Caring for women: the potential
contribution of formal theory to
midwifery practice
Vivien Woodward
Objective: to explore the interpretations midwives and nurses attach to the concept of
caring, how caring values are manifest clinically and might be encouraged educationally.
Design: ethnographic ¢eldwork was undertaken in UK National Health Service palliative
and maternity-care hospital settings for 12 and 10 days respectively.This involved nonparticipant observation, semi-structured, audio-taped interviews with seven midwives
and six nurses. Ad hoc conversations with service-users were also undertaken and
contextual information, such as sta¤ng levels, was collected.The data were thematically
analysed against a conceptualisation of caring developed from nursing and philosophical
literature.
Findings: comparison of observational and interview data across the settings identi¢ed
qualitative di¡erences in care delivery. In the palliative care setting, practice was othercentred, receptive, responsive and attentive to the patient's person and experience. In
comparison, caring values appeared eroded in the maternity setting, where practice was
often routinised, task-orientated and, on occasions, unresponsive to women's needs.
Features existed in the palliative care setting which appeared instrumental in facilitating a
caring practice culture. In particular, clinical leaders facilitated team cohesion through daily
`debrief' meetings and care enhancement against theoretical frameworks.These
encompassed caring values and provided the source of problem identi¢cation and remedial
strategy.No such collective, theoretical perspectives were evident in the maternity setting.
Discussion and implications for practice: whilst acknowledging the limitations of formal
theory, it is suggested that midwifery goals and priorities of care could be utilised to
theoretically frame, critically evaluate and guide practice.This has the potential to
heighten awareness of care de¢cits and enable midwives to work collectively to
enhance women's experience of childbirth at both clinical and political levels.
& 2000 Harcourt Publishers Ltd
INTRODUCTION
Vivien Woodward
MSc, PhD, RM, PGCEA,
Senior Research Fellow,
Midwifery Education,
School of Educational
Studies,
University of Surrey,
Guildford,
Surrey GU2 5XH, UK.
E-mail:
[email protected]
Received 2 February 1999
Revised 4 April 1999
Accepted 24 June 1999
Midwives frequently use the phrase `with woman' to symbolise their role in safeguarding
childbirth as a uniquely self-ful®lling and empowering experience (e.g. Bryar 1995, Page
1995). Indeed, authors emphasise that women
may look to midwives as their advocates in an
increasingly medicalised maternity-care context
(Kitzinger 1988). It is, therefore, paramount that
midwives maintain a caring, woman-centred
identity, in order that childbearing is not
routinely and irreversibly reduced to a medically
Midwifery (2000) 16, 68 ^75 & 2000 Harcourt Publishers Ltd
doi:10.1054/midw.1999.0198, available online at http://www.idealibrary.com on
dominated intervention. The challenge this poses
for midwives is immense. For example, their
autonomy and authority are constrained by low
organisational status, which leaves them powerless to advocate for women when faced with
government, medical or management agendae
which threaten the quality of care provision. The
many examples include sta€ shortages, bed
closures and technology that is made policy
despite research evidence (Goer 1995). Additionally, reports have ensured that childbirth has
become institutionalised (Ministry of Health
1959, Central Health Services Council Standing
Formal theory in midwifery care for women
Maternity and Midwifery Advisory Committee
1970, House Of Commons Social Services
Committee 1980) and this involves the inherent
tendency for activity to become habitualised,
standardised (Berger & Luckmann 1966) and
presumptive (Jarvis 1995). Institutionalisation
relies upon shared knowledge, values and activity
which provide boundaries for what constitutes
acceptable practice and practice imperatives.
According to Bourdieu (1990), `the unconscious'
nature of practice `makes questions of intention
super¯uous...' (p. 58), indicating an absence of
conscious re¯ection and uncritical performance
of role and practice behaviours (Kestenbaum
1982). Additionally, the original values and
meanings of activity become taken-for-granted
and subordinated by ritual and custom (Berger &
Luckmann 1966). As a result, the taken-forgranted understandings and values embedded in
daily practice, establish and perpetuate the work
culture and care ethos. In consequence, it is
crucial that these are critically scrutinised, in
order to ensure that care ful®ls women's hopes
and expectations, and the profession's aims.
Bryar (1995) suggests that:
The quality of the thinking that midwives
undertake will have a direct e€ect on their
actions, their care of the woman, her family and
the community (p. 6).
On this note, authors suggest that theory can be
utilised to guide and eradicate non-re¯ective
practice (Brook®eld 1992, Usher et al. 1997),
yet it appears that, traditionally, midwives reject
this potential contribution of theoretical frameworks (Mander 1992, Bryar 1995). Views that
theory is incompatible with intuitive practice,
empathy and spontaneity are also reported
(Kitzinger 1988, Bryar 1995). The study ®ndings
reported in this paper con®rm that some midwives view theoretical models unfavourably. In
order to contest such a perspective, arguments
which support the theoretical framing of practice
are o€ered. The implications for education are
outlined. For the purposes of the paper, the
terms, models of care, formal theory and
theoretical frameworks are used synonymously.
METHODS
Based on the concern that professional, educational and government policies emphasise the
instrumental elements of care, the overarching
research aims of the study were to explore the
interpretations and values that midwives and
nurses attach to the concept of caring, and how
these are manifest clinically and might be
enhanced educationally (Woodward 1998). In
this paper the potential contribution of formal
69
theory to practice, which emerged as a signi®cant
theme, is examined.
An ethnographic design, was adopted. This is
used to study cultural groups (Morse & Field
1996) and assumes that culture is a determinant
of behaviour and experience (Polit & Hungler
1995). Between November 1996 and July 1997
®eldwork was undertaken consecutively within a
National Health Service palliative care hospice
and maternity ward providing care for women
antenatally and following childbirth. In studying
any phenomenon, it is necessary to ®rstly
identify the situations in which it is most likely
to occur (Rosenfeld 1982). Palliative care is
regarded as having developed expertise in caring
(Samarel 1989) and was, therefore, considered an
ideal setting for the research. While midwifery
and palliative care may appear diverse contexts,
they both involve intense emotional, spiritual
and social elements which necessitate a practitioner's caring awareness and responsiveness.
Also, despite the uniqueness of the two settings,
nurses and midwives are equally responding to
implement principles such as family centredness,
partnership in care, client/patient choice and
autonomy encompassed within current government policy (DoH 1991, 1993).
The study involved a multi-method design,
comprising non-participant observation and
semi-structured, audio-taped interviews. The
use of two data-generation methods both enhanced validity and enriched the data. For
example, personal knowing in practice may be
tacit and dicult to articulate (Polanyi 1958) and
observation therefore provided insights which
interviews could not. In terms of rigour, articulated values and practice may be at odds (Schon
1987), and observation was used to con®rm that
espoused values were manifest in reality. Interviews provided opportunity to explore practitioners' values and understandings of practice,
and to clarify and con®rm researcher interpretations
Twelve observational visits were undertaken in
the palliative care hospice and ten in the
maternity ward, during a period of six weeks
each, and lasted approximately six hours on each
occasion. Similar processes were undertaken in
both settings. Trust and acceptance by the sta€
are central to maximising the quality and
quantity of data generated (Mason 1996), and
the initial three days in both settings were used to
develop this and to become familiar with the
language, behaviours, organisation and structure
of the team. They also served as a pilot study in
deciding how observations and note taking
would best be managed. On each visit, observations were made from a vantage point within a
®ve or six bedded bay, which was selected on a
daily basis in negotiation with the sta€. Concurrent notes were made detailing qualitative
70 Midwifery
aspects of sta€ and client activity, and interactions and contextual in¯uences, such as pressure
of work, which a€ected care giving. Data
collected involved between six and eight clients
on each occasion, and any sta€ who entered the
observation area. Observation at the bedside and
of intimate care was kept to a minimum in order
to reduce intrusion and to maintain client
dignity.
Semi-structured, audio-taped interviews were
undertaken during the ®nal observation week in
each of the settings. These involved a convenience sample of six nurses and seven midwives.
Nurses and midwives who were involved most
frequently in observation were invited to participate. Open-ended questions explored midwives'
and nurses' work biography and perceptions,
understandings and experiences of caring for
clients and patients. Opportunistic conversations
with clients and patients regarding their experiences of care received were undertaken and
written up afterwards.
Ethical considerations included informed consent, voluntary participation by clients, patients,
midwives and nurses, and the assurance of
anonymity and con®dentiality. Information
sheets for individual distribution were prepared
for this purpose and assurances were orally
reiterated. Approval to undertake the research
was obtained from the Local Research Ethics
Committee, and access to the settings was
negotiated with the head of midwifery, the
clinical area manager, in the case of the
maternity setting, and the nurse manager and
consultant in the palliative care hospice.
The length of time in the ®eld was determined
by a variety of factors including the available
time frame in which to undertake the study, but
primarily the decline in the number of new
patterns of activity observed which related to the
research aims.
Following data collection, transcription and
immersion in the ®ndings, data were analysed
using thematic analysis and identi®cation of
categories as described by Morse and Field
(1996). Analysis was undertaken both against
the research conceptual framework and independently to enable previously unidenti®ed factors
to emerge. Interview and observational data
relating to individual practitioners were triangulated in order to validate information and to
achieve deeper insights in relation to the research
aims.
FINDINGS
Only ®ndings pertinent to the aims of this paper
are presented and readers are referred to the full
study for further details (Woodward 1998).
Nurses and midwives who were observed and
who participated in interviews were all established members of the care team and experienced
in the ®eld of practice. Senior nurses and
midwives, who were in a position to act as
clinical leaders, were included in the sample, as
they potentially provide the greatest in¯uence on
the practice culture. In terms of organisation and
ethos of the two settings, there were strong
contrasts. The palliative care setting experienced
relatively favourable sta€-to-patient ratios,
although the nature of the work was extremely
emotionally and physically demanding. During
the days on which observation was undertaken
there were, on average, eleven patients cared for
by three quali®ed nurses and two or three
nursing assistants in the palliative-care setting.
In comparison, the maternity ward stang
comprised two or three midwives, two nursing
assistants and a ward clerk who cared for, on
average, seven antenatal women and 11 postnatal mothers and their respective babies.
Activity in the maternity setting was increased
by the frequent admission of women either from
home or the delivery unit, and transfer of women
to the care of the community midwife. Patients
stayed in the hospice for an average of 10 days,
compared to women who remained in the
maternity ward from between six hours and four
days. The nurses enjoyed good interdisciplinary
relationships with medical sta€ and relative
autonomy. In contrast, tensions were sometimes
apparent between midwives and doctors who
constrained midwives' scope of practice, for
example, with regard to the transfer of women
home.
There was a strong service orientation in the
palliative care and nurse±patient interactions
were mutually supportive. During interviews,
the palliative-care nurses constantly expressed
concern for the patient's experience, which
correlated with their care practices observed
during ®eld work. The nurses strove to maintain
caring principles and ideals encompassed within
a theoretical framework, which provided focus
and direction. While the nurses' work was
demanding, the work culture enabled good selfesteem and energy to develop group cohesion,
legitimated nurses' internalised values and consequently endowed practice with personal meaning. No such collective, theoretical perspective
was evident in the maternity setting and in
comparison, although there were examples of
caring, activity often appeared task-orientated
and, on occasions, unresponsive to women's
needs. Data exemplify situations in which some
midwives failed to respond to women's signals of
discomfort, vulnerability or need. For example,
data suggest missed cues of pain while performing postnatal examinations, undetected fear prior
to elective caesarean section and women were
Formal theory in midwifery care for women
sometimes ignored at the midwives' station while
midwives chatted together. Women/parents appeared to have an `at-home' orientation. For
example, partners lay on beds and freely accessed
ward resources, such as items for the baby and
¯ower vases. On several occasions, antagonism
towards midwives was observed.
The qualitative di€erences across the two
research settings exemplify how practitioners
can shape their sphere of practice and provoked
an exploration of in¯uential features. The role of
theory in unifying and guiding practice appeared
instrumental. Research data are now presented
which demonstrate di€erences between the two
settings regarding the perceived bene®ts of
theoretical frameworks. During the interview
extract below, the nurse has just identi®ed that
building patient con®dence and optimising independence within the patient's capabilities are
elements of what caring means to her:
VW: Does that tie in with what you're trying to
achieve in your day-to-day interactions with
patients?
Nurse C: Well, obviously it ties in with the nursing
models that we're using and our philosophy of care
and what we try to achieve in those. We've done a
lot of work on those (The Burford and O'Berle, and
Davies models).
VW: What are the elements in particular?
Nurse C: It's looking at the patient's perceptions of
what's needed and also trying to trying to avoid us
making judgements, like this person has got pain
therefore they must want tablets for it. Not
assuming that the patient wants a wash everyday;
that may not be what they normally do. I think
there's in-bred in nursing, a tiny element that says
`we must `do' the patients'. I think, certainly within
nursing sta€ it varies as to how much they really
think about what we're doing and what we're doing
here.
The Burford model advocates the importance of
the nurse±patient relationship and places emphasis on the patient's experience, the therapeutic use of self and being totally present for the
person, the validation of the patient's experience
and identi®cation of de®cits intuitively and
through `subjective feeling' (Kitson 1993, p.
35). The O'Berle and Davies (1990) model
combines the following principles: valuing, connecting, empowering, doing for, ®nding meaning
and preserving the nurse's own integrity. The
in¯uence of these models was exempli®ed by a
nurse who had worked in the unit for eighteen
months and explained to me how her values
had been transformed from a task-completion
exercise to an individual-patient orientation.
While there is insucient space for the many
examples, interview data provided ample evidence of nurses' vocal legitimation of the
encompassed values, and observational data
71
strongly supported the interpretation that these
values were internalised and manifest in practice.
In contrast to the use of models and philosophy of care in the palliative care setting, an
interview with one midwife re¯ects Bryar's
(1995) assertion, mentioned earlier, that models
may well be rejected and perceived as having
little usefulness in practice (Ford & Walsh 1994):
VW: Are there any other values that you can
identify that you incorporate into your care, or any
aspect of models that you have worked with or
important aspects that are important to you?
Midwife O: I know in nursing they're always
talking about models and stu€ and I don't know
if they're good, bad or indi€erent. I sometimes hate
things like that because they're so rigid and you
don't think about the actual person, you just think
about ful®lling the model or the criteria and I don't
know if I actually agree with that.
When asked about their understandings of
caring, midwives referred to meeting emotional
and physical needs, which may derive from
Henderson's need-based model (Wesley 1995),
possibly encountered during nursing socialisation. Despite the focus on Changing Childbirth
(DoH 1993) for the past ®ve years, there was
little evidence that the principles it encompasses
were used as a framework to direct and evaluate
day-to-day practice. The view that theoretical
frameworks have little to o€er midwifery practice is indicated by a senior midwife in the
following extract:
VW: Are you familiar with any particular models
of caring?
Midwife H: Yes, Orem's is the nearest that, as
midwives, we would apply, there is no real
midwifery model of care designed. I think it
would be very dicult, the subject is so diverse.
VW: So from Orem's, do you think there is any
in¯uence at all on your caring from that model?
Midwife H: I don't know, you read about these
things and you don't know if you're doing it
without your knowledge, but it's not a conscious
way of practising, by someone's model, you just do
it, because that's what you do as a midwife, you
know, it just comes naturally to do it like that,
whether it's somebody's model or not.
It is suggested that the identi®cation of the
underlying goals of practice is essential not only
to provide direction, but also to enable representation of the midwifery profession's contribution to fellow members of the multi-disciplinary
health care team. Arguably this best provides the
necessary foundations for a trusting and equal
working partnership and the basis to promote
the quality of women's experience. The following
extract indicates a midwife's resignation that the
development of care relationships is not valued
by the doctors and is subordinated accordingly.
She describes her care of a woman requiring
72 Midwifery
close monitoring due to serious pregnancy
complications:
Midwife D: I think you can lose sight, I have done,
I must admit. You lose sight of the fact that women
can be just as frightened as anyone else, about
what's happened to her, but most of the time, when
they're on the protocol (for pre-eclampsia), you
come away from a shift thinking, well, I've met her
physical needs perfectly and I've done all her obs.
and then you wonder, you know, about all the
things you didn't do, you never did have a chance
to talk to her about how she feels about the delivery
or anything really. The thing is, going back to the
protocol, it doesn't carry any weight with the
doctors, is the other thing. If you wrote in the
notes, have not done Mrs X's observations for the
last hour because we've been chatting, that carries
no weight at all and to the medical sta€ that's not
important, they would want to know, why hasn't
her blood pressure been done ?
The data suggest that midwives failed to
critically examine and actively shape practice in
other ways. For example, the expectations and
care of women following caesarean section
di€ered little from women following normal
delivery. For example, midwives failed to ensure
that women had a drink of water to accompany
medication or to o€er assistance with baby care.
One possible interpretation is that the theoretical
discourse that emphasises childbirth as a physiological event and rejection of a nursing model
of care may inhibit midwives' perceptions of
women's experiences of fear and vulnerability.
In the palliative-care setting, senior nurses
utilised models of care to challenge the traditional structures of practice and to provide
positive role-modelling and philosophical and
professional direction for other sta€ members.
This was facilitated by daily `debrief' meetings
which provided a forum for nurses to evaluate
practice against their theoretical frameworks,
problem-solve diculties which posed a threat to
the provision of their vision of optimum care,
and for the group to renew motivation and
allegiance to caring values.
In summary, there were stark di€erences
across the two research settings in terms of
how midwives and nurses conceptualised and
shaped their practice and the use of theoretical
frameworks appeared in¯uential.
DISCUSSION
Limitations of the study
Due to the small numbers of participants
involved, qualitative research may be perceived
as less creditable than quantitative approaches in
terms of generalisability, reliability and validity.
Even so, Hakim (1987) argues that qualitative
approaches achieve greater internal validity,
since there is sucient detail obtained from
participants to ensure that accounts and views
are as complete and comprehensive as possible.
It is acknowledged that the researcher's preunderstandings in¯uence interpretation of qualitative data (Brannen 1992) and this potential
source of bias was addressed by constantly
seeking out alternative perspectives. Reassurance
regarding the interpretations of the data were
provided by the research settings themselves. In
keeping with an agreement when negotiating
access, the sites were visited following completion of the study. In both cases, interpretations
appeared to mirror their own perceptions of
what was occurring in the units.
Women's short length of stay and the rapid
turnover in the maternity setting undoubtedly
presented a major challenge to the achievement
of individualised, woman-centred care. Certainly, pressure of work, due to chronic sta€
shortages appeared to be a factor which led to
routinisation of care and defeated midwives'
energies and motivations to appraise and develop practice. Nonetheless, while time is crucial, it
is argued that without identi®cation and internalisation of professional goals, activity may
become, random, routinised and non-re¯ective.
It is argued that the adoption of a framework for
practice not only increases the salience of quality
issues for the individual midwife, but also
potentially facilitates the professional cohesion
necessary to have greater in¯uence over practice
and to increase powers of advocacy in the wider
political arena. Whilst this paper recognises the
value of personal, practice knowledge (informal
theory), it is suggested that a combination of
formal and informal theory provide the optimum
foundation for professional practice.
The dichotomy between formal and
informal theory
The contemporary dichotomy between formal
and informal theory as a basis for practice is
acknowledged and, indeed, it is important to
understand the limitations and potential disadvantages as well as the bene®ts of theoretical
frameworks. While acknowledging that models
of care can o€er an ideal representation of an
approach to practice (Ford & Walsh 1994), there
can be no one universal theory that ®ts all
situations (Levine 1995). Ford and Walsh (1994)
also argue that rigid implementation of models
can inhibit practice unless they are adapted or
developed by sta€ in the light of real experience.
Currently, the limitations of formal theory to
guide practice are being debated and there is a
focus on personal tacit and practical knowledge
popularised in particular by Schon (1983) and
Benner (1984). Schon (1983) challenges the
`technical-rationality' model of professional
practice, on the basis that formal theory (such
Formal theory in midwifery care for women
as theoretical frameworks) alone is insucient to
support professional practice. Schon (1997)
maintains that theory fails to satisfy `the rigour
of relevance' (p. 13), by which he suggests that
theories have limited capacity to solve the
complex problems within professional practice.
Additionally, solutions to practice problems may
be ine€ective if situations are made to ®t into
categories of a theoretical framework and
practitioners may be desensitised to information
which does not ®t the theory. For example,
midwives' failure to anticipate women's discomfort following caesarean section, mentioned earlier, may be a result of the theoretical position
which rejects women's sick role behaviours.
Schon's (1983) perspective places emphasis on
the nature of knowledge that professionals utilise
in practice. Instead of what is learned theoretically, Schon (1983) focuses on what he terms
`re¯ection-on-action', as a means to uncover the
`knowing in action'. This knowledge involves a
tacit understanding of the speci®cs and involves
practical knowledge based on a learned repertoire of actions derived through previous experience. Mander (1992) reports that midwives
attached:
73
ends and values today or tomorrow (Usher et al.
1997). While Schon (1983) identi®es the mis®t
between theory and practice, arguably, practical
knowledge also has to evolve in order to
®nd ways to incorporate new principles. Moreover, a clear sense of professional goals enables a
critical evaluation of imposed change and the
necessary basis on which to challenge detrimental policy.
The role of theory in enhancing practice
Importantly, meanings and understandings of
practice shape the consciousness of practitioners
about the nature and signi®cance of their work
(Brook®eld 1992). While Schon (1983) refers to
the potential problems of formal theory, he
identi®es the bene®ts of utilising theory to guide
practice. As he states:
An overarching theory does not give a rule that can
be applied to predict or control a particular event,
but it supplies language from which to construct
particular descriptions and themes from which to
develop particular interpretations (Schon 1983,
p. 273).
Schon also suggests:
...considerable importance to learning by their
experience ... It is their occupational experience
(author's emphasis) which teaches them most about
the care they consider they should be providing
(Mander 1992, p. 13).
...each individual develops his own way of framing
his role. ...the problem he sets, the strategies he
employs, the facts he treats as relevant, and his
interpersonal theories of action are bound up with
his way of framing his role (Schon 1983, p. 210).
In the extract presented earlier, midwife H's
statement, `... you just do it, because that's what
you do as a midwife.' indicates reliance upon
personal, informal theory as a basis for practice
and the view that formal theory is often perceived as `remote, irrelevant and useless' (Usher
et al. 1997, p. 123). The extract also exempli®es
the potential for practice to become taken-forgranted, routinised and non-re¯ective, as mentioned in the introduction and, in consequence, a
deeper understanding of care may not be sought.
If taken to its furthest conclusion, reliance on
informal theory mirrors the situation when nurses and midwives knew how, but not why tasks
and procedures were undertaken and which initiated e€orts to produce the `knowledgeable
doer' via Project 2000 programmes (UKCC
1987). A further limitation of informal knowledge derives from the need to respond to rapid
changes in practice provoked by government
policy, such as The Patient's Charter (DoH 1991)
and the Changing Childbirth report (DoH 1993).
Practice is continuously evolving and professionals are called upon to incorporate principles
of care, such as empowering women and working
in partnership (DoH 1993), for which they have
accumulated limited practical experience. Accordingly, practical knowledge which worked successfully yesterday may not necessarily realise the
Accordingly, if caring values are internalised,
patient distress and vulnerability will be salient
and will motivate remedial agency. However,
alternative practice goals, such as getting the
work done, perfecting instrumental technique, or
negating sick role behaviours, as mentioned
earlier, will highlight di€erent elements. Application of theoretical frameworks facilitates learning in practice by enabling re¯ection and
evaluation against practice ideals. Despite Mander's (1992) ®ndings alluded to earlier, that
midwives prize learning from experience, it is
important to be aware that experience does not
necessarily lead to learning. In Jarvis' (1995)
model of experiential learning, the source of
learning is created when there is `disjuncture'
between an individual's values and understandings and experience. This creates problematic
situations where existing knowledge fails to
explain perceptions, and there is a quest for
meaning and understanding which results in
transformation and learning. An individual's
knowledge, understanding, values and attitudes,
therefore, determine whether experience acts as a
source of learning or constitutes non-re¯ective,
presumptive and static practice.
The scenario depicted in the ®nal extract in
which midwife D focuses on instrumental care
exempli®es this point. While not advocating that
74 Midwifery
the monitoring of the woman's physical wellbeing should have been delayed, the perceived
requirement, at least verbally, to placate obstetricians, misplaces women's trust in midwives as
their advocates. The extract represents the failure
of midwives to determine their own practice and
internalisation of a medical model of care.
Belenky et al. (1986) indicate that women may
devalue their own authority to know, in favour
of external authority ®gures and Hart (1991)
notes that carers undermine knowledge not
valued by the scienti®c community. It appears
crucial that midwives articulate midwifery priorities of care and ensure that these become
embedded in practice and the work culture. It is
suggested that if midwives in the research setting
had a clearly constructed framework which
prioritised woman-centredness, any threats to
this aim would create disjuncture and stimulate
problem-solving and strategic planning. Arguably, critical re¯ection of practice framed against
a theoretical framework which encompasses
woman-centred principles, could be transformative.
Building a collective vision
In the palliative care setting, data suggest that
the theoretical framework facilitated development of a work culture in which the encompassed values and goals achieved in¯uence and
¯ourished. Based on Benner's (1984) novice-toexpert model, Ford and Walsh (1994) suggest
that more experienced practitioners are less likely
to base care on models. This latter assertion was
not supported by the research data, since it was
the clinical leaders who commitedly shaped a
work culture which gave the conceptual frameworks value, meaning and in¯uence. Dennis
(1998) found that the development of a shared
model of practice appeared to result in a more
cohesive and con®dent team, with a clearer
direction of practice. A possible explanation
may be that frameworks provide the necessary
language for social and intellectual interactions
(Mead 1934) and facilitate a sense of `we-ness'
with others (Belenky et al. 1986, p. 26±27) or
`Sisterhood' (Kitzinger 1988, p. 2).
In the maternity setting, there was no focused
opportunity to collectively discuss practice.
Arguably, the lack of a collective approach to
practice may derive from the individualistic
emphasis that midwives are independent practitioners in their own right (Tower & Bramall
1986). If this is the case, lack of cohesion also has
negative implications for clinical leadership
which will be ine€ective where there is lack of
unity regarding central practice goals. It is
argued that theoretical frameworks and group
re¯ection are a means to achieve collective and
cohesive midwifery practice, and the ability to
clearly articulate the profession's goals and
contribution to health. With such a voice and
vision, midwives would be empowered to in¯uence policy and achieve being `for' as well as
`with' women.
Educational implications
While strategies for the organisation of care
provision, such as teams and case loads, appear
amply addressed, data support Bryar's (1995)
concern that there is inadequate examination of
the nature of the care provided. It is suggested
that lecturers situated in higher education
institutions, lecturer-practitioners and clinical
leaders, including supervisors of midwives, need
to unite in order to create a work culture in
which theoretical frameworks are used to critically evaluate and enhance practice. It is
necessary to introduce to student and quali®ed
midwives both the bene®ts and limitations of
utilising formal theory to inform and develop
practice. Educators might facilitate an appreciation of the possible, multiple perspectives with
which to frame practice and make visible the
numerous ways in which practice can be developed for the bene®t of women and families. For
example, theory may comprise the underlying
knowledge base for clinical procedures and skills,
it may assist empathetic visualisation of a
woman's or family's experience or encompass
fundamental moral values and principles to be
upheld in practice. In addition to knowledge,
re¯ection can focus upon feelings, values, attitudes and action aspects of experience (Boud
et al. 1985). It can be aimed at raising awareness
(Johns 1998) or applied to uncover hidden
personal assumptions (e.g. Mezirow 1991). At
practice level, education and service can work
collaboratively to develop strategies which ensure the time, the safe environment for selfexpression and sharing, and a learning culture
which constantly seeks to enhance practice.
In summary, it is argued that midwives are
placed to positively in¯uence the quality of
women's childbearing experiences. This obligation is particularly challenging since midwives'
practice is constrained by external forces, such as
governmental, managerial and medical policy.
Constraints also exist due to the process of
institutionalised practice which has a tendency to
routinisation and non-re¯ective activity. Discussion has been generated surrounding interpretations of data obtained during an ethnographic
study, which demonstrated qualitative di€erences between the articulations and practice
across the two research settings. Three factors
appeared to be inter-related: the application of
theoretical frameworks, team cohesion and
clinical leadership. These have been theoretically
explored and suggestions of how they might
Formal theory in midwifery care for women
contribute in creating a re¯ective and progressive
work culture postulated. While it is concluded
that professional practice necessarily comprises
both formal theory and personal knowledge, it is
suggested that the application of theoretical
frameworks might enable clinical leaders to
facilitate re¯ective practice. Additionally, these
provide the language to share meanings and
visions of midwifery practice, which may foster
team cohesion and practice development. It is
maintained that these professional characteristics
are paramount if midwives are to in¯uence and
safeguard women's experience of childbirth.
ACKNOWLEDGEMENTS
I wish to express my grateful thanks to all who
participated in the study.
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