:
Follow local escalation procedures to senior midwifery and obstetric staff when CTG abnormalQueensland Health, 2017, p. 26
The other was from a “work instruction” which mandated practice for staff at the hospital, and stated:
Consultation with senior midwife or medical officer is required when fetal heart rate or CTG is interpreted as abnormal.p. 1
Note that in both of these the person doing the escalation has no discretion to first determine whether it was necessary, unlike what was written in the RANZCOG guideline. Here it becomes clear that midwives must escalate care when the CTG was abnormal, irrespective of whether it was clinically appropriate. The baby may have been in the process of being born, or the woman may have had another pressing need for care that should be prioritised over the CTG, but the removal of the power to decide whether to escalate care or not put midwives in a very difficult position. They could prioritise good care, or follow the mandatory guideline.
One way the “midwives must” effect played out at the hospital, which had a central fetal monitoring system, was that these guidelines justified disrupting midwives’ work. Midwives were sometimes unable to adequately assess what was causing the CTG to be abnormal and take actions aimed at restoring the CTG to normal as they were interrupted by a senior midwife or a member of the obstetric team coming to the room as they had seen the abnormal CTG outside the room. The guidelines made it logical for someone viewing the CTG to assume that their interpretation of the CTG as abnormal was correct, and that if the midwife had not yet escalated care, then they should have done so and therefore going to the room to find out why that had not happened was the professionally appropriate action. The midwife then needed to prioritise communicating with this new person on top of the work they were already doing to try to address what was causing the issue with the fetal heart rate pattern.
As a senior obstetrician who is the one on the other end of the escalation process, I was interested to reread the guidelines through the lens of Institutional Ethnography and to ask what they required of me and other senior obstetricians relating to the process of escalating care. It is important to note that escalating care is an inherently social process. It requires more than one person (the one escalating and the one being escalated to) and each requires knowledge about what is required by both parties to successfully complete this process. As we have seen, the guidelines are clear about midwives’ roles in initiating the process.
Completely absent from the guideline is any description of what my role as a senior obstetrician should be. There are no recommendations, and certainly no mandatory requirements, in these same three documents which set out the responsibilities of the “more experienced practitioner” within the escalation process. What response is required? What is the time frame for that response? What are the expectations about clinical documentation and communication with the care team and the woman? It would appear that obstetricians may do what they want in relation to escalation of care.
Most midwives will during their career experience at least one occasion where they have difficulty in getting a senior obstetrician to respond in an appropriate way when they escalate care. There is a large body of research which links poor perinatal outcomes to delays in appropriate responses to abnormalities of the fetal heart rate seen in CTG monitoring. It appears that the guideline writers have assumed that the problem lies with asking for escalation, rather than with the response to this request. The guidelines offer no means of ensuring the accountability of senior obstetricians in the escalation process.
Rewriting the guidelines
The importance of well-structured guidelines that clearly set out who is doing what became clear to me in conducting this research. Given that there are hierarchies of guidelines, with national guidelines standardising care across one or more countries and other guidelines intended for use within a local context, slightly different approaches are needed depending on the intended audience for the guideline. National guidelines are best developed by ensuring the active participation of representatives of the people that the guideline will impact: in this instance midwives, obstetricians, and birthing women.
Historically it has been common for one group to write the guideline and invite a selected representative from other groups to comment on the draft. This was the case for the RANZCOG guideline. Co-leadership of guideline development is a more challenging process but will generate robust guidelines that are more likely to generate a positive impact on healthcare outcomes. All professions should be equally accountable for their conduct if the guideline is well designed.
At local level, it is important that guideline writers critically reflect on the assumptions built into the wording of the relevant national guideline and ask whether this is a good fit for the values of their organisation. Local guidelines could explicitly replace people doing the work back into the guidelines and ensure that there are clear expectations for all professionals involved in the complex social task of providing teamwork in maternity care.
Queensland Health. (2017). Maternity and neonatal clinical guideline: Intrapartum fetal surveillance. https://www.health.qld.gov.au/qcg/publications
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2014). Intrapartum Fetal Surveillance. https://www.ranzcog.edu.au/intrapartum-fetal-surveillance-clinical-guidelines.html
(Note that there are more recent versions of each of these guidelines – they were analysed as they were current at the time of data collection.)
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2021). Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.05.001