The role of the obstetric physiotherapist is well defined, during the antenatal phase, they ‘aim to prevent or alleviate the physical and emotional stresses of pregnancy and labour.’ Postnatally, they ‘help the mother in her recovery by teaching exercises, back care and general health education, including coping with the stresses of parenthood [including] painful perineum, backache and incontinence’ (Association of Chartered Physiotherapists in Women's Health (ACPWH), 2013). But is this clearly defined role of obstetric physiotherapists recognised and utilised within the obstetric services?
Midwives are the ‘key route for information delivery [within maternity services], although the Pregnancy book and leaflets also provide important back-up’ (TNS System Three 2005:3). Considering the emphasis on patient centred care and active patient decisions, ‘patients will be in charge of making decisions about their care’ (Department of Health (DH), 2010: 1), it would be helpful if multidisciplinary teams (MDT) knew that physiotherapists can have a role to play in antenatal and postnatal care.
A mixed perception is presented whether physiotherapists' involvement in obstetrics is recognised and accepted.
The absence of physiotherapists included within expert maternity panels and references of the profession within key government maternity documents (Mantle, 2004) demonstrated within Supporting Families in the Foundation Years (Department of Education and DH, 2011) and Changing Childbirth (DH, 1993) questions the recognition of physiotherapist's role within this health speciality.
However, the hands-on spectrum of the healthcare hierarchy portrays a different view. The Myles Textbook for Midwives includes women's health physiotherapists within the MDT caring for women during pregnancy, labour and puerperium (Lee and Thomas, 2009). Furthermore, Dame Barnes (2004: ix) states physiotherapists ‘have a special role which cannot be properly undertaken by others not trained in their methods’.
A literature search explored electronic databases: MEDLINE, CINAHL, AMED, MIDIRS, ACPWH and the RCM. MeSH terms included: ‘student midwi’, ‘midwi’, ‘physiotherap’, ‘antenatal’, ‘postnatal’, ‘obstetric’, ‘understand’, ‘role’, ‘attitude’, ‘belief’, ‘perception’, ‘recognise’ and ‘interprofessional’. Articles which were English transcribed and published between 2007–2012 were reviewed. Very few relevant articles were identified; therefore the search was expanded to start from 1990. Further articles were identified from articles reference lists.
The literature predominantly links obstetric physiotherapists' role to three areas: pelvic girdle pain (PGP), incontinence and postnatal depression.
Individualised physiotherapist-taught exercises are the recommended treatment for pregnancy PGP (Lennard, 2003), which effects 4–76.4% of pregnancies (Vleeming et al, 2008), and is the first-line of treatment for incontinence (National Institute of Health and Clinical Excellence (NICE), 2006). Pelvic floor exercise promotion should be instigated antenatally with limited advice postnatally (Ewing et al, 2005). Physiotherapy input is perceived as inexpensive and effective.
Postnatal depression affects 13% of new mothers within the first 3 months. Exercise and face-to-face health education postnatally has been shown to improve new mothers' wellbeing (Normon et al, 2010). However, the utilisation of physiotherapist's skills to reduce the risk of postnatal depression is an area with limited research. But are midwives aware of the role physiotherapists can undertake?
Interprofessional relationships enables role understanding, recognition and promotes patient quality through ‘maximising health goals, minimising duplication of tasks and increasing job satisfaction’ (Opoku 1992: 119). Collaborative working centres around recognising and accepting expertise, mutual respect, trust, understanding, appreciation of each other's role (Opoku, 1992) and ‘effective communication’ (Caldwell et al, 2006: 1250). The latter being a significant contributing factor discussed throughout the Francis inquiry into the Mid-Staffordshire NHS Foundation Trust's failings (Francis, 2013).
Interprofessional education (IPE), a core competency developed as societal professionalism expectations grew, prepares students for interprofessional practice (Verma et al, 2006; Nisbet et al, 2008). It ‘resolves misunderstandings, overcome prejudice and negative stereotyping, improve communication, and acquire collaborative competencies’ (Verma et al, 2006: 114). However, there is conflict surrounding the timing of introducing IPE within health course syllabuses. One perception suggests personal professional identity is needed prior to understanding others (Forte and Fowler, 2009).
Stereotypical thoughts between health professionals impacts on interprofessionalism. Stereotyping is formed prior to attending university, particularly amongst students with parents in health professions (Tunstall-Pedoe et al, 2003). Views continue to be established during university and are carried over into the workplace (Parker and Chan, 1986, Streed and Stoeker, 1991). Negative perceptions maybe promoted through teaching staff influences (Nisbet et al, 2008).
Students adopt from role models; lecturers, peers and clinical educators, selected elements to incorporate into personal conduct. Mentors play a pivotal role impacting on the confidence and self esteem of student midwives (Hughes and Fraser, 2011). During educational practices students adapt to their mentors, as failing to conform leads to conflicts and experience issues (Bluff and Holloway 2008).
Working together: Midwives perception
The tripartite agreement: Working together in psychophysical preparation for childbirth written in 1994 (Brayshaw 2003: x–xi) emphasises the importance for close professional collaboration, shared learning and defines midwives', health visitors' and physiotherapists' antenatal roles. Physiotherapists are depicted as: teachers, advisers, health promoters and treaters. They possess skills beneficial to multiple topics: Musculoskeletal problems, pain, healing, relaxation, breathing awareness and positioning, facilitated through their anatomy and physiology knowledge (Mantle, 2004; Barton, 2004).
However, according to Anderson (1999) in practice, physiotherapists and midwives provide antenatal services acting independently of each other, with limited interaction and lack awareness of the other discipline's role.
Health professionals have a duty to advise and refer patients to appropriate health practitioners (Nursing and Midwifery Council (NMC), 2008). Research suggests health professionals lack understanding and recognition of other professional's roles.
Considering this, student midwives should be introduced to the role and services physiotherapists play within obstetrics during their studies.
The aim of this paper is to explore student midwives understanding of physiotherapy in obstetrics and what role they recognise it plays within UK healthcare.
A qualitative, exploratory approach was adopted. Significant depth was gained through exploring subjectively research participants experiences and actions by ‘seeking to understand the[ir] thoughts, feelings and experiences’ (Polgar and Thomas 2008: 83/84).
A focus group was carried out with seven third year Coventry University midwifery students who fulfilled the study criteria. Participants were recruited using purposive sampling, selecting participants deliberately in relation to the predefined criteria. Following an announcement during a lecture interested third year midwifery students were asked to contact the researcher.
Participant inclusion and exclusion criteria
Participants signed consent forms accepting to take part in the research and in confidentiality and anonymity.
A research assistant, present throughout the focus group meeting, recorded key themes and observations. The focus group was also audio recorded.
Proposed questions were piloted during a one-to-one interview with a potential participant of the focus group, thereby aiding clarity of wording and highlighting potential issues (Polgar and Thomas, 2008).
Due to the integral role the researcher played in gathering and analysing their own data, reflexivity was implemented in order to recognise the ‘personal biases and experiences’ which may influence the participant (Baker, 2006: 531). Utilisation of a research journal aided exploration of the researchers influence and positionability prior to and throughout the study.
The thematic analysis process was adopted with the aim to report key elements of the data (Green and Thorogood, 2005) and aid data organisation. Braun and Clarke's (2006) six phase analysis method was adopted but adapted to increase appropriateness in relation to the study aim. The six phases were 1) data transcription verbatim; 2) manual coded generation; 3) code sorting into themes; 4) themes reviewed; 5) generation of clear defined themes and 6) write up.
Ethical approval was gained from Coventry University. Permission was also gained from the Associate Head of Midwifery at Coventry University prior to contacting midwifery students.
Results and discussion
During the data analysis, five overarching themes became evident:
Each theme is considered individually.
Role recognition is needed
Role recognition implies understanding professionals' expertise and function. An element all health professionals need to consider (Dalley and Sim, 2000). This enables service and skill utilisation that encourages best care practice.
Participants described the importance of professional role recognition in terms of professional requirement and as part of midwives scope of practice which encourages an MDT approach:
‘That is what we as professionals need to know’
As the key informers for maternity services, midwives need to understand the role of other professionals. This enables services and skills utilisation thereby encouraging best care practice.
Lack of knowledge: ‘But we don't know what a physiotherapist does’
Whilst role recognition is important, participants felt they lacked knowledge in relation to physiotherapy in terms of role, services available and referral: how and to whom.
‘I'm sure that the physio[therapists] do loads that we don't know relating to pregnant women’
Communication breakdown and course structure were underlying factors. In order for knowledge to be acted upon it needs to be available and accessible. The educational communication skills taught tend to focus on professional to patient scenarios and not professional to professional circumstances (Hall, 2005). Spending time with physiotherapists would be beneficial.
Whose responsibility is it to find out about others roles was questioned.
‘Do you think the physio[therapist]s need to come and tell us or do we need to go find out the physiotherapists services are available?’
Both professions regulating bodies: Health and Care Professions Council (HCPC) and the NMC state each has a responsibility to gain service available information knowledge in order to make appropriate referrals.
Ignorance resulted from numerous factors, including minimal and poor training, interprofessional opportunities and little interaction with physiotherapists in university and on placements. P4 reflected on her IPE year 1 experience as:
‘You are sort of oblivious to it, you are going along with it, you are bumberling along, … cause I was just thrown into it’
IPE opportunities lacked meaningful ways in terms of content relevance. Further logistical constraints meant interaction exclusion. Overall, participants felt their IPE experience had failed to promote role understanding.
‘I don't think you actually, you actually thought about their role, the importance to your role and you know how it's going to affect you as a professional’
This decreased awareness prevented choice promotion.
The need for collaborative working has escalated due to increased problem complexity, consumer and media pressure, medical and technical advances increasing professional speciality, optimal resource use in relation to economics (Barr and Low, 2012) and shorter hospital stays (Makadon and Gibbons, 1985). Fagin (1992) recommends the formation of collaborative relationships requires changes within educational institutions, centred on health professionals' perceptions of themselves and others; stepping away from traditional attitudes of single-discipline-centred and redefining a broader, shared perspective approach towards the healthcare system.
Whilst participants acknowledged IPE formed part of their curriculum, they considered it to be a negative and a poor experience. A different portrayal to that of Forte and Fowler (2009) who concluded IPE improves students' knowledge and increases their confidence with patients.
Professional identity needs to be formed prior to IPE (Forte and Fowler, 2009). Collaboration therefore is particularly beneficial during the final year. The participants in this study, all final year students, still had one interprofessional module and a placement to complete prior to qualifying; if data collection had been conducted after completion of these modules students may have expressed a different outlook.
Faculty members play key roles within IPE, but it requires time to implement collaborative working (Hall, 2005). With the increasing pressures straining small midwifery university departments (Mallik et al, 2011), time is an issue.
Community physiotherapy services would prevent accessibility barriers following childbirth. This concept reflects current maternity service changes, including increased birthing choices providing options away from hospitals, the national reorganisation of services to community orientation and reemphasis on primary care.
The redefining of midwives' responsibility towards a leading care role within normal pregnancies is encouraging maternity services to move away from traditional hierachical care (Hall, 2005). However confidence, competence, litigation fears and risk concepts prevent midwives from resuming this role (Meerabeau et al, 1999). To enable professional collaboration traditional hierarchy needs to be reformed. P6 stated:
‘We do whatever the doctor say’
It appears that the traditional hierarchy between doctors and midwives still occurs.
A perceived view
Although ignorance of the role of physiotherapy was recognised, participants still had a perceived view on the role of obstetric physiotherapy. This centred on SPD, diagnosing, offering advice and aiding mobility, and treating the effects of a traumatic birth. The role was not always perceived as treating pain related aspects of pregnancy. This view correlates with research and clinical guidelines perceptions: antenatal and postnatal SPD, pregnancy-related incontinence, 3rd and 4th degree tears, caesarean sections and multigravida (Lee and Thomas, 2009; ACPWH, 2013). Postnatal depression was not mentioned, a topic referred to within the literature review as requiring further research.
Participants also raised other characteristics away from conditions, such as listeners and advisors, skills depicted within the Tripartite Agreement.
Pelvic floor exercises were seen essential for incontinence prevention, but queried whose role it was to teach them; the midwife or the physiotherapist?
‘But the thing is we can do that you know what I mean, we can be involved with that, we should be the experts in pelvic floor’
As with Anderson's study (1999) overlapping views occurred between midwives and physiotherapists roles. ‘Role blurring’ (Falck, 1977) caused by confusion in role boundaries, can result in professionals feeling under utilised (Hall, 2005). However, undefined boundaries increase professional flexibility and promote wider career opportunities (DH, 2000).
Confusion and differences of technique of pelvic floor exercises was apparent between participants.
‘Don't clench your stomach or buttocks’
‘I always got told you have clench your tummy’
Physiotherapist's skills and knowledge utilising ice therapy, ultrasound, exercise knowledge and other pain management techniques/advice including ergonomics are also beneficial for healing promotion and pain management (Mantle 2004: 209–219).
Utilised? ‘Yes. But…’
Utilisation of physiotherapy varied significantly between hospitals including ward access to physiotherapists, to referral systems. Leaflets were often used to substitute or support physiotherapy. The perceived role is often fulfilled by midwives or non-health professional resources: media, family and the internet. The reliability of non-professional sources accessed is a concern. Numerous barriers preventing utilisation were identified.
Task prioritisation occurs amongst both women and professionals which may prevent promotion and accessing of services. Participants suggested utilisation of physiotherapists skills had become a ‘past’ action and referrals were completed out of empathy and not professional duty.
Women have mixed responses to physiotherapy they want referrals but are often too busy to attend appointments. Barton (2004: 207) suggests that psychologically, women are more concerned with their baby than themselves.
Professional and organisational constraints, including hierarchy and ignorance, impact on students. Focus on course marks not knowledge expansion determines their behaviour. Mentors are ‘not just gatekeepers to learning but more importantly they … [are] gate keepers to the profession’ (Armstrong 2009: 30). Conflict is avoided by adopting mentors attitudes (Bluff and Holloway, 2003).
Contemplation of these barriers needs consideration in relation to rehabilitation aims, service location and availability timing.
‘I think when it works, it works really well’
‘The whole mentality that I've [in reference to the woman] got someone to see about this problem, it kind of puts you at ease instantly’
Based on their minimal feedback received, participants views reflected that of Lennard (2003) and Wellock and Crichton (2007). Supported by clinical guidance proven through critical analysis including cost effectiveness suggests physiotherapy has a beneficial role within maternity services.
However barriers impact on this, notably long waiting times. Participants suggested long appointment waits caused some women to request to be induced. Perceived appointment waiting times appeared excessive compared to those described by Lennard (2003) and a survey for the Chartered Society of Physiotherapy (JJ Consulting, 2011). Waiting times for women with SPD impacts negatively on women's overall perception of physiotherapy services (Wellock and Crichton, 2007).
Participants related benefit uncertainty to their ignorance, lack of patient feedback, and placement lengths preventing opportunity. Barriers occur at all levels of the healthcare system, including patient and individual professional; patient mediated interventions improve clinical practice (Grol and Grimshaw, 2003). Continuing auditing and patient feedback are required to determine the benefit of obstetric physiotherapy.
Representational generalisation and transferability is not appropriate (Lewis and Ritchie, 2003) due to study size and geographical limitations. The researcher's limited experience may have also had an adverse effect on the study. However, peer reviewing codes and themes may have increased credibility and confirmability.
Numerous areas would benefit from further research. Including exploration of practicing midwives and lecturers understanding and what do physiotherapists view their role to be within obstetrics.
Clinical and educational implications and conclusions
Physiotherapists have a role to play within obstetrics, as key informers midwives need knowledge and understanding of this role. To gain this knowledge, interaction between physiotherapists and midwifery students would be beneficial at training level. IPE topics should include role understanding, team interaction skills and opportunities to observe physiotherapists.
Physiotherapists have a responsibility and a need to promote their skills to increase student midwives awareness of what role they can play. Accessibility to physiotherapy services also needs consideration, including increasing community services.
Student midwives recognised the importance of understanding other professional's roles and had a perceived view of the physiotherapists. However, they lacked understanding and knowledge in relation to: role, services available and referral system.
Numerous identified barriers prevent understanding and service utilisation. Predominantly physiotherapist's roles are replaced by midwives and non-health professional sources. Physiotherapy service provision appeared lacking in continuity between hospitals and trusts and waiting times are inappropriately long. Benefits of physiotherapy were identified.
University IPE experience had not promoted or aided the recognition of physiotherapy benefits due to limited interaction, time and lack of focus on role recognition.
Considering current focus promoting patient choices, patient centred care and patient service awareness it appears student midwives are unable to promote physiotherapy services appropriately. A concerning factor for obstetric physiotherapists and service users.