Realist evaluation of an Integrated Pregnancy and Parenting Support Service (IPPSS) for mothers with drug and alcohol problems in Scotland

BackgroundIntegrated multidisciplinary team approaches have been widely promoted for maternity services for women with drug and alcohol problems to support sharing of information, coordination of care and improve maternal and infant outcomes. National Institute for Clinical Excellence (2010) guidelines recommend woman-centred care, colocation of services, integration of multi-agency approach and non-discriminatory practices for this population. However there has been little research to evaluate the impact of this approach in the UK context.AimTo evaluate a local service in Scotland to identify how the service works, for whom and in what way and what context to achieve effective communication, information sharing and service user engagement in order to achieve improved maternal and infant outcomes.MethodsThe evaluation was in three phases: developing initial programme theories, testing theories and refining theories. A mixed methods approach included: shadowing practitioners, and conducting interviews and questionnaires with service users, staff and key stakeholders. Middle Range Theories including Trust Level Theory and Interactionist theories were utilised throughout the study to support theory development, testing and refinement.FindingsFindings include:1. Relational based practices reduce barriers to support and engage service users longer term.2. Service ethos must be consistent across all agencies in policy agenda and practice to support integration.3. Transparent approaches promote compassionate team working, improving staff morale and communication. 4. Stigma remains embedded within the wider social context and affects the interactions and success service users have with services.ConclusionTo support the wider holistic needs, practitioners should be encouraged to embrace personal approaches moving away from professional facades. Overall, services should consider what practices and interactions might contribute to stigmatising and discriminatory experiences for this population. These findings advocate for reflection on organisational integration, promotion of relational based practices and consideration of the barriers to integration such as incongruent policies, guidelines, agendas and practices

Implementing continuity of midwife carer – just a friendly face? A realist evaluation

BackgroundGood quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan.MethodsParticipatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed context-mechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context.ResultsTrusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women’s care journey, which in turn changed their perspective of how they provided care and of women’s care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed.ConclusionLeadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women’s care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change