Extended essay on the skills required by a midwife to facilitate effective communication at the booking interview.
For the purpose of this essay, I will briefly explain what the booking interview is and what can be gained from it. I will then go on the explore, via the literature and research, the skills a midwife needs in order to effectively communicate with the woman, and to carry out a successful interview.
The ante-natal booking clinic was described by Scott et al (1987) "as the shop window, or entrance lounge to the maternity service". It is usually the first time the expectant mother will meet a midwife, potentially one who may be involved in her pregnancy, birth and post-natal period. The first ante-natal consultation, i.e. a booking interview, is regarded as crucial to the planning of care (Chamberlain 1991, Lilford et al 1992), counselling (Galloway 1994), and to the initiation of the relationship between the expectant mother and the midwife (Methven 1989, Winter & Davies 1992).
Methven (1989), describes ante-natal booking interviews of British midwives, as the recording of an obstetric history, directed by the ante-natal record, which interfered with creating a trusting relationship with the expectant mother.
Chng et al (1980) consider that the ante-natal booking interview is an opportunity to: review the medical and obstetric history of the pregnant woman, make a physical examination, perform appropriate investigations, arrange suitable ante-natal care for the rest of the pregnancy, and book confinement in a setting with the facilities and professional expertise likely to be necessary. Advice on diet, alcohol consumption, and other health matters may be given, and any problems discussed.
The booking interview may be regarded as just a form filling exercise, and an opportunity to obtain and record information as required by the obstetric notes. Methven (1990), described the interview as, "in its broadest sense, an opportunity for the midwife to discuss parents’ expectations for childbirth, ante-natal management, labour and the post-natal period, and to plan care accordingly".
The first ante-natal visit is an unknown quantity for most women. Galloway (1994) writes how anxiety, fear and apprehension can lead to vagueness in the answers that some women give. It is therefore essential that women feel relaxed, comfortable and at ease with the situation. Facilities for the woman to use the toilet, a drink, and a comfortable chair should all be available. If the woman is comfortable, she is much more likely to feel at ease, and open up to the midwife. Winter & Davies (1992), who are independent midwives, write how they feel it is important for the woman’s partner to be present at booking. Of course, this is not always possible, depending on individual circumstances, but in some cases, the woman may feel less nervous if her partner is with her. She may, on the other hand, feel more comfortable alone.
The location of the interview is of paramount importance when it comes to getting a full, and often very personal history from the woman. Wherever possible, a quiet room should be found. DeJulia (1980) wrote that a quiet area of the ward/unit is better than a busy hospital corridor. Methven (1990) found that privacy was lacking in nearly half the interviews she observed, some of which were subject to interruptions on up to three occasions. There is no doubt that lack of privacy and/or constant interruptions would affect the flow of the interview, and according to Methven (1990), reduce the sense of trust placed by the mother in the interviewing midwife. Winter & Davies (1992) prefer to book the woman in her own home. This is usually the case with independent midwives. They found that the advantages of this were obvious: they are on the woman’s home ground, as guests, and the couple’s thoughts and feelings are more likely to be respected.
The midwife should have had practice at interview technique. This is not something that we are born with; it is a style that is learned over time. Methven (1989) suggested that student midwives should not undertake the unsupervised conduct of a booking interview until the final part of their training. It is therefore important that students have the opportunity to learn interview technique in a classroom situation, and that they see enough booking interviews carried out by experienced midwives. This way, they will be able to develop an interviewing style of their own. Marriner (1975) wrote that interviewing is an observational technique. It s a method of learning about people through purposeful, goal-directed communication. During the booking interview, the goal is a successful interview, when the midwife has obtained the required information, and the mother is happy that her questions have been answered, and her antenatal care planning has begun. DeJulia (1980) wrote that the interviewer must continuously strive for self-actualisation in order to achieve a conducive atmosphere. She wrote that self-actualisation is a quality that shows the nurse (midwife) to be polite, healthy, confident, compassionate, in control of herself and her impulses; it shows she can avoid hurting others, can focus on accepting of self and others, can focus on problems outside herself and can relate inter-personally at a deeper level, to name but a few characteristics. This is basically saying that the midwife can focus completely on the woman, and leave her own issues aside, to make the woman feel relaxed, valued and cared for.
Sensitivity is also an issue that should be taken into account at the booking interview. If the woman is made to feel upset or embarrassed, the midwife will not elicit a full response from the woman during the interview. According to deJulia (1980), the interviewer (in this case the midwife) should try not to harass the patient, or probe deeper than she should in some areas, if the woman is unwilling to give information. In the case of the booking interview, the questions most likely to cause upset or offence, are asking unmarried mothers who the child’s father is, and questions surrounding previous obstetric history. A woman may have had a previous pregnancy terminated that their current partner is unaware of. Methven (1990) wrote about mothers having personal access to their obstetric record, and how the midwife must ensure that whatever is written is acceptable to the mother.
A very important skill, that the midwife must learn in order to facilitate effective communication during the interview, is that of a skilled interview technique. As mentioned before, a skilled technique is something that we can learn, and the student must have plenty of opportunities to observe the skilled practitioner. According to deJulia (1980); there are eight interview techniques, in the form of question types.
Direct questions are those that require a specific response. They are used with a definite purpose in mind and restrict the patient’s response. For example, asking, "What did you eat for breakfast?" Marriner (1975) wrote that the direct question technique elicits a response, but the patient is able to reveal little about themselves.
Non directive questions are general in nature and can be answered in a variety of ways. They are usually used to encourage the patient to talk, for example, " Tell me something about yourself".
Open questions are those that allow the patient to freely express themselves. When answering this sort of question, the patient is more likely to give personal information. For example, when discussing a patient’s social situation, " How does this situation look to you?"
Closed questions are however, directly the opposite of this. They require a response of only a few words, in most cases only yes or no. For example, "Have you had your blood pressure taken today?"
Leading questions are those which will, to a certain degree, influence the nature of the patient’s response. For example, asking the patient, "Have you read the consent form?"
Another form of leading question is the partly answered question. In effect, the interviewer will answer part of the question for the patient. To a certain extent, the response is determined by the information already given in the question. For example, "Why did you get out of bed? I expect you are eager to go home."
Planned questions are thought out in advance as part of a logical sequence. For example, " What would your suggestion be on this plan of care?" This would probably be asked of another health care professional, rather than a patient.
Probing questions, which are often used in psychiatric care, are those which probe beneath the surface of a previous answer to uncover attitudes or motivations behind it. For example, "And you approved of this?"
It can be seen from this lengthy list of question types, that the field of communication in midwifery, or indeed in any medical profession, is an extensive one. In the case of the booking interview, it may not be possible to structure the interview too rigidly, because every woman is an individual, and every woman will give different answers. The midwife should remember this, and treat every woman as unique.
Olsson et al (1996) found that considering the uniqueness of the expectant parents, means that the midwife is showing willingness and pleasure in learning to know them in their specific life situation. If every mother is made to feel special and unique by the midwife, as early on as the booking visit, the midwife is likely to elicit a much greater response, than if she treats the visit as just a form filling exercise, that has to be completed.
Another communication skill that does not immediately come to mind, is that of body language, or non-verbal communication. According to Robertson (1994), up to 90 percent of what a person communicates is sent non-verbally through posture, facial expressions, gestures, tone of voice, and many other factors. The anthropologist Desmond Morris (1989) has extensively studied body language and human behaviour. He subdivided body language into five categories of actions:
Inborn actions are those we do not have to learn. Morris (1989) observed that people all around the world perform a rapid eyebrow-flash greeting. Even though it does not provide conclusive proof, the global distribution of this facial movement strongly suggests that this action is inborn.
Discovered actions are those that we discover for ourselves, such as arm folding.
Absorbed actions are those we acquire unknowingly from our companions – gestures and postures that may be group or culture specific.
Trained actions are those we have to be taught, such as winking.
Mixed actions are acquired in several ways, such as leg crossing, which is a discovered action, but as women become older, they may be taught that one way is more ‘feminine’ than another and so the action becomes modified.
Experienced midwives can often tell just by looking at a woman, how she is feeling and the state of mind she is in. She can do this by observing her facial expressions, posture, tone of voice, gestures and general body language. In the booking clinic this can be particularly useful in assessing whether the woman is nervous, anxious, upset, or even ecstatic to be pregnant and even to be at the clinic. This is a skill that is invaluable to midwives in assessing a woman’s state, and knowing how to approach her.
O’Driscoll (1997) considers the point that the midwife should be aware of her own body language. She should remember that some body language, including touch, could be interpreted as over familiarity. The midwife needs to develop a relationship with the woman, but must remember that at first she is a stranger. There may be things that she does not wish to share with the midwife, especially in a booking clinic, where it is quite often the mother’s first contact with the midwife, and she does not feel she has enough of a trusting relationship. Body language is such an integral part of our communication style, that it is often not thought about, neither its effect on other people. The good communicator develops the art of body language, so that it enhances and compliments the spoken word (O’Driscoll 1997).
Another technique employed when interviewing someone in a situation such as the booking clinic, is that of listening. According to deJulia (1980) the midwife should allow the woman to speak if she wants to. The midwife cannot listen effectively if she is talking herself, so she must always be aware of this.
Gerard Egan, in his book, "The Skilled Helper" (Egan 1995), considers the acronym SOLER when talking about non-verbal means of communication and listening. SOLER stands for:
S: Squarely facing the client: The midwife should adopt a position that indicates to the woman that she is being attended to.
O: Open posture: It is important that the midwife does not display any defensiveness. She should not sit with her arms crossed and legs folded.
L: Lean forward: By doing this, the midwife physically indicates her presence, her interest in the client and her wish to attend.
E: Eye contact: The amount of eye contact must be balanced between too much and too little. It conveys both receptiveness and potential discomfort. The appropriate amount of eye contact is open to varying cultural norms (Egan 1995).
R: Relaxed attitude: Even if she does not feel particularly relaxed, it is important that the midwife appears so to the client. It will encourage further disclosure by the client, and make the client feel more relaxed in the presence of the midwife.
Psychologist Carl Rogers (1951) proposed that core conditions of unconditional positive regard, empathy and genuineness are dependent on effective listening.
It has been suggested by Argyle (1983), that the non-verbal aspect of communication is five times more powerful than verbal communication. It is therefore self-explanatory that listening skills are of vital importance also. Butler & Jackson (1998) wrote how important it is that the midwife is aware of her body language and the subliminal messages that she may inadvertently be sending to the client regarding the degree of both listening and attending. Ralston (1998) writes that although listening is usually considered a passive process of receiving information, it is actually an active process that requires the midwife’s complete attention. We must remember that listening involves the mind as well as the ears, and the midwife must be alert and free to concentrate on two levels of communication, both the verbal and non-verbal (Ralston 1998).
Listening skills are of vital importance during the booking interview, as an adjunct to information giving (Butler & Jackson 1998), and in the decision making process. It can allow the parents to opportunity to discuss their feelings openly if they are confident that the midwife is listening and assimilating the information they are giving.
The most major barrier to effective listening is that of the time constraint. The midwife is likely to feel rushed if she knows there are other women waiting to see her, and this is likely to lead to her not listening fully to the woman that is with her. Although not directly related to the booking interview, this factor was highlighted in Changing Childbirth (1993) in relation to screening for fetal abnormality. The Expert Maternity Group found that the focus of the visits were on the tests themselves, as opposed to listening and providing support.
Wilkinson (1999) wrote that listening is a difficult skill to sustain, because we formulate a response before the patient finishes what they are saying. Their dialogue triggers our thought processes to consider how we are going to respond. She also wrote that we are far often happier talking to patients rather than listening to them, because if we are doing the talking, we remain in control of the situation, and are therefore unlikely to have questions posed that we may have difficulty handling.
We must also consider the skill of empathy during the booking interview. Wilkinson (1999) describes empathy as, "the ability to perceive the meaning and feelings of another, and to communicate those feelings to the other person". The midwife must however, be careful not to sound patronising, as this will alienate the woman instantly.
So, it can be seen from the previous discussion, that there are a multitude of skills that a midwife must consider in order to facilitate effective communication during the booking interview, and also in her other work as a midwife. It is imperative that the midwife remembers that it is quite often the woman’s first contact with the maternity services, and the impression that is given at the first visit, is likely to be remembered during the rest of her ante-natal care. She must remember that although there are a huge number of questions to be answered, the woman should not be made to feel she is on a conveyor belt. Every woman should be made to feel unique. The woman must be made to feel relaxed, and there should be a certain degree of privacy, as there may be things the woman is going to disclose that are very personal.
Question technique is important. The midwife must make herself aware of the many different question types, and be aware of the correct situations in which to use them. She must think ahead of herself, and think of the type of response she is likely to get from the question she is asking. If she is asking a series of closed questions, she must realise that she is going to get a series of one-word answers. For a fuller answer, she must ask perhaps a non-directive question.
As I have already discussed, these skills are learned, and student midwives must realise this. It is vital that students are given plenty of opportunity to practice questioning techniques and interviewing skills. Perhaps direct-entry midwifery students have an advantage here, with their course being three years long, they may have more opportunity to practice their communication skills.
The midwife must remember the non-verbal skills of communication as well. These include body language and listening skills. The midwife must be aware of so many things, from something as important as her facial expression, down to the way she is sitting. As O’Driscoll (1997) wrote, the good communicator develops the art of body language so that it enhances and compliments the spoken word.
Listening skills must not be forgotten during the interview. The midwife must allow the woman to speak when she wants to, and according to Rogers (1951) have unconditional, positive regard for the woman. Listening involves the mind as well as the ears, and the midwife must be able to concentrate on what she is hearing and what she is seeing.
We must not forget empathy, which means the ability to perceive the feelings of others, and to communicate these feelings. It is good for the mother to know that someone else is trying to understand how she feels.
There is so much literature and research available to midwives surrounding the area of communication, and the development of communication skills. It cannot be stressed enough that these skills must be practised, and students must have plenty of opportunity to learn, and practice first on their peers, and then on the pregnant woman.
Finally, we must remember that first impressions last, and the ante-natal booking clinic, which is the beginning of the ‘maternity experience’ , must be the beginning of an informative and communicative relationship between the woman and her midwife.