 I'm pleased to introduce Danielle McDonald. She's an assistant professor at the School of Nursing, Queens University in Kingston, Ontario, Canada. Her research focuses on understanding the experiences of global birthing care. Specifically, she is interested in collaboration, midwifery and nursing, birthing people and their families. Dr. McDonald has experienced teaching nursing in culturally complex contexts, most recently in the Middle East. She is thrilled to be back in Canada and looks forward to creating inclusive relationships to collaborate and learn about the experiences of birthing care globally. Thank you, Tanya, for that introduction. It's really, I'm really delighted to be here today and I'd like to wish everyone on the call, first and foremost, a very happy international day of the midwife. This is very exciting to be sharing this work with all of you today. So I'd like to just start by, oops, second here, present review, oh, there we go, there. I'd like to just do a land acknowledgement. So I am actually in Kingston, Ontario, in Canada and Queens University where I work is situated on traditional Anishinaabe and Haudenosaunee territory and it's really important to recognize the land of this territory that I'm on. I'd also like to recognize Mi'kmaki, which is where I actually did the research and where I'm originally from. So I have a deep gratitude for that part of Canada as well. So just to begin, just to sort of touch so that you know a little bit about who I am and I know Tanya has started this off and telling you a bit about me, but I've had a lifelong interest in midwifery and global birthing care experiences. Since I was a little girl, I was always the one that was looking for the newborns and the new moms and interested in breastfeeding. And that interest and passion has followed me through my career, I'm a registered nurse and definitely a fierce advocate for midwifery here in Canada and globally. I definitely situate myself as a feminist. I'm originally from Nova Scotia. I finished my PhD in 2019 and this is the research that I did to complete that. And I was delighted to join Queen's University School of Nursing this past September. And just to let you know, my program of research really looks at global birthing care experiences and specifically when we're thinking about that as they relate to midwifery and nursing, birthing people and collaboration. Okay, so a bit about the background for this work. Here in Canada, midwifery is a provincially regulated profession and this has really led to different practice arrangements in the different provinces. And so we know that the integration of midwifery into existing perinatal services in Canada hasn't always been smooth. And we know also that there are historic sort of overlapings of skills and roles and identities when we're talking about nurses and midwives and nurse midwives. And that's specific to Canada, but we can also see that globally as well. These historic tensions specifically have been documented in Canada in provinces of Ontario and Alberta. More recently, Nova Scotia and British Columbia. And we can see that this overlapping of these skills and roles and identities have really, we can see that reflected in different scopes of practice, different educational pathways and models of practice for midwives and perinatal nurses globally. In 2015, I conducted a systematic review and I looked at the experiences of collaboration between midwives and nurses. And I was specifically looking at qualitative research that had been done about this. And there wasn't much. There were five studies total that I was able to find, three of which were Canadian studies. And really the conclusion from this review was that we needed to know more about collaboration between midwives and nurses in a variety of clinical practice contexts. So this brings us to Nova Scotia. Nova Scotia is a province in Canada. Midwifery was regulated there in 2009. So it's, midwifery is a relatively new sort of regulated profession in that province. At the time of the study, there were seven practicing registered midwives. And there are currently now 17 midwives that are filling 16 full-time positions. There are three model sites. They are the original three model sites that were set up when midwifery was initially regulated. So the services have not extended beyond those three particular sites. And there's just one little error here on the model sites. And that was that during the time of data collection, it was actually the bridge water site that was suspended. But it's important to know that two of these sites are rural and one is urban. In Nova Scotia, we have registered nurses that are providing perinatal care. And they're providing it anti-natally, interpartum and postpartum. We also have registered nurses who are attending home versus second attendance where they actually go and support the midwives and birthing people and their families in a second attendant role. And it's at the time of the study, the College of Registered Nurses of Nova Scotia, it's now changed to a different name, but they were really clear to highlight the distinction between nurses and midwives and had two policies regarding that that really outlined the responsibilities and expectations for registered nurses who may hold a nursing license to practice and a midwifery license to practice, but also what the expectations were for nurses who were working as second attendance at home births. So the study purpose was really to explore collaboration between midwives and nurses in Nova Scotia. And I was really interested in understanding how midwives and nurses collaborate during perinatal healthcare in Nova Scotia. So I used feminist post-structuralism as the theoretical perspective. The feminism piece really allowed me to attend to power dynamics that are related to gender and sort of thinking about patriarchy and what role that has had as it related to the research question. And then post-structuralism really allowed me to challenge what had been taken for granted with her. This idea that thoughts and experiences and language have plural meanings and mean different things for different people. And so sort of recognizing the power of discourse and how different discourses can really act as meeting points for power and knowledge. So together combining feminism and post-structuralism really provided a lens to explore power relations and the role that gender and discourses play in those power relations as they related to collaboration between midwives and nurses. I used a case study methodology and really I used what Stake refers to as an instrumental case. And so the idea here was that I was using the case to facilitate a really in-depth understanding of that specific case in order to understand the phenomenon beyond it. So I was using Nova Scotia, the case of midwives and nurses collaborating in Nova Scotia to understand what that might look like beyond that specific case. Case studies really context specific and really was a great methodology to choose to create a deep understanding of this phenomena. It's great for answering how and why questions and this idea of binding the case of really, it was a way of defining the case to create these boundaries around the case and you can use geography or time or activity. So in this specific study, I used the geographic boundaries of Nova Scotia. So the setting, I've touched on this a little bit before but essentially the setting, the boundary of the case was Nova Scotia. So I was speaking to participants at the three model sites, Nanaganish, Bridgewater and Halifax. At the time, there was one and there continues to be one health authority and then also the IWK health center which is a tertiary healthcare center for birthing people and children and it has its own sort of jurisdiction but works in collaboration with the health authority. At the time, there were nine midwifery positions. There were five positions at the IWK, two at Nanaganish and Bridgewater had two and there were seven practicing midwives during the data collection and at the time, there were registered nurse second attendants for home births at all three sites. The other thing, as I mentioned before was that one of the sites that is the Bridgewater site the services were suspended and that happened right at the beginning of the recruitment and so things were sort of in flux around the time that I was starting my data collection. I used purposeful and snowball strategies to recruit the participants. So the snowball sampling was really important because it allowed the participants to share information about the study with other potential participants. I used two types of data sources. So the primary source really relied on interviews with all the participants and those were face-to-face interviews. I had a semi-structured interview guide. They took place in private locations and they range from 30 to 90 minutes in length and all the participants signed consent forms. I also used secondary sources, primarily document review where I looked at 24 documents. Most were media reports. I did look at one policy and one was an actual report and then I did also maintain field notes to keep track of what was going on. And then the individual and group discussions once I had done the preliminary analysis I shared those findings with the participants and keeping with the feminist tenant of including participants throughout the process. This was the analysis I used feminist post-structuralist discourse analysis and I won't go into great depth with this here but just to know that essentially I looked at I read and listened to the interviews and then identified and named what important issues I found in the transcripts and within each of those quotations of the issues I identified the values, beliefs, practices and discourses within that quotation and then brought together. I also considered concepts of gender and power relations, agency and subject positions and then aggregated the similar issues together to create the sub themes and the themes and I'm happy to answer more questions about that later. So the participants, I ended up with 17 participants in total. I actually interviewed 18 participants but one of the participants she thought she had been attended at her home birth with a nurse and midwife and contacted me after to say that actually it was two midwives that attended her birth. So I had five midwives, six nurses, three mothers, one care provider colleague and three stakeholders. The stakeholders were decision makers or folks that were in the administration and I had ethical approval from the University of Ottawa which is where I did my research, where I did my PhD as well as the two health authorities. Okay, so the findings. So this is the really fun stuff I think and the stuff that really kind of gets me excited. And so there were four main themes and there were 11 sub themes. So the main themes were negotiating roles and practices. Every nurse is different. Every midwife is different. Every birth is different. The second was sustaining relationships. The more we can just build relationships with one another. The third theme was reconciling systemic tensions, the medical model and the midwifery model and then the fourth theme was moving forward modern model for nurses and midwives working together. So for the first thing, negotiating roles and practices. One of the things that really stood out was how the participants talked about how they constantly negotiated their roles and this was an ongoing thing that happened when they came together to provide care for birthing people and their families. They also talked about how there was a crossover of skills and practices. And so Chelsea was a midwife and she said it really does crossover quite a bit like the skill set, like the actual clinical skill set as well as supportive care piece because typically nurses are doing all the supportive care until a doctor comes in and catches a baby. So with midwives, because we're there once a client is established in our active labor, some nurses really enjoy that, that supportive care piece and aren't sure then what their role is. So I do always try to have a chat with a nurse as we're settling in to say like, you do what you do and I'll just follow your vibe and my client's vibe. I'll kind of work around you all. And the other something that was part of this theme was this idea of communication and good anticipating. And midwives and nurses talked about how important it was to have clear, honest communication and how the midwives actually appreciated the nurse's ability to anticipate what their needs may be in terms of the supports they may need but also what the birthing people and families may need in their care. The second theme had to do with sustaining relationships and there were three sub themes along with this. So this testing trust, if they did not trust us, they would not sign up. So this idea that trust was really intrinsic to specifically nurses working in the role of second attendant at home birth but also in the hospital as well. So that trust almost needed to be met and almost needed to be tested and assured that it was there so that they would work well together. The midwives, depending on nurses, we could not do our job without them. That came through and through and was really interesting because the second attendant birth for nurses attending home births actually helped to support the stability of the home birth services. And so the midwives really recognized that and that was great. And then needing more opportunities together, they're not the unknown anymore. So Bridget was a nurse and she said, I can tell you things that I think have strengthened here is a Morrow B program, learning together, not just going to a midwifery course or going to a course on a nursing or going to a course on a physician skills. It's we all sit down at the same classroom and we all learn the same stuff. I think that was huge for collaboration and I think being in the same facility, working closely in the same unit together makes a huge difference. I think that's a huge strength and I think playing together, doing social things outside the work. The third main theme was reconciling systemic tensions. And this was really interesting, this first sub theme of the invisibility of collaboration and the best kept secret. And so there was this notion amongst participants that midwives and nurses collaborating was actually sort of invisible and was something to be protected. Florence was a midwife and she said, because the best kept secret and we all chat about it is that when you have a birth and a nurse and a midwife in the room at the hospital, it's easy because we clean up with them. Like we're all doing the same. There's so much overlap in our rules that we're taking a huge burden off of them with a client that isn't epiduralized usually and would be a lot of work. And then they're taking a huge burden for us. So there was this real sense of protecting this collaboration and how well it worked for fear that it may change. There were the other sub themes that this theme had to do with resisting and accepting institutional expectations. And so there were examples from participants where they were doing both that there were times that they stood up to those institutional expectations when it didn't support collaboration or the birthing person's needs and others when they accepted them. And then this idea of the medical approach versus midwifery approach sort of very recognizing the differences in what those approaches were and what the participants had to do to kind of come together to collaborate. The final theme was moving forward. And there were two sub themes with this. And the first one was the birthing culture has changed. And so Daisy was a nurse. And she said, well, I think if it's, I think that's a modern midwifery model if we can have nurses collaborating with midwives and working like, why can a nurse go to work at a midwifery clinic with them and work with them in their office and see patients? Like we should be doing things like that. I think if we can just change the way that the whole model of care, like that would be ideal. But yeah, I think like we should be working with them and having a modern model from nurses and midwives working together. There was a real interest in working together and creating innovative models that sort of upheld midwifery values. And the more that came both from nurses and midwives that they had worked on these relationships and valued what each brought to the care that they were providing. There was also this something with advocacy with allies and advocates and this idea that nurses could really be strong allies and advocates for midwives. There were more of them. They were, there were larger communities of them. They were everywhere. And in Canada, Nova Scotia particularly, having nurses who were well-trusted in communities where perhaps there isn't midwifery services available right now was something that was seen to be a potential way to support sustainable midwifery and the expansion of midwifery services. So in terms of discussion, it really brought up four kind of main things. So this idea of sustainability. We know that sustainability of midwifery is an issue in Canada. We've seen it in Nova Scotia. We've seen different practice sites closing for different reasons and then opening. We know globally that this is a challenge. We've just had the state of the midwifery report come out and clearly we're 900,000 midwives short globally. So the sustainability is really a challenge. And what this research offers is an idea to think about innovative approaches to delivery the delivery of midwifery services and how we can really collaborate with one another to ensure that that sustainability is supported. The second was this idea of midwives, nurses and hegemonic medical discourses. And so we know that there are historical and contemporary midwifery discourses and we know that there are nursing discourses and medical discourses. And often we see a lot of tension when those discourses come together in ways where those ideas have been siloed. And so the idea of coming together may feel threatening. And so this idea that this example of midwives and nurses working together provides hope for reconciling some of that and sort of calling into the need of making, celebrating those opportunities to acknowledge what is working when collaboration is working well. This also really highlighted sort of this idea of persons centered cultures. And so participants did talk about how the culture was changing. It was person centered. It was this idea that everybody on the care team was important and that while the focus was rightfully so on and with and for the birthing person and family, there was that care and concern and interest was extended to the care providers and everybody that was a part of that birth experience. And so this is a really, we talk about woman centered care, we talk about patient centered care, but this idea of person centered care where everybody is valued for being part of the team is I think something that we need to start thinking about and how we can use that in our collaboration. And then this idea again of a new collaborative model of care. It's not to say that this model is perfect. It's a one size fits all. That's certainly not the suggestion, but we know that midwife led models of care have excellent outcomes. We know we need more midwives. How can we support that? And I think as a nurse myself, knowing that it can work gives me hope that we can make some change and really be collaborative and honor those midwifery values. So the recommendations really were to explore collaboration between midwives and nurses and other jurisdictions in Canada. We are unique in Canada because we have midwives and nurses that we do have perinatal nurses working and we do have midwives and some of their roles overlap. Midwives are primary care providers in Canada and nurses are not, but nurses can support that, but let's see what's happening in collaboration in other jurisdictions. We need to explore how working with midwives is changing nursing beliefs, values and practices. We need to explore the feasibility of a midwife led and nurse supported model of low risk perinatal care. And really we need to raise the public profile of midwifery home birth and collaboration between midwives and nurses amongst the public and also really importantly with other healthcare providers. I think we also need to look at educational pathways between nursing education and midwifery education. Are there things we could do to ease entry from one profession to the other? Are there things that we can do to help socialize the professions to each other so that they truly understand what they do and who they are and the values that they're working with? And then we need to look for more opportunities and create more opportunities for midwives and nurses to build professional relationships. When we're concluding just to say, I think collaboration between midwives and nurses in Nova Scotia is complex, it's ongoing, it's not something that sort of is an arrived at point, but something that needs to be continually worked at. The findings really illustrated that collaboration for the most part was working pretty well. And this was working well even within a context of systemic challenges. This case study really provides a positive example of birthing care that works and really underlined that it's emerging from and within the challenges of building sustainable midwifery services in Nova Scotia. And really it illustrates the great potential for building collaborative teams of midwives and nurses in Nova Scotia in Canada and really beyond. So just to finish up, I'd just like to acknowledge my supervisor, Dr. Josephina Toa who supervised the study and all of the study participants, these are not the real names, these are their pseudonyms. So a big thank you to Annabelle, Bridget, Chelsea, Claire, Colin, Daisy, Elizabeth, Emma, Eve, Florence, Ina, Janet, Jean, Mary, Melissa, Sunny, and Susan and then as well some funding that I received to do the work. So I thank you very much for your attention and I leave it open to any of your questions or comments. Oh, Cecilia. We always do our best at UBC when we have student applications from Nova Scotia to facilitate learning for those students for a long way away, but we know the need of midwives in all of Canada. Thank you, Cecilia. That's wonderful. And I do know we have UBC grads in Nova Scotia. So it's wonderful to see that you're facilitating that for future midwives from Nova Scotia. Thank you. Lorraine, smile to you too, Lorraine. I saw that you're from Annapolis Valley, which is exactly where I'm from. So it's lovely to see you here. Are there any other questions or comments? I'm so curious to know if this resonates with folks, if this is new in different ways, if it reaffirms anything, maybe your experiences have been different or similar. Please feel free to jump in. From here in the Southwest, Arizona, that felt very salient and very much what we need and what we've experienced, like both on the positive side and the negative side of our relationships with nurses and midwifery. So thank you for starting the conversation. Thank you, Tanya. Yep, do I need to unmute you? I've got it, thanks. This really resonated with me. Midwifery in British Columbia had its own college and it was too expensive to maintain that college. And the Ministry of Health said to some of the smaller colleges two years ago that they would need to amalgamate. Nursing welcomed midwifery in a way that medicine didn't. And half of the BC midwives were very worried about aligning with nursing and being able to keep a separate identity. Your work goes a long way in making midwifery comfortable with nursing college. And I thank you, thank you, Tanya. Oh, gosh, thank you, Cecilia. I had come to know that the colleges had come together the nursing and midwifery colleges in British Columbia. And it's interesting because when you look globally, that's the case in many places, right? And part of that has to do with the tradition of nurse midwifery were so, I think, so unique and so fortunate to have a clear distinction of midwifery and nursing in Canada. And I understand that it has been challenging and continues to be challenging for a whole series of reasons. I think, though, is two predominantly female dominated professions. Between us, we have a lot in common as long as we pay attention to those distinctions. And ultimately, we share very similar goals. I mean, we want healthy, birthing people and families. We want good outcomes. We have orientations professionally to work in communities, to work with communities, to work in hospitals and in homes. I mean, those are similarities that are professional. And so, coming together, working together, I mean, I see great potential in being able to grow midwifery, sustainable midwifery in our communities by working together and supporting each other. And I know that's not easy. We're, you know, in Nova Scotia, we're 12 years in and have gotten to a pretty good place. But there's always challenges. I mean, those are three sites. If there was a new site to be introduced, in the future, there may be challenges in establishing some of those relationships and trust as well. But I think if we're all working, you know, together working at it, there's great potential. So thank you, Cecilia. I really appreciate your comments. And I see your other one, I agree about mutuality of midwifery nursing, sometimes working together administratively as a financial reality. Yeah, and sometimes I think there are financial barriers too, right? And, you know, I'm certainly learning more and more about what some of those barriers are to collaboration and to being able to freely collaborate. Yeah, thank you. I see there are a few more folks who are typing, so give them a chance to add your comments. Oh, Rihanna, the saying stronger together is definitely true. Yeah, I think so. And I, you know, for me, it was, this research has been really hopeful. And, you know, I've certainly been asked, you know, is this too good to be true? And I mean, nothing's perfect. And certainly, you know, everything is a work in progress. But I think it's hopeful because I think it demonstrates possibility for others, right? And ways that we can work together. Yeah, Tanya, learning together is a powerful takeaway. Yeah. And I think it was actually having a conversation with a midwife in the last week or so. And she was preparing a presentation to OBA residents and med students and sort of asked sort of what my thoughts were around what you should focus on. And, you know, should I get back to the basics or something specific? And I sort of said, this is your chance to really socialize them to midwifery. What is it about? And what did midwives do? And what are the values? And, you know, grab them now so that they, they, you know, can really understand that midwives are a part of the team and important intrinsic to good outcomes and good teamwork. And so, you know, it's not just nursing, but I think historically we've sort of been positioned with tension between us. And I think it's time to reframe that and look at how we can look at those similarities and support each other. See, there's more typing, right? The let is saying nurse midwife is the highest in number in the health workforce and their collaboration will bring great change. Absolutely. And I think more and more we're seeing reports about that. And, you know, certainly our situation with the COVID-19 pandemic has really illuminated how important nurses and midwives are for primary healthcare in all its facets. And so, yeah, we make up the most numbers. So how can we work together to really advocate for our own professions, each other's professions and also the families that we're working with? Alicia is asking, having nursing students learning from midwives and midwifery students learning from registered nurses is a huge part of setting the foundations for great working relationships. Yes, Alicia, that's great. And I think I noticed that you're here in Kingston and when I arrived here at Queens, I was really excited to see that we actually have our nursing students. There are, some of our nursing students are able to have placements with midwives as part of their maternity course and their undergraduate nursing program and nurse practitioners. That's right, Alicia. And so that's really, I was really excited when I found out about that here because I thought that's how we establish collaboration. That's how we work together and learn about each other and send nurses out into the world who know what midwives are and what midwives do and trust it as an evidence-informed practice. So, yeah, that was really exciting and I agree with you, Alicia. We need to look for and create more of those opportunities to learn together for sure. Alicia's saying Ontario's midwifery education program also has labor and delivery nursing rotations and NICU nursing as well. Yes, and I actually just was speaking to a midwifery student recently and she was telling me that she had had a placement with a nurse, a labor and delivery nurse and how much she learned and how much she enjoyed that placement. So, yes, absolutely. Thanks, Alicia. Belit is saying in Ethiopia, the Midwife and Nurse Associations are working together to bring on remarkable change. Oh, that's great. Do you have any specific examples of what they're doing in Ethiopia, Belit? I'm not sure if I'm saying your name correctly. I apologize if I'm not. I'd love to know if there's anything specific that they're doing. You know, it's really interesting. Are there any other questions or comments? It's wonderful to see so many folks from around the world. I'm always curious to know what folks are doing, where they live and work and what we can learn from each other. So, it's great. And certainly feel free if you have questions or any comments, please do feel free to send me an email or you can tweet me on Twitter. Find me on Twitter. I'd be happy to talk to you more about this work or really anything related to midwifery nursing collaboration or birthing experiences. So, we have someone typing. We've got a couple of people typing. Give them a second. It takes a minute to... Also, please feel free to unmute yourself and ask your question directly. Oh, yeah, that'd be great too. Java is easiest. Oh, great. I look forward to hearing from you. I'd love to speak to you later too. Thank you. A few more people typing. Sort of takes a couple of minutes to... Margaret's saying thank you. An interesting discussion working collaboratively together is often a challenge across all professions. Thanks, absolutely, Margaret. And it's, you know, I think we sort of look at the structures in place and the systems in place and how they've been created and how those structures then reinforce ways of being, ways of working, ways of knowing with each other. And I know we're certainly doing a lot of work here to really, you know, dismantle some of those silos in the ways that we work and think and learn, right? And so often when we do that, then that opportunity to come together and learn how to work together in different ways is fostered and supported for sure. Rihanna is saying learning from other professionals has definitely been my favorite way of learning and also sharing my knowledge. Yeah, and I think that's it too. I can remember one of the participants was telling a story when I was doing this research about something that she shared with a med student but also I think it was a nurse and they'd never seen what she was telling them about and just sort of that ability to share or, you know, some nurses saying, wow, like, you know, I can remember talking about, you know, having midwives come and sort of seeing unmedicated births is a big deal for some nurses who sometimes enter their practice after school and everything and they've never seen an unmedicated birth before. It's that idea of sitting on your hands and letting labor unfold on its own. And so, you know, what's being missed in that piece is if we don't have opportunities to learn with each other. So, yeah, it's great. And it's great, I think, to solidify our own practices too, right? When you're teaching someone else, you're also, you know, seeing your own practice with new eyes. So that's really great too. Yeah, that's great. I think we're getting close to time, aren't we, Tanya? Yes, we are. Yeah. Any final questions or comments? And please feel free, if not here, please feel free to reach out email or Twitter. I'd be happy to receive any of your comments or feedback. Thank you so much.