An initiative to strengthen the midwife’s role in reducing health inequalities used drama to illustrate how social issues can affect mothers’ engagement with services
This article examines some of the training resources NHS Education for Scotland is using to support the Scottish government’s refreshed framework for maternity care. One of the key issues underlying the framework is how social inequality can affect the long-term health of mothers and their babies. NES has used interactive drama to raise awareness of this issue and enable midwives to develop care plans to suit individuals and their social circumstances. This article focuses on one element of the programme: a piece of drama telling the story of a pregnant mother and her journey through the maternity care system. This is used to help maternity staff see the impact of social context on the way in which women engage with services.
Citation: Smith S, Walker E (2013) Using drama to improve service engagement. Nursing Times; 109: Online issue.
Author: Sandra Smith is educational projects manager, NHS Education for Scotland; Esther Walker is director, Forum Interactive.
- This article has been double-blind peer reviewed
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The Scottish government has developed a suite of policy and guidance seeking to improve maternal, newborn and infant health. The Refreshed Framework for Maternity Care in Scotland (2011) is central to this policy landscape and seeks to strengthen the role of maternity care in reducing the impact of social inequalities on health outcomes. It is crucial to the Scottish government’s commitment to giving all children the best start in life and fulfilling the ambitions of the Early Years Framework (Scottish Government, 2009).
NHS Education for Scotland, NHS Scotland’s education and training body, plays a key role in supporting the implementation of government policy by developing educational resources for staff that are relevant to their day-to-day work. In this project, NES used stories, told through drama, sound and photographs, to support and develop the maternity care workforce. The fictionalised stories are drawn from real experiences; through them, complex policy and research evidence can be translated into practical, meaningful improvements in practice.
The resources aim to build on staff’s existing skills and knowledge, and connect them with new insights, experiences and understanding. The programme focuses specifically on how social inequality affects the long-term health of mothers and their babies, and seeks to develop a culture in which:
- The important role of maternity staff - not only in relation to direct maternity care but also with regard to influencing wider public health outcomes - is recognised and used;
- Staff recognise and respond to the health and social issues affecting pregnant women and their families, and adopt an approach to care that is flexible, personalised and sensitive to these social circumstances.
Learning through drama
The first learning resource developed by NES in partnership with Forum Interactive, a learning and development consultancy, was a drama telling the emotional story of a woman and her partner as they experienced pregnancy and the birth of their first baby. Designed specifically for midwives, it focused on midwives’ important role in promoting public health, recognising their critical role as the first point of contact for most pregnant women and their families.
The drama was introduced at six learning events, which were held in March 2012 in Glasgow, Dundee and Inverness. It introduced the story of new parents Mairi and Jason (fictional names) through a series of scenes participants could watch and with which they could interact. Between each scene, participants were asked a critical question by the facilitator; this was designed to encourage them to reflect on their own practice and discuss key issues raised by the story. The questions were designed to reflect the words used in the Getting it Right for Every Child approach (Scottish Government, 2004), which has been widely adopted in Scotland. For example:
Q: What is getting in the way of Mairi and/or her baby’s wellbeing?
A: Poor maternal nutrition, Jason’s “hidden” history, lack of prenatal preparation, alcohol consumption, poor housing, mental health issues, insecure relationship.
Q: As a midwife, which of these factors do you see as your direct concern and what additional help might be needed from others?
A: Midwives identified Mairi’s stress levels and alcohol intake as their direct concern, and that additional help might be needed to support Mairi and Jason’s housing situation. Other factors identified were Jason’s potential addiction, confidence issues as well as education and support for Mairi to prepare her for motherhood.
After these learning events, the drama was made available to all midwives in NHS Scotland via an online resource that included a user guide to assist with self-learning and internal training. The live scenes were translated into a digital format using audio and photography to tell the story, and the user guide included policy information, reflective questions and exercises, together with comments and feedback from midwives who attended the learning events. The guide is designed to encourage members of a wider audience to reflect on their public health role.
A key issue highlighted within the Mairi and Jason play, which ties it to the policy framework, is the impact that social inequality and social circumstance can have on the way people engage with maternity services and vice versa. The drama was used to explore how these issues can affect the behaviour of women and their families, and how midwives can respond by adapting their own approach to care. It showed how approaches like “strength-based” and “inequalities-sensitive” practices can have a positive impact on the health of both women and their families.
A strength-based approach is one in which the midwife focuses on what the woman and her unborn baby have going for them, rather than focusing on the negative factors in their lives. For example, in the case of Mairi and Jason, it would highlight strengths like: “they show affection for one another”; “they are both in work”; “Jason is no longer taking illegal drugs”; and “Mairi is motivated to attend the antenatal clinic”.
Where midwives are using inequalities-sensitive practice, they are aware of the ways in which social inequalities can affect a woman’s access to, and engagement with, services. As a result, they will be able to make necessary adjustments to the way they work with the woman.
Delivery of the programme
Live learning events
The play sets the scenes and follows the couple’s journey through various stages of maternity care, from prenatal, to birth and postnatal care.
Some scenes are hard hitting and deal with difficult and sometimes uncomfortable situations, including an altercation between Jason, the young father, and a senior midwife. Jason is upset because a midwife on the postnatal ward implied he was not holding his daughter properly. The scene ends with the midwife preparing to call security to have him removed from the hospital. Participants were asked to reflect on what might happen next, and identified important consequences for the family’s health and wellbeing:
“The fragile beginnings of a relationship between Jason and his baby will have been spoiled and an opportunity to connect Jason with the importance of his role as a father would have been lost.”
“Security will escort Jason from the building and this experience will have confirmed all his mistrust of hospitals and health professionals, creating a barrier for future access to healthcare services.”
“Mairi, upset and embarrassed, will discharge herself and they’ll return home tense and anxious, with little support.”
The scene is then replayed but with participants able to stop and intervene, ask the midwife questions and suggest alternative, more productive ways of approaching the situation. Through their interventions, a better outcome is achieved: Jason meets his daughter and the midwife shows him how to hold her safely.
The midwives’ response to the interactive format is reflected in the following comment:
“I really enjoyed the event, it was really useful. The actors were fantastic - it was very effective to use these methods and really made me think about my practice. I look forward to using the online resources.”
The alternative outcomes that can be achieved by adopting different approaches to maternity care are also clearly shown in the online resource. For example, the scene described above, involving Jason and a senior midwife in altercation, is presented in two versions. This allows learners to see how adopting different attitudes and behaviours can result in different public-health outcomes for the mother, baby and wider family.
The online resource is designed to generate a similar level of engagement with the issues as generated by the live learning events. The use of audio and photographs in soundslides:
- Encourages users to feel emotionally engaged with the characters; and
- Shows alternative ways of approaching the same situation.
The user guide can be accessed as a PDF download and shows how the resource can be used flexibly by individuals and groups. It is designed to ensure learning is engaging, relevant, accessible and easily applied in practice.
Benefits of using drama
Encouraging culture change is a long and complex process. People need to be given opportunities to question their own habits of behaving and thinking in a way that encourages them to be open and interested. Stories provide a way of showing multiple perspectives on any given situation and allow issues to be raised without judgement. Those listening to or watching the stories are free to respond to what is most relevant to them, which is more likely to hold their interest. They also get involved in the characters’ stories and engage with the issues because they are enjoying the process:
“This was a fantastic way to learn the importance of communication at all levels. It resonated deeply with me.”
Practitioners do not always have the time to read research reports or policy documents and often feel overwhelmed by what they see as new demands imposed on them by national policy (Eckosgen and the University of Bedfordshire, 2012). Many elements of these “new demands” are already embedded in everyday practice and evident in pre- and post-registration midwifery education (Queens University Belfast, 2011). Drama and stories provide a way of educating and raising awareness around key issues in a way that is accessible and immediately relevant.
“This course was excellent at helping me piece together my role within the numerous government policies and agenda for maternity services.”
Following each of the learning events, NES asked 160 participants to complete a questionnaire as a means of collecting feedback on how much of what they learnt was new and how much reinforced existing good practice. Over a number of months this has resulted in a database of quotes and comments, helping NES to evaluate the programme’s success. Comments received include:
“The drama reminded me that there were a whole lot of reasons why women might not give up [smoking] and some of them had never crossed my mind before. The problem is never that they did not have enough information. What women need is support in identifying small manageable steps and encouragement to keep going.”
The programme also helped to reinforce the importance of midwifery skills and the impact they have on wider public healthcare.
“I don’t think we realise how skilled we are at that [public health] because we do it day in day out. This story reminded me of how important my job is.”
Although all respondents accepted the drama and methodology, a small number of midwives felt the training covered issues and methods of care that were already familiar and used in everyday practice. This reflected the fact that participants came to the training from different starting points - while some required direction, skills development and understanding, others were at a more advanced stage, which may have caused them to see the content as “familiar ground”. However, on balance, the programme was broad enough to be able to adequately cater for the majority of needs and development stages, and flexible enough to allow participants to take away that which was most important and relevant to them.
Given the overwhelming level of support and positive feedback, NES is using the same approach to develop two further story-based resources as part of the Compassionate Connections project:
- The story of Mairi and Jason is being extended to cover more of their pregnancy journey and the way all maternity care staff engage with them.
- A second story about a teenage mother is being developed to explore issues of poverty, domestic abuse, drug misuse and the importance of nurturing relationships.
Pilot and evaluation of the Compassionate Connections learning resources will be undertaken at early implementer sites in six NHS boards and three higher education institutions across Scotland between September 2013 and March 2014. A national workshop to launch the resources will take place in the autumn of this year in central Scotland.
- Social and health inequalities can affect the way pregnant women engage with maternity services
- Midwives can play a crucial role in reducing the impact of social inequalities on the long-term health of mothers and babies
- This requires midwives to adapt their practice to individual women’s needs
- Drama can help health professionals to see situations from their patients’ perspective
- This method can be transferred to online learning resources
Eckosgen and the University of Bedfordshire (2012) Learning Needs Analysis to Support Implementation of A refreshed Framework for Maternity Care in Scotland. Glasgow: GEN
Queens University Belfast (2011) Public Health and Midwifery Education: A Scoping Project. Belfast: Queens University.
Scottish Government (2011) A Refreshed Framework for Maternity Care in Scotland: The Maternity Services Action Group. Edinburgh: Scottish Government.
Scottish Government (2009) The Early Years Framework.
Scottish Government (2004) Getting it Right for Every Child.