© Longman Group UK Ltd 1991
Midwifery
Midwife/client relationship: Midwives" perspectives Hally McCrea, Valerie Crute
This study set out to explore midwives' u n d e r s t a n d i n g of the factors which affected the development of a therapeutic relationship with clients. A qualitative approach was adopted for the study to avoid placing pred e t e r m i n e d categories u p o n midwives' perceptions. Because o f the qualitative n a t u r e o f the study in-depth interviews were conducted to allow midwives to explore in depth their perceptions o f the research topic. T h e m e s identified within the interview data indicated conflicting needs/interests which in turn seemed to cause dilemmas for the midwives interviewed. It seemed appropriate t h e r e f o r e to take the data analysis one step f u r t h e r by utilising dilemma analysis. Consideration o f the situations in which the midwives experienced 'good' or 'poor' relationships revealed a complex picture o f the factors affecting relationships with clients. Four main issues were identified: the n a t u r e and value of the midwives' role; recognition of authority/autonomy in practising this role; emotional involvement with clients; and maintaining personal integrity. From dilemma analysis of the data it appears that when midwives were successful in managing these issues then the relationship became 'special' and therapeutic for clients. Mismanagement o f these issues in contrast led to dilemmas which then inhibited development o f meaningful relationships between the midwives and clients. In view of the fact that clients and midwives value this 'special' relationship a case is m a d e for midwives to be p r e p a r e d educationally to m a n a g e effectively issues which are raised in their everyday practice. Only then will the midwife/client relationship become therapeutic.
INTRODUCTION
Hally McCrea BSc, MSc, RGN, RM, Lecturer, Dept of Nursing and Health Visiting, University of Ulster, Coleraine, N.I. Valerie Crute BSc, PhD, formerly Lecturer, University of Ulster, Magee Manuscript accepted 23 August 1991 Requests for offprints to FIMcC
Midwives have a professional responsibility to promote the emotional and psychological wellbeing of their clients in addition to meeting their physical needs. The expertise and skills which are applied to this end include knowledge of the biological and social sciences and specialised knowledge and techniques of therapy. However, a less acknowledged and understood resource lies in the relationship which develops between 183
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the midwife and client. In the field of counselling the therapeutic importance (i.e. healing effect) of this relationship is widely recognised. In discussing the nature of helping for example MacLean and Gould (1988) assert that all helping takes place within the relationship and that 'it is the relationship that is the vehicle for any change in the client' (pl 1). These writers also recognise that 'many so-called helping relationships have been less than productive and many quite destructive' (pl 1). Many o f the relationships which develop between midwives and clients could be described as 'good' in that they do not involve open conflict or bad feelings and indeed often involve cooperation. However in this study the researchers were interested in exploring instances where the relationship goes beyond the norm of 'getting on well' with clients to actually having a therapeutic relationship with them. Equally important were those instances where the relationship between midwives and clients was poor or even hostile; i.e. nontherapeutic. Data are not available to quantify the instances of therapeutic or nontherapeutic relationships but reports of clients' perceptions highlight the midwife/client relationship as often having an important positive or negative impact on them. This is evidenced by the lasting memories of such meetings. From the literature (Lautman, 1988; Hutton, 1988) and from personal experience it appears that clients have vivid memories of midwives whom they have encountered. Even after many years they remember particular midwives and what they did and said. It seems to the researchers that some 'special relationship' is created between the midwife and client. This does not always happen, but when it does it seems to have a most beneficial healing or therapeutic effect for clients. Clients do not seem able to express exactly the factors leading to the development of either a therapeutic or a nontherapeutic relationship. Midwives on the other hand may have some understanding of this relationship since they have many opportunities to examine their relationships with clients. This most important aspect o f midwifery practice seems to have received little research atten-
tion and the few studies which have attempted to explore the midwife/client relationship have done so from the consumers' perspective. Consumers have relatively few experiences of this relationship whereas midwives interact continuously with clients. It is reasonable therefore to expect that midwives will have developed their own opinions of this aspect of their work. The focus of this study was on those relationships which had a major impact on midwives; that is relationships which clients found to be therapeutic and where midwives knew they were doing 'good work', and those relationships which were nontherapeutic and where midwives could identify that this was the case. By concentrating on these relationships the researchers believed that it would be possible to identify those factors which were influential in these relationships. It is important at this point to note that the researchers acknowledge that the majority of midwife/ client relationships could be described as 'good'. However, it is possible that with greater understanding of the factors which influence this relationship, a higher proportion could become therapeutic.
METHODS This study was concerned with midwives' opinions, feelings and attitudes of the midwife/client relationship. Its primary aim was to explore with midwives their explanations for those particularly therapeutic or nontherapeutic relationships between themselves and clients. Therefore, it was appropriate for the study to adopt a qualitative approach; qualitative in the sense that the study did not place pre-determined categories upon midwives' perceptions. Additionally the researchers wanted participants to collaborate actively in developing knowledge that would be relevant and meaningful to both groups. For this reason an initial meeting with a group of practising midwives from the hospital where the research was to take place was organised to clarify the relevance of the research topic. Because of the qualitative nature of the study in-depth interviews were conducted to allow
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midwives to explore in depth their perceptions on the research topic. Ethical approval for the study was obtained from one Area Health Board in N o r t h e r n Ireland. Access to midwives was achieved following discussion with the midwife manager for the research location. An initial meeting was held with midwives interested in participating in the study so that the researchers could discuss with them their estimation of the importance of the research topic and their interest in participating actively in the research process. Following this initial meeting a pilot study was conducted to test whether the research instrument would generate valid and reliable data. T h e format of the interview involved asking the midwives to a) describe the types of clients they are likely to meet in their daily work and to reflect back to specific experiences of therapeutic or nontherapeutic relationships and b) to develop some thoughts on the closure of each interview. T h e main reason for asking midwives to describe the types of clients they are likely to meet was to establish general conversation in order to help them to relax and also to call to mind specific relationships in preparation for the recall of those relationships which had a positive or negative impact on them. When recalling instances of specific experiences the midwives were encouraged to explore freely their understanding o f these experiences. For their part the researchers engaged in active listening in an attempt to understand the midwives' experiences. In view of the sensitive nature of the research topic and the requirement to discuss personal experiences (both positive and negative) it was considered important to communicate the researchers' understanding of this difficulty by providing midwives with some sense of achievement. T o this end a s u m m a r y of the main ideas described by each midwife was given and this seemed to help some midwives come to a better understanding as to why they found some relationships more 'positive' or m o r e 'negative'. Analysis of the pilot study data and consultation with colleagues experienced in qualitative research indicated that the interview schedule was valid and reliable in terms of generating
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explanations of midwives' relationships with clients. Sixteen midwives of ward sister/staff midwife grades volunteered to participate in the main study; this voluntary response was essential since it was important that midwives were willing to talk freely about their feelings and opinions on the research topic. Each midwife was interviewed using the same approach and format as described for the pilot study. Interviews took place during midwives' working hours and lasted f r o m approximately 45-90min. Interviews were tape-recorded with the permission of each midwife and only after assurance was given that the information provided would be treated in confidence and that anonymity would be maintained in the written report. Each midwife interviewed agreed to meet with the researchers at a later date to discuss interpretations of the data. Interview data were transcribed and following a n u m b e r of reviews of the transcripts and several replays of interview tapes it seemed to the researchers that the midwives interviewed were indicating that quite complex issues influenced how they would relate with clients. At this point in the data analysis the opinions of a n u m b e r of colleagues, who were experienced in qualitative research, were sought on the researchers' perceptions and interpretations of the data. This continued questioning demonstrated the relevance of the data to the research question. It became evident that issues which midwives described were causing conflicts resulting in dilemmas in their everyday interactions with clients. It seemed appropriate therefore to utilise dilemma analysis for this study in order to highlight the conflicts midwives experience in clinical practice. This method of data analysis is discussed in greater detail by Winter (1982). In brief, dilemma analysis involves analysing the interview data in terms of issues which create conflict resulting in dilemmas and a description of how the dilemmas are, or are not resolved. Many of the themes identified within the interview data could be expressed in terms of the 'dilemmas' faced by the midwives in their daily work. In fact Winter (1982) makes the point that
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most institutions (including maternity units) are 'constellations of actual or potential conflicts of interests, that motives are mixed, purposes are contradictory and relationships are ambiguous, and that the formulation of practical action is unendingly beset by dilemmas'. Working from this premise the interview data were examined for issues which created conflict resulting in dilemmas for the midwives in their relationships with clients. Having identified all the issues the data were subsequently examined tbr stimuli which were responsible for these issues being raised. In the final stage of the dilemma analysis each issue, including the responsible stimuli was summarised, supported by direct quotes where appropriate and a description given of how the dilemma was or was not resolved. In using dilemma analysis it was even more important that the researchers r e t u r n e d to the midwives in the study to check that interpretations of the data were valid. Generally the midwives who participated in the study agreed with the researchers' interpretations of the findings.
FINDINGS On considering the situations in which the midwives had experienced 'good' or 'bad' relationships, a complex picture of the factors affecting relations with clients was identified. Four main issues were identified: 1) the nature and value of the midwife's role; 2) recognition of authority and autonomy in practising this role; 3) emotional involvement with clients; and 4) maintenance of personal integrity. Each issue is described below with illustrations of the midwives' understanding of t h e m and how they affected the development o f a therapeutic relationship with clients.
The nature and value of the midwife's role • Linked to this issue was the midwives' own confidence in the value o f their role and their ability to p e r f o r m this role in a worthwhile
manner. This was evident in a n u m b e r of ways: 1) midwives perceptions o f how clients perceived them; 2) the extent to which clients meet midwives half way in building relationships; and 3) crisis of confidence on the part o f midwives regarding the value of their role. 1) Many midwives described how important it was for clients to acknowledge their help. This feeling of being needed was seen as a recognition of the midwives' role. Some midwives described how they felt close to clients who requested their help personally and that this personal request somehow made them feel 'important' to their clients. Instances of negative responses to the midwives' help and advice on the other hand appear to have a negative impact on the midwife/client relationship. For example, one midwife explained that 'when mothers don't listen to you, you feel worthless, you just go through the process of helping them but there is no relationship there'. In such instances the midwives felt that clients looked to the doctor for information and that they were simply there to 'keep the place going'. This feeling o f not being needed roused anger and resentment which the midwives felt affected how they related to clients. 2) Midwives mentioned the difficulty of working with clients who did not respond to them. T h e y described practices of trying to build a relationship with clients, approaching them on several occasions but if there was no 'come back' they would not continue indefinitely. Examples included extremes of when a client would say very little throughout her labour, to clients who were simply quiet and did not respond in conversation. On these occasions the midwives felt 'left out' of the proceedings and could not get the relationship established. On the positive side the midwives often noted that it was easier to build a relationship with clients who were 'chatty, outgoing', also those who were 'willing to o p e n up' and share their problems. T h e midwives would presumably receive some feedback f r o m such clients. Clients with a clear physical or emotional need would also in some way 'come towards' the midwives or
MmWlVEgV 187 meet them halfway through the expression intentionally or unintentionally of this need, for example breast-feeding clients who needed help fixing their baby onto the breast. 3) One of the factors which e m e r g e d from this research relates to the degree of confidence which the midwives possess regarding their own worth. Midwives described how they felt confident whenever they were able to 'do something' for clients. They spoke of 'achieving something' or 'feeling satisfied'. Two notable areas in relation to this mentioned satisfaction were working with clients who are in need of advice, support and encouragement, for example with breast feeding, and secondly, providing for the emotional and advice needs o f clients in 'abnormal' situations, for example the delivery of a stillbirth, or abnormal baby. In interaction with some clients the midwives described experiences of 'crisis of confidence' regarding their role and the value of their work. Midwives described how clients' reactions to them often led to a questioning of their 'part' in the care process and the importance or value of their contribution. T h e y characterised these feelings as 'what am I doing here?' and 'am I doing something worthwhile?'. T h e i r confidence seems to be shaken when clients do not seem to value their work, are indifferent or actively hostile toward their efforts. T h e midwives indicated that some feedback f r o m clients w a s important to give them assurance that they are 'doing the right thing'. Confidence seems to diminish whenever clients have no clear needs, or when other professionals take over aspects of the midwives' role. For example, most of the midwives mentioned a deterioration in their confidence when a doctor intervened in their care of clients. Such interventions, in the midwives view, take the form of usurping their role in making professional judgements regarding their clients' care. In these situations the midwives said they would avoid contact with the clients. They are therefore withdrawing from the relationship in the way that many clients do but they expressed guilt at this response and a sense of not having come to terms which such a strategy.
Recognition of authority/autonomy in practising the midwife's role In describing 'good' and 'poor' relationships the midwives raised the issue of the degree to which they were able to work autonomously and with authority and responsibility for their actions. For example, some of the features of the circumstances under which 'good' relationships developed were that the midwives were: 1) in full control of decisions made in the situation; 2) their authority and decisions were respected and accepted by other staff; and 3) clients recognised and were confident in the midwives' authority and decisions. Many midwives cited night duty, when there were no other staff present (especially senior midwives and doctors), as being a time when good relations might be established. However, they raised the issue of their authority being brought into question by clients' perceptions of them. T h e midwives m a d e the suggestion that many clients are unaware of midwives' knowledge, skills and responsibilities. T h e y described differing responses f r o m clients which ranged from a simple ignorance of the facts to a belief that 'midwives are simply there to do the dirty work', or to act 'as scivvy'. Some midwives expressed strong feelings of resentment and frustration with such perceptions which they felt often led to difficulty in establishing a relationship with clients. Clients' trust and confidence in the midwife was mentioned frequently as factors in determining the nature of the relationship. T h e midwives described some clients as lacking in confidence in their judgements, as witnessed by them (clients) asking for second opinions, for example, from doctors.
Emotional involvement with clients A further issue identified as being influential in the development of therapeutic relationships concerns that of emotional involvement with clients. Midwives in this study highlighted the dilemma of what they described as 'the conflict between being professional and being a friend'
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to clients. T h e y noted that in therapeutic relationships they had been involved emotionally with the clients, for example when a stillborn or abnormal baby was delivered they had the opportunity to be both 'professional and friend to the client'. Being totally 'professional' was described by the midwives as a response to a difficulty in establishing a relationship with clients. An example o f this was caring for 'difficult/demanding clients', in situations where the midwives either did not feel they had total responsibility for the care of the client, for example 'private patients', or where the midwives' responsibility and authority were not accepted or respected. In these circumstances the midwives reported that they would simply do what was necessary physically, but would not become emotionally involved. According to the midwives this lack of emotional involvement constituted a deficit in practice whereas emotional involvement represents 'doing their job properly, most effectively' or at least in the most 'satisfying manner'. As one midwife succinctly puts it 'the best comes out of me when I can feel with the mothers'. Despite this apparent resolution o f the issue of emotional involvement with clients there remained for many of the midwives a dilemma in practice. T h e y mentioned in their description of 'poor' relationships a hesitation in responding emotionally to clients, particularly when other health professionals were present. T h e y also seemed to struggle with the notion of the importance of being 'detatched, objective and in control'.
Maintaining personal integrity T h e final issue identified within the interview data as having an impact on the midwife/client relationship was the need to maintain personal integrity in carrying out the midwife's role. Two areas of practice a p p e a r e d particularly relevant to this issue and influential in the development and maintenance of a therapeutic relationship with clients. T h e first of these areas was the implementation of hospital policies which were in conflict with what the midwives considered to
be good practices in relating to clients. Examples were given where, for instance, hospital policies on information-giving would have required the midwives to be less honest with clients. One midwife cites the example o f the dilemma of whether or not to inform a client of the condition of her baby when asked, rather than await the conclusion of a series o f medical examinations. In describing these dilemmas the midwives expressed strong feelings regarding the importance of honesty and trust in their relationships with clients in their care. T h e second area where personal integrity was mentioned was in relation to the midwives' own emotions. T h e midwives reported a range of emotions experienced in response to various situations where they were not allowed to 'show their feelings'. One classic example cited was when they had 'a had day' yet were expected to be 'nice'. Although they would adopt this 'artificial appearance' the midwives felt that this approach had a negative impact on how they would relate to the clients. T h e midwives felt strongly that as a g r o u p they should be allowed to express how they feel, since they are 'after all only human'.
Limitations of the study In discussing the findings of this study a n u m b e r of limitations must be taken into consideration. Firstly, it must be recognised that the study was conducted within a qualitative research paradigm and thus incorporates the strengths and weaknesses o f this methodology. It is acknowledged that the information is gathered from a small sample o f midwives (16) in a single hospital setting. However, as noted earlier, adoption of this paradigm involved an attempt to examine in d e p t h the views of the midwives. At this exploratory stage this approach was felt to be m o r e appropriate than surveying the views of a large sample of midwives on predetermined categories. Knowledge of the factors affecting the relationships between midwives and clients is insufficient at this stage to construct such a measure. Further research is necessary to determine the
MIDWIFERY 189 extent to which the findings o f this study can be generalised to other midwives and institutional settings. T o this end it might be fruitful to investigate the generalisability of the findings by designing a questionnaire, based on the qualitative data generated in this study, which could be used to provide quantitative assessment of the validity of the factors suggested to be affecting the relationship between midwives and clients. A further area for investigation as a check upon the validity of the findings might involve examining clients' responses to the ideas expressed by the midwives in this study. It is recognised that this study focused u p o n only one of the parties involved in the relationship. However it has been suggested that research investigating health professional/client relationship should recognise the importance of clients in defining the relationship (Kelly & May, 1982). Finally it is acknowledged that in qualitative research the analysis of data remains the interpretation by the researchers o f what is said and is therefore open to alternative interpretations. This limitation is recognised and while the researchers in this study reported the findings firstly to the midwives involved and received favourable responses to their interpretations of the data, it is nevertheless possible that on reviewing the data collected, other researchers might identify further ideas not discussed in this paper. These limitations must be borne in mind when assessing the findings of this study.
DISCUSSION AND CONCLUSIONS T h e first issue to emerge f r o m the dilemma analysis concerns that of self-worth and threats to the midwife's role. Situations which typically raised this issue, according to the midwives' comments, included being m a d e to feel a nuisance/unnecessary, negative or non-response from clients and experiencing 'a crisis of confidence regarding their role and the value of their work'. Such threats to self-worth would have clear implications for midwives' self-esteem and may well contribute to lack of security which the midwives will then bring to the relationship with
their clients. Personal adequacy has in fact been shown to influence both overt and covert behaviours in interactions (Cromier & Cromier, 1985). For midwives to have meaningful relations with clients it would be crucial therefore for them to resolve this issue. Midwives in this study r e m a r k e d that it was important for them to feel needed. Yet they must also accept that clients are m o r e informed today and therefore may not d e p e n d on midwives for all their care. F u r t h e r m o r e it must be recognised that some clients may not make their needs known explicitly, for example the quiet or shy mother, and this could well account for negative/non-response. In these instances it will be the midwives' responsibility, through effective communication skills, to instil confidence in these clients so that they can come 'towards the midwives' in making their needs known. In other instances of negative/non-response it may even be necessary for midwives to make all the 'moves' rather than wait for clients to take up their side of the partnership. This would obviously entail preparing midwives to be m o r e effective communicators. In the final analysis however midwives may have to accept that negative/non-response is likely f r o m some clients. This acceptance would be vital in helping midwives avoid threats to their self-worth. Obviously confidence in their own ability and their work as well as having the confidence to assert their position in the care process to other health professionals and to their clients would be crucial to their self-worth. Threats to self-worth may however be further complicated by the issue of recognition of authority/autonomy in practising the midwife's role. In brief this issue is concerned with the midwives', authority to act being brought into question by either clients or other health professionals. One possible explanation for this issue being raised centres on the medicalisation of childbirth which has, to a large extent, blurred both the public's and other health professionals' perceptions of the midwife's role. Indeed many midwives in this study c o m m e n t e d that junior doctors and clients do not seem aware of, or are ignorant of, the midwife's role. This finding
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receives support from an earlier study of the role and responsibilities of midwives (Robinson, 1989). Although clients do not have authority to determine how health care is delivered, for example how midwives carry out their work, they (the clients) can institute strategies which create constraints and dilemmas for midwives. In this study, for example, midwives described situations where clients would 'look to the doctor' for explanations and advice rather than the midwives. Constant questioning of the midwives' authority to act will clearly u n d e r m i n e their own confidence in their ability and could well bring into question their self-respect as autonomous practitioners. Yet respect within the relationship with clients is an essential c o m p o n e n t for it to be therapeutic (Rogers, 1951; Egan, 1982). To resolve this issue account must be taken of the fact that midwives are accountable for their actions [United Kingdom Central Council (UKCC) 1984] and therefore it is vital that they are given the authority to make i n f o r m e d judgements and to act on these judgements. This would entail co-operation and consultation between midwifery and medical hierarchy to define exactly what is the role of the midwife and the level of responsibility that goes with this role. For their part midwives must be p r e p a r e d to be more assertive in what they do, to both their clients and the public at large. Midwives in this study highlighted the dile m m a of what they described as a conflict between being 'a professional' and being 'a friend' to clients. One obvious source for this conflict was the clients themselves, especially those 'difficult to get on with' or those who questioned the midwives' authority and responsibility. T h e presence of other health professionals and their expectations o f professional behaviours also inhibited the midwives from responding emotionally to clients. One possible explanation for this conflict may be the ambiguity in nursing/midwifery regarding the appropriate extent of emotional involvement with patients/clients. In the classroom students are taught to be cheerful and to care for the whole person whereas on the ward they are
expected to develop 'professional' behaviours that include dignity, deference and distance (Mauksch, 1965; Rosenthal et al, 1980). But if nurses/midwives are committed to providing holistic care then being emotionally involved must be given high priority (Burnard, 1988). It would seem f r o m the literature that clients also value being cared for by friendly midwives (Metcalf, 1983). However it must be recognised that emotional involvement must be of a level that does not cloud objectivity within the relationship ( B r e m m e r & Shostrom, 1982). Socialised as they are to be 'professional', midwives would clearly have difficulty empathising with clients. Yet empathic understanding of clients' concerns is considered a vital component for a relationship to move towards therapeutic ends (Mearns & Thorne, 1988). Findings reported in this study in fact suggest that on those occasions when midwives were able to establish such a relationship they described how 'being emotionally involved makes you feel you have done your j o b well and this gives you satisfaction in your work, this is how it should always be'. Attempts to resolve the dilemma of emotional involvement with clients must begin during professional preparation where the value of emotional support to clients is not only taught but also put into practice. This would require support f r o m educators and managers to encourage rather than frown on midwives becoming emotionally involved with clients. Opportunities for midwives to discuss emotional issues encountered in practice would be crucial to ensure objectivity within relationships. Support services for midwives to discuss their own emotional needs would be vital as well if they are to be honest and aware o f their own feelings; to be their true self in the relationship. T h e final issue raised in this study concerns the midwives' ability to maintain personal integrity in carrying out this role. Two particular stimuli which raised this issue were identified as the implementation o f hospital policies which conflicted with the midwives' perceptions of good practices in relating to clients, and the conflict for them between caring for their own emotional well-being and that of their clients.
MIDWIFERY 191 O n e factor which m a y well a c c o u n t for this issue b e i n g raised centres o n the b u r e a u c r a t i c o r g a n i s a t i o n o f the N a t i o n a l H e a l t h Service (NHS) with its rules a n d r e g u l a t i o n s to which midwives, as e m p l o y e e s , a r e e x p e c t e d to conf o r m , r e g a r d l e s s o f w h e t h e r they m a y j u d g e t h e m to have a negative i m p a c t o n client care. T h e p r o b l e m is e v e n m o r e c o m p o u n d e d by the fact t h a t the h i e r a r c h y within m i d w i f e r y , with its divisions o f l a b o u r , limits m i d w i v e s ' ability to m a k e decisions p e r t a i n i n g to t h e i r own a r e a o f practice ( K i r k h a m , 1989). T h e p o w e r s t r u c t u r e within the N H S m a y also be p a r t l y r e s p o n s i b l e f o r t h e conflict midwives face b e t w e e n m e e t i n g t h e i r o w n e m o t i o n a l n e e d s a n d those o f t h e i r clients. T h u s f a r little cons i d e r a t i o n has b e e n given to p r o v i d i n g f o r the e m o t i o n a l n e e d s o f carers. T h e p o i n t to c o n s i d e r in this issue is that if midwives a r e n o t h o n e s t in the relationship, t h e n clients m a y well lack trust a n d c o n f i d e n c e in t h e i r ability as ' p r o f e s s i o n a l s ' a n d 'friends'. Yet trust is vital f o r a r e l a t i o n s h i p to be t h e r a p e u t i c (Foy & Cox, 1983). Equally if midwives a r e u n a b l e to b e t h e i r ' t r u e self' e m o t i o n a l l y t h e n it is difficult to see h o w they can d e v e l o p u n d e r s t a n d i n g o f t h e i r clients' needs. I n fact C r o m i e r a n d C r o m i e r (1985) feel that unless we a r e a w a r e o f o u r o w n feelings a b o u t ourselves t h e n we a r e unlikely to establish a n y k i n d o f a r e l a t i o n s h i p with o u r clients. It is obvious that, f o r midwives to resolve this d i l e m m a , they m u s t b e given t h e responsibility to d e c i d e the a p p r o p r i a t e n e s s o f h o s p i t a l policies at an i n d i v i d u a l level. T h i s will b e crucial if they a r e to take t h e i r role as client a d v o c a t e seriously. C o n s i d e r a t i o n m u s t also be given a n d positive steps t a k e n to p r o v i d e s u p p o r t services for midwives to m e e t t h e i r own e m o t i o n a l n e e d s so that they can b e m o r e effective in facilitating clients to m e e t t h e i r e m o t i o n a l needs. D i l e m m a analysis o f the d a t e e m e r g i n g f r o m this s t u d y indicates t h a t the t h e r a p e u t i c value o f the midwife/client r e l a t i o n s h i p seems to be i n f l u e n c e d by a n u m b e r o f issues which a r e raised in e v e r y d a y clinical practice. It a p p e a r s that, w h e n the midwives w e r e successful in resolving these issues, t h e n the r e l a t i o n s h i p b e t w e e n the midwives a n d clients w e n t b e y o n d the n o r m to b e c o m e 'special' a n d t h e r a p e u t i c .
H o w e v e r , w h e n these issues were n o t r e s o l v e d successfully they b e c a m e d i l e m m a s which t h e n inhibited d e v e l o p m e n t o f m e a n i n g f u l r e l a t i o n s b e t w e e n the midwives a n d clients. I n view o f the e v i d e n c e s u g g e s t i n g t h a t clients value this 'special' r e l a t i o n s h i p a n d f r o m t h e findings o f this s t u d y t h a t midwives also g a i n satisfaction f r o m this r e l a t i o n s h i p , t h e n it seems r e a s o n a b l e to a r g u e f o r c h a n g e s within m i d wives' e d u c a t i o n a l p r e p a r a t i o n as well as o r g a n i s ational c h a n g e s a n d t h e p r o v i s i o n o f s u p p o r t services for midwives. O n l y w h e n these c h a n g e s a r e m a d e will the r i g h t e n v i r o n m e n t prevail to e n c o u r a g e the d e v e l o p m e n t o f t h e r a p e u t i c relationships b e t w e e n midwives a n d t h e i r clients.
References Bremmer L M, Shostrom E L 1982 Therapeutic psychology : fundamentals of counselling and psychotherapy. Prentice Hall, London Burnard P 1988 Coping with other profile's emotion. Professional Nurse 4(1): 11-14 Cromier W H, Cromier L S 1985 Ingredients of an effective helping relationship. Brooks/Cole Pub. Co., California Egan A 1982 Reason and motion in psychotherapy. Lyle Stuart, New York Foy M L, Cox B G 1983 Trust as an underlying dynamic in the counselling process : how clients test trust. Personnel and Guidance Journal 62:163-166 Hutton E 1988 The importance of the midwife : women's memories of pregnancy, labour and the post-natal period. Midwives Chronicle 101 (1208): 273-274 Kelly M P, May D 1982 Good and bad patients : a review of the literature and a theoretical critique. Journal of Advanced Nursing 7(2): 147-156 Kirkham M 1989 Midwives and information giving during labour. In Robinson S and Thomson A M (eds) Midwives, Research and Childbirth, Vol 1, Chapman and Hall, London Lautman B 1988 As I sit here. Midwives Chronicle 101(1208): 269-270 Mauksch H 1965 Becoming a nurse .' a selective review. In Skipper J K, Leonard R C (eds) Social Interaction and Patient Care. Lippincon, Philadelphia MacLean D, Gould S 1988 The helping process : an introduction. Croom Helm, Kent Mearns D, Thorne S 1988 Person-centred counselling in action. Sage, London Metcalf C 1983 A study of change in the method of organising the delivery of nursing care in a ward of a maternity hospital. In Wilson-Barnett J (ed) Nursing Research : Ten Studies in Patient Care. Developments in Nursing Research, Vol 2. John Wiley and Sons, Chichester
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Robinson S 1989 Caring for childbearing women : the interrelationship between midwifery and medical responsibility. In Robinson S and T h o m s o n A M (eds) Midwives, Research and Childbirth, Vol 1. Chapman and Hall, London Rogers C R 1951 Client-centred therapy. HoughtonMigglin, Boston Rosenthal, C J, Marshall V W, Macpherson A S e t al
1980 Nurses, patients and families. Croom Helm, London United Kingdom Central Council (UKCC) for Nurses, Midwives and Health Visitors 1984 Exercising Accountability, UKCC, London Winter R 1982 Dilemma analysis : a contribution to methodology for action research. Journal of Curriculum Studies 12(3): 168
Midwifery
Midwife/client relationship: Midwives" perspectives Hally McCrea, Valerie Crute
This study set out to explore midwives' u n d e r s t a n d i n g of the factors which affected the development of a therapeutic relationship with clients. A qualitative approach was adopted for the study to avoid placing pred e t e r m i n e d categories u p o n midwives' perceptions. Because o f the qualitative n a t u r e o f the study in-depth interviews were conducted to allow midwives to explore in depth their perceptions o f the research topic. T h e m e s identified within the interview data indicated conflicting needs/interests which in turn seemed to cause dilemmas for the midwives interviewed. It seemed appropriate t h e r e f o r e to take the data analysis one step f u r t h e r by utilising dilemma analysis. Consideration o f the situations in which the midwives experienced 'good' or 'poor' relationships revealed a complex picture o f the factors affecting relationships with clients. Four main issues were identified: the n a t u r e and value of the midwives' role; recognition of authority/autonomy in practising this role; emotional involvement with clients; and maintaining personal integrity. From dilemma analysis of the data it appears that when midwives were successful in managing these issues then the relationship became 'special' and therapeutic for clients. Mismanagement o f these issues in contrast led to dilemmas which then inhibited development o f meaningful relationships between the midwives and clients. In view of the fact that clients and midwives value this 'special' relationship a case is m a d e for midwives to be p r e p a r e d educationally to m a n a g e effectively issues which are raised in their everyday practice. Only then will the midwife/client relationship become therapeutic.
INTRODUCTION
Hally McCrea BSc, MSc, RGN, RM, Lecturer, Dept of Nursing and Health Visiting, University of Ulster, Coleraine, N.I. Valerie Crute BSc, PhD, formerly Lecturer, University of Ulster, Magee Manuscript accepted 23 August 1991 Requests for offprints to FIMcC
Midwives have a professional responsibility to promote the emotional and psychological wellbeing of their clients in addition to meeting their physical needs. The expertise and skills which are applied to this end include knowledge of the biological and social sciences and specialised knowledge and techniques of therapy. However, a less acknowledged and understood resource lies in the relationship which develops between 183
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the midwife and client. In the field of counselling the therapeutic importance (i.e. healing effect) of this relationship is widely recognised. In discussing the nature of helping for example MacLean and Gould (1988) assert that all helping takes place within the relationship and that 'it is the relationship that is the vehicle for any change in the client' (pl 1). These writers also recognise that 'many so-called helping relationships have been less than productive and many quite destructive' (pl 1). Many o f the relationships which develop between midwives and clients could be described as 'good' in that they do not involve open conflict or bad feelings and indeed often involve cooperation. However in this study the researchers were interested in exploring instances where the relationship goes beyond the norm of 'getting on well' with clients to actually having a therapeutic relationship with them. Equally important were those instances where the relationship between midwives and clients was poor or even hostile; i.e. nontherapeutic. Data are not available to quantify the instances of therapeutic or nontherapeutic relationships but reports of clients' perceptions highlight the midwife/client relationship as often having an important positive or negative impact on them. This is evidenced by the lasting memories of such meetings. From the literature (Lautman, 1988; Hutton, 1988) and from personal experience it appears that clients have vivid memories of midwives whom they have encountered. Even after many years they remember particular midwives and what they did and said. It seems to the researchers that some 'special relationship' is created between the midwife and client. This does not always happen, but when it does it seems to have a most beneficial healing or therapeutic effect for clients. Clients do not seem able to express exactly the factors leading to the development of either a therapeutic or a nontherapeutic relationship. Midwives on the other hand may have some understanding of this relationship since they have many opportunities to examine their relationships with clients. This most important aspect o f midwifery practice seems to have received little research atten-
tion and the few studies which have attempted to explore the midwife/client relationship have done so from the consumers' perspective. Consumers have relatively few experiences of this relationship whereas midwives interact continuously with clients. It is reasonable therefore to expect that midwives will have developed their own opinions of this aspect of their work. The focus of this study was on those relationships which had a major impact on midwives; that is relationships which clients found to be therapeutic and where midwives knew they were doing 'good work', and those relationships which were nontherapeutic and where midwives could identify that this was the case. By concentrating on these relationships the researchers believed that it would be possible to identify those factors which were influential in these relationships. It is important at this point to note that the researchers acknowledge that the majority of midwife/ client relationships could be described as 'good'. However, it is possible that with greater understanding of the factors which influence this relationship, a higher proportion could become therapeutic.
METHODS This study was concerned with midwives' opinions, feelings and attitudes of the midwife/client relationship. Its primary aim was to explore with midwives their explanations for those particularly therapeutic or nontherapeutic relationships between themselves and clients. Therefore, it was appropriate for the study to adopt a qualitative approach; qualitative in the sense that the study did not place pre-determined categories upon midwives' perceptions. Additionally the researchers wanted participants to collaborate actively in developing knowledge that would be relevant and meaningful to both groups. For this reason an initial meeting with a group of practising midwives from the hospital where the research was to take place was organised to clarify the relevance of the research topic. Because of the qualitative nature of the study in-depth interviews were conducted to allow
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midwives to explore in depth their perceptions on the research topic. Ethical approval for the study was obtained from one Area Health Board in N o r t h e r n Ireland. Access to midwives was achieved following discussion with the midwife manager for the research location. An initial meeting was held with midwives interested in participating in the study so that the researchers could discuss with them their estimation of the importance of the research topic and their interest in participating actively in the research process. Following this initial meeting a pilot study was conducted to test whether the research instrument would generate valid and reliable data. T h e format of the interview involved asking the midwives to a) describe the types of clients they are likely to meet in their daily work and to reflect back to specific experiences of therapeutic or nontherapeutic relationships and b) to develop some thoughts on the closure of each interview. T h e main reason for asking midwives to describe the types of clients they are likely to meet was to establish general conversation in order to help them to relax and also to call to mind specific relationships in preparation for the recall of those relationships which had a positive or negative impact on them. When recalling instances of specific experiences the midwives were encouraged to explore freely their understanding o f these experiences. For their part the researchers engaged in active listening in an attempt to understand the midwives' experiences. In view of the sensitive nature of the research topic and the requirement to discuss personal experiences (both positive and negative) it was considered important to communicate the researchers' understanding of this difficulty by providing midwives with some sense of achievement. T o this end a s u m m a r y of the main ideas described by each midwife was given and this seemed to help some midwives come to a better understanding as to why they found some relationships more 'positive' or m o r e 'negative'. Analysis of the pilot study data and consultation with colleagues experienced in qualitative research indicated that the interview schedule was valid and reliable in terms of generating
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explanations of midwives' relationships with clients. Sixteen midwives of ward sister/staff midwife grades volunteered to participate in the main study; this voluntary response was essential since it was important that midwives were willing to talk freely about their feelings and opinions on the research topic. Each midwife was interviewed using the same approach and format as described for the pilot study. Interviews took place during midwives' working hours and lasted f r o m approximately 45-90min. Interviews were tape-recorded with the permission of each midwife and only after assurance was given that the information provided would be treated in confidence and that anonymity would be maintained in the written report. Each midwife interviewed agreed to meet with the researchers at a later date to discuss interpretations of the data. Interview data were transcribed and following a n u m b e r of reviews of the transcripts and several replays of interview tapes it seemed to the researchers that the midwives interviewed were indicating that quite complex issues influenced how they would relate with clients. At this point in the data analysis the opinions of a n u m b e r of colleagues, who were experienced in qualitative research, were sought on the researchers' perceptions and interpretations of the data. This continued questioning demonstrated the relevance of the data to the research question. It became evident that issues which midwives described were causing conflicts resulting in dilemmas in their everyday interactions with clients. It seemed appropriate therefore to utilise dilemma analysis for this study in order to highlight the conflicts midwives experience in clinical practice. This method of data analysis is discussed in greater detail by Winter (1982). In brief, dilemma analysis involves analysing the interview data in terms of issues which create conflict resulting in dilemmas and a description of how the dilemmas are, or are not resolved. Many of the themes identified within the interview data could be expressed in terms of the 'dilemmas' faced by the midwives in their daily work. In fact Winter (1982) makes the point that
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most institutions (including maternity units) are 'constellations of actual or potential conflicts of interests, that motives are mixed, purposes are contradictory and relationships are ambiguous, and that the formulation of practical action is unendingly beset by dilemmas'. Working from this premise the interview data were examined for issues which created conflict resulting in dilemmas for the midwives in their relationships with clients. Having identified all the issues the data were subsequently examined tbr stimuli which were responsible for these issues being raised. In the final stage of the dilemma analysis each issue, including the responsible stimuli was summarised, supported by direct quotes where appropriate and a description given of how the dilemma was or was not resolved. In using dilemma analysis it was even more important that the researchers r e t u r n e d to the midwives in the study to check that interpretations of the data were valid. Generally the midwives who participated in the study agreed with the researchers' interpretations of the findings.
FINDINGS On considering the situations in which the midwives had experienced 'good' or 'bad' relationships, a complex picture of the factors affecting relations with clients was identified. Four main issues were identified: 1) the nature and value of the midwife's role; 2) recognition of authority and autonomy in practising this role; 3) emotional involvement with clients; and 4) maintenance of personal integrity. Each issue is described below with illustrations of the midwives' understanding of t h e m and how they affected the development o f a therapeutic relationship with clients.
The nature and value of the midwife's role • Linked to this issue was the midwives' own confidence in the value o f their role and their ability to p e r f o r m this role in a worthwhile
manner. This was evident in a n u m b e r of ways: 1) midwives perceptions o f how clients perceived them; 2) the extent to which clients meet midwives half way in building relationships; and 3) crisis of confidence on the part o f midwives regarding the value of their role. 1) Many midwives described how important it was for clients to acknowledge their help. This feeling of being needed was seen as a recognition of the midwives' role. Some midwives described how they felt close to clients who requested their help personally and that this personal request somehow made them feel 'important' to their clients. Instances of negative responses to the midwives' help and advice on the other hand appear to have a negative impact on the midwife/client relationship. For example, one midwife explained that 'when mothers don't listen to you, you feel worthless, you just go through the process of helping them but there is no relationship there'. In such instances the midwives felt that clients looked to the doctor for information and that they were simply there to 'keep the place going'. This feeling o f not being needed roused anger and resentment which the midwives felt affected how they related to clients. 2) Midwives mentioned the difficulty of working with clients who did not respond to them. T h e y described practices of trying to build a relationship with clients, approaching them on several occasions but if there was no 'come back' they would not continue indefinitely. Examples included extremes of when a client would say very little throughout her labour, to clients who were simply quiet and did not respond in conversation. On these occasions the midwives felt 'left out' of the proceedings and could not get the relationship established. On the positive side the midwives often noted that it was easier to build a relationship with clients who were 'chatty, outgoing', also those who were 'willing to o p e n up' and share their problems. T h e midwives would presumably receive some feedback f r o m such clients. Clients with a clear physical or emotional need would also in some way 'come towards' the midwives or
MmWlVEgV 187 meet them halfway through the expression intentionally or unintentionally of this need, for example breast-feeding clients who needed help fixing their baby onto the breast. 3) One of the factors which e m e r g e d from this research relates to the degree of confidence which the midwives possess regarding their own worth. Midwives described how they felt confident whenever they were able to 'do something' for clients. They spoke of 'achieving something' or 'feeling satisfied'. Two notable areas in relation to this mentioned satisfaction were working with clients who are in need of advice, support and encouragement, for example with breast feeding, and secondly, providing for the emotional and advice needs o f clients in 'abnormal' situations, for example the delivery of a stillbirth, or abnormal baby. In interaction with some clients the midwives described experiences of 'crisis of confidence' regarding their role and the value of their work. Midwives described how clients' reactions to them often led to a questioning of their 'part' in the care process and the importance or value of their contribution. T h e y characterised these feelings as 'what am I doing here?' and 'am I doing something worthwhile?'. T h e i r confidence seems to be shaken when clients do not seem to value their work, are indifferent or actively hostile toward their efforts. T h e midwives indicated that some feedback f r o m clients w a s important to give them assurance that they are 'doing the right thing'. Confidence seems to diminish whenever clients have no clear needs, or when other professionals take over aspects of the midwives' role. For example, most of the midwives mentioned a deterioration in their confidence when a doctor intervened in their care of clients. Such interventions, in the midwives view, take the form of usurping their role in making professional judgements regarding their clients' care. In these situations the midwives said they would avoid contact with the clients. They are therefore withdrawing from the relationship in the way that many clients do but they expressed guilt at this response and a sense of not having come to terms which such a strategy.
Recognition of authority/autonomy in practising the midwife's role In describing 'good' and 'poor' relationships the midwives raised the issue of the degree to which they were able to work autonomously and with authority and responsibility for their actions. For example, some of the features of the circumstances under which 'good' relationships developed were that the midwives were: 1) in full control of decisions made in the situation; 2) their authority and decisions were respected and accepted by other staff; and 3) clients recognised and were confident in the midwives' authority and decisions. Many midwives cited night duty, when there were no other staff present (especially senior midwives and doctors), as being a time when good relations might be established. However, they raised the issue of their authority being brought into question by clients' perceptions of them. T h e midwives m a d e the suggestion that many clients are unaware of midwives' knowledge, skills and responsibilities. T h e y described differing responses f r o m clients which ranged from a simple ignorance of the facts to a belief that 'midwives are simply there to do the dirty work', or to act 'as scivvy'. Some midwives expressed strong feelings of resentment and frustration with such perceptions which they felt often led to difficulty in establishing a relationship with clients. Clients' trust and confidence in the midwife was mentioned frequently as factors in determining the nature of the relationship. T h e midwives described some clients as lacking in confidence in their judgements, as witnessed by them (clients) asking for second opinions, for example, from doctors.
Emotional involvement with clients A further issue identified as being influential in the development of therapeutic relationships concerns that of emotional involvement with clients. Midwives in this study highlighted the dilemma of what they described as 'the conflict between being professional and being a friend'
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to clients. T h e y noted that in therapeutic relationships they had been involved emotionally with the clients, for example when a stillborn or abnormal baby was delivered they had the opportunity to be both 'professional and friend to the client'. Being totally 'professional' was described by the midwives as a response to a difficulty in establishing a relationship with clients. An example o f this was caring for 'difficult/demanding clients', in situations where the midwives either did not feel they had total responsibility for the care of the client, for example 'private patients', or where the midwives' responsibility and authority were not accepted or respected. In these circumstances the midwives reported that they would simply do what was necessary physically, but would not become emotionally involved. According to the midwives this lack of emotional involvement constituted a deficit in practice whereas emotional involvement represents 'doing their job properly, most effectively' or at least in the most 'satisfying manner'. As one midwife succinctly puts it 'the best comes out of me when I can feel with the mothers'. Despite this apparent resolution o f the issue of emotional involvement with clients there remained for many of the midwives a dilemma in practice. T h e y mentioned in their description of 'poor' relationships a hesitation in responding emotionally to clients, particularly when other health professionals were present. T h e y also seemed to struggle with the notion of the importance of being 'detatched, objective and in control'.
Maintaining personal integrity T h e final issue identified within the interview data as having an impact on the midwife/client relationship was the need to maintain personal integrity in carrying out the midwife's role. Two areas of practice a p p e a r e d particularly relevant to this issue and influential in the development and maintenance of a therapeutic relationship with clients. T h e first of these areas was the implementation of hospital policies which were in conflict with what the midwives considered to
be good practices in relating to clients. Examples were given where, for instance, hospital policies on information-giving would have required the midwives to be less honest with clients. One midwife cites the example o f the dilemma of whether or not to inform a client of the condition of her baby when asked, rather than await the conclusion of a series o f medical examinations. In describing these dilemmas the midwives expressed strong feelings regarding the importance of honesty and trust in their relationships with clients in their care. T h e second area where personal integrity was mentioned was in relation to the midwives' own emotions. T h e midwives reported a range of emotions experienced in response to various situations where they were not allowed to 'show their feelings'. One classic example cited was when they had 'a had day' yet were expected to be 'nice'. Although they would adopt this 'artificial appearance' the midwives felt that this approach had a negative impact on how they would relate to the clients. T h e midwives felt strongly that as a g r o u p they should be allowed to express how they feel, since they are 'after all only human'.
Limitations of the study In discussing the findings of this study a n u m b e r of limitations must be taken into consideration. Firstly, it must be recognised that the study was conducted within a qualitative research paradigm and thus incorporates the strengths and weaknesses o f this methodology. It is acknowledged that the information is gathered from a small sample o f midwives (16) in a single hospital setting. However, as noted earlier, adoption of this paradigm involved an attempt to examine in d e p t h the views of the midwives. At this exploratory stage this approach was felt to be m o r e appropriate than surveying the views of a large sample of midwives on predetermined categories. Knowledge of the factors affecting the relationships between midwives and clients is insufficient at this stage to construct such a measure. Further research is necessary to determine the
MIDWIFERY 189 extent to which the findings o f this study can be generalised to other midwives and institutional settings. T o this end it might be fruitful to investigate the generalisability of the findings by designing a questionnaire, based on the qualitative data generated in this study, which could be used to provide quantitative assessment of the validity of the factors suggested to be affecting the relationship between midwives and clients. A further area for investigation as a check upon the validity of the findings might involve examining clients' responses to the ideas expressed by the midwives in this study. It is recognised that this study focused u p o n only one of the parties involved in the relationship. However it has been suggested that research investigating health professional/client relationship should recognise the importance of clients in defining the relationship (Kelly & May, 1982). Finally it is acknowledged that in qualitative research the analysis of data remains the interpretation by the researchers o f what is said and is therefore open to alternative interpretations. This limitation is recognised and while the researchers in this study reported the findings firstly to the midwives involved and received favourable responses to their interpretations of the data, it is nevertheless possible that on reviewing the data collected, other researchers might identify further ideas not discussed in this paper. These limitations must be borne in mind when assessing the findings of this study.
DISCUSSION AND CONCLUSIONS T h e first issue to emerge f r o m the dilemma analysis concerns that of self-worth and threats to the midwife's role. Situations which typically raised this issue, according to the midwives' comments, included being m a d e to feel a nuisance/unnecessary, negative or non-response from clients and experiencing 'a crisis of confidence regarding their role and the value of their work'. Such threats to self-worth would have clear implications for midwives' self-esteem and may well contribute to lack of security which the midwives will then bring to the relationship with
their clients. Personal adequacy has in fact been shown to influence both overt and covert behaviours in interactions (Cromier & Cromier, 1985). For midwives to have meaningful relations with clients it would be crucial therefore for them to resolve this issue. Midwives in this study r e m a r k e d that it was important for them to feel needed. Yet they must also accept that clients are m o r e informed today and therefore may not d e p e n d on midwives for all their care. F u r t h e r m o r e it must be recognised that some clients may not make their needs known explicitly, for example the quiet or shy mother, and this could well account for negative/non-response. In these instances it will be the midwives' responsibility, through effective communication skills, to instil confidence in these clients so that they can come 'towards the midwives' in making their needs known. In other instances of negative/non-response it may even be necessary for midwives to make all the 'moves' rather than wait for clients to take up their side of the partnership. This would obviously entail preparing midwives to be m o r e effective communicators. In the final analysis however midwives may have to accept that negative/non-response is likely f r o m some clients. This acceptance would be vital in helping midwives avoid threats to their self-worth. Obviously confidence in their own ability and their work as well as having the confidence to assert their position in the care process to other health professionals and to their clients would be crucial to their self-worth. Threats to self-worth may however be further complicated by the issue of recognition of authority/autonomy in practising the midwife's role. In brief this issue is concerned with the midwives', authority to act being brought into question by either clients or other health professionals. One possible explanation for this issue being raised centres on the medicalisation of childbirth which has, to a large extent, blurred both the public's and other health professionals' perceptions of the midwife's role. Indeed many midwives in this study c o m m e n t e d that junior doctors and clients do not seem aware of, or are ignorant of, the midwife's role. This finding
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receives support from an earlier study of the role and responsibilities of midwives (Robinson, 1989). Although clients do not have authority to determine how health care is delivered, for example how midwives carry out their work, they (the clients) can institute strategies which create constraints and dilemmas for midwives. In this study, for example, midwives described situations where clients would 'look to the doctor' for explanations and advice rather than the midwives. Constant questioning of the midwives' authority to act will clearly u n d e r m i n e their own confidence in their ability and could well bring into question their self-respect as autonomous practitioners. Yet respect within the relationship with clients is an essential c o m p o n e n t for it to be therapeutic (Rogers, 1951; Egan, 1982). To resolve this issue account must be taken of the fact that midwives are accountable for their actions [United Kingdom Central Council (UKCC) 1984] and therefore it is vital that they are given the authority to make i n f o r m e d judgements and to act on these judgements. This would entail co-operation and consultation between midwifery and medical hierarchy to define exactly what is the role of the midwife and the level of responsibility that goes with this role. For their part midwives must be p r e p a r e d to be more assertive in what they do, to both their clients and the public at large. Midwives in this study highlighted the dile m m a of what they described as a conflict between being 'a professional' and being 'a friend' to clients. One obvious source for this conflict was the clients themselves, especially those 'difficult to get on with' or those who questioned the midwives' authority and responsibility. T h e presence of other health professionals and their expectations o f professional behaviours also inhibited the midwives from responding emotionally to clients. One possible explanation for this conflict may be the ambiguity in nursing/midwifery regarding the appropriate extent of emotional involvement with patients/clients. In the classroom students are taught to be cheerful and to care for the whole person whereas on the ward they are
expected to develop 'professional' behaviours that include dignity, deference and distance (Mauksch, 1965; Rosenthal et al, 1980). But if nurses/midwives are committed to providing holistic care then being emotionally involved must be given high priority (Burnard, 1988). It would seem f r o m the literature that clients also value being cared for by friendly midwives (Metcalf, 1983). However it must be recognised that emotional involvement must be of a level that does not cloud objectivity within the relationship ( B r e m m e r & Shostrom, 1982). Socialised as they are to be 'professional', midwives would clearly have difficulty empathising with clients. Yet empathic understanding of clients' concerns is considered a vital component for a relationship to move towards therapeutic ends (Mearns & Thorne, 1988). Findings reported in this study in fact suggest that on those occasions when midwives were able to establish such a relationship they described how 'being emotionally involved makes you feel you have done your j o b well and this gives you satisfaction in your work, this is how it should always be'. Attempts to resolve the dilemma of emotional involvement with clients must begin during professional preparation where the value of emotional support to clients is not only taught but also put into practice. This would require support f r o m educators and managers to encourage rather than frown on midwives becoming emotionally involved with clients. Opportunities for midwives to discuss emotional issues encountered in practice would be crucial to ensure objectivity within relationships. Support services for midwives to discuss their own emotional needs would be vital as well if they are to be honest and aware o f their own feelings; to be their true self in the relationship. T h e final issue raised in this study concerns the midwives' ability to maintain personal integrity in carrying out this role. Two particular stimuli which raised this issue were identified as the implementation o f hospital policies which conflicted with the midwives' perceptions of good practices in relating to clients, and the conflict for them between caring for their own emotional well-being and that of their clients.
MIDWIFERY 191 O n e factor which m a y well a c c o u n t for this issue b e i n g raised centres o n the b u r e a u c r a t i c o r g a n i s a t i o n o f the N a t i o n a l H e a l t h Service (NHS) with its rules a n d r e g u l a t i o n s to which midwives, as e m p l o y e e s , a r e e x p e c t e d to conf o r m , r e g a r d l e s s o f w h e t h e r they m a y j u d g e t h e m to have a negative i m p a c t o n client care. T h e p r o b l e m is e v e n m o r e c o m p o u n d e d by the fact t h a t the h i e r a r c h y within m i d w i f e r y , with its divisions o f l a b o u r , limits m i d w i v e s ' ability to m a k e decisions p e r t a i n i n g to t h e i r own a r e a o f practice ( K i r k h a m , 1989). T h e p o w e r s t r u c t u r e within the N H S m a y also be p a r t l y r e s p o n s i b l e f o r t h e conflict midwives face b e t w e e n m e e t i n g t h e i r o w n e m o t i o n a l n e e d s a n d those o f t h e i r clients. T h u s f a r little cons i d e r a t i o n has b e e n given to p r o v i d i n g f o r the e m o t i o n a l n e e d s o f carers. T h e p o i n t to c o n s i d e r in this issue is that if midwives a r e n o t h o n e s t in the relationship, t h e n clients m a y well lack trust a n d c o n f i d e n c e in t h e i r ability as ' p r o f e s s i o n a l s ' a n d 'friends'. Yet trust is vital f o r a r e l a t i o n s h i p to be t h e r a p e u t i c (Foy & Cox, 1983). Equally if midwives a r e u n a b l e to b e t h e i r ' t r u e self' e m o t i o n a l l y t h e n it is difficult to see h o w they can d e v e l o p u n d e r s t a n d i n g o f t h e i r clients' needs. I n fact C r o m i e r a n d C r o m i e r (1985) feel that unless we a r e a w a r e o f o u r o w n feelings a b o u t ourselves t h e n we a r e unlikely to establish a n y k i n d o f a r e l a t i o n s h i p with o u r clients. It is obvious that, f o r midwives to resolve this d i l e m m a , they m u s t b e given t h e responsibility to d e c i d e the a p p r o p r i a t e n e s s o f h o s p i t a l policies at an i n d i v i d u a l level. T h i s will b e crucial if they a r e to take t h e i r role as client a d v o c a t e seriously. C o n s i d e r a t i o n m u s t also be given a n d positive steps t a k e n to p r o v i d e s u p p o r t services for midwives to m e e t t h e i r own e m o t i o n a l n e e d s so that they can b e m o r e effective in facilitating clients to m e e t t h e i r e m o t i o n a l needs. D i l e m m a analysis o f the d a t e e m e r g i n g f r o m this s t u d y indicates t h a t the t h e r a p e u t i c value o f the midwife/client r e l a t i o n s h i p seems to be i n f l u e n c e d by a n u m b e r o f issues which a r e raised in e v e r y d a y clinical practice. It a p p e a r s that, w h e n the midwives w e r e successful in resolving these issues, t h e n the r e l a t i o n s h i p b e t w e e n the midwives a n d clients w e n t b e y o n d the n o r m to b e c o m e 'special' a n d t h e r a p e u t i c .
H o w e v e r , w h e n these issues were n o t r e s o l v e d successfully they b e c a m e d i l e m m a s which t h e n inhibited d e v e l o p m e n t o f m e a n i n g f u l r e l a t i o n s b e t w e e n the midwives a n d clients. I n view o f the e v i d e n c e s u g g e s t i n g t h a t clients value this 'special' r e l a t i o n s h i p a n d f r o m t h e findings o f this s t u d y t h a t midwives also g a i n satisfaction f r o m this r e l a t i o n s h i p , t h e n it seems r e a s o n a b l e to a r g u e f o r c h a n g e s within m i d wives' e d u c a t i o n a l p r e p a r a t i o n as well as o r g a n i s ational c h a n g e s a n d t h e p r o v i s i o n o f s u p p o r t services for midwives. O n l y w h e n these c h a n g e s a r e m a d e will the r i g h t e n v i r o n m e n t prevail to e n c o u r a g e the d e v e l o p m e n t o f t h e r a p e u t i c relationships b e t w e e n midwives a n d t h e i r clients.
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