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The Role Of Courage In Midwifery

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‘Courage is the most important of all the virtues because without courage you can’t practise any other virtue consistently.’ Maya Angelou. In order to prevent the failings of history, it is essential to have courage to speak out when a patient or practice are put in jeopardy or courage is absent (Cummings, 2015). The aim of this essay is to explore and appraise the concept of courage within the clinical setting of midwifery using Walker and Avant’s eight step model. This essay will focus on a case based in a clinical setting to demonstrate the concept analysis that will be examined through the use of Enquiry Based Learning (EBL). It is recommended by Fitness for Practice (1999) as an efficient scheme within pre-registration education in order to aid students when linking theory to practice. Furthermore, it supports learning techniques and teamwork development.

Within this essay, the declaration that there is no breach of confidentiality is paramount. In relation to the case study, all of the identifiable information has been removed and no personal information has been distributed with any unauthorised personnel. I understand my responsibility of anonymity and confidentiality as a student midwife (Nursing and Midwifery Council [NMC], 2015).

The purpose of Walker and Avant (2011) concept analysis is to advance and enhance practice. A concept analysis is a “limited exploration … investigat[ing] ‘what is’ rather than ‘what ought to be’” (Barnum, 1990, p. 101).

The ability to differentiate a concept from another stems from the systematic process of concept analysis. Walker & Avant (2011) emphasise that the misuse, overuse of concepts in practice can be aided by the systematic process of concept analysis. Additionally, it can also elucidate concepts that have not been clearly defined or are inaccurate within a theory.

Analysing the concept of courage is multifaceted, as there has been limited research on it’s influence in practice despite being a fundamental virtue. There is limited research and knowledge in regards to courage in practise, even though having been acknowledged as a crucial element of care (Lindh et al., 2010; Spence, 2004; Cummings and Bennett, 2012). Furthermore, courage has many different aspects; physical, social, moral, emotional, intellectual and spiritual. Which definition should be incorporated in midwifery practice? An exploration into the plethora of definitions allows one to understand the concept.

‘Courage enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working’. (Cummings and Bennett, 2012). Courage can further be identified as an emotional strength entailing “the exercise of will to accomplish goals in the face of opposition, external or internal” (Peterson & Park, 2004, p. 437).

An aspect of courage is moral courage which is a trait that is highly respected. This type of courage is demonstrated during challenging ethical dilemmas by individuals who disregard personal risk and adversity. One may aim to take the right approach regardless that other individuals may decide on a less ethical behaviour approach that can also involve no action being taken at all (Lackman, 2009; Sekerka & Bagozzi, 2007.

Defining attributes, similar to signs and symptoms, are critical characteristics that help to differentiate one concept from another related concept and clarify its meaning (Walker & Avant, 2005). The defining attributes of courage are caring, knowledge, overcoming, advocacy and empowerment. It is these keywords that appear frequently in the NMC code of conduct (2015) and are reiterated throughout midwifery practice.

A concept analysis according to Walker and Avant (2005) includes a model case as a part of the eight steps which incorporates all attributes that define the concept. A model case of courage within midwifery is discussed in the case study below.

At the end of a night shift on labour ward, midwife Cassie was directed to take handover from midwife Millie. Cassie introduced herself to the woman in labour, Nadine and explained that she will be taking over care. Handover was undertaken with hushed tones in the corner of the room. Millie handed over the situation, background, assessment and recommendation. Cassie was informed that Nadine was not fluent in English, but had a general understanding and was able to express herself. From Millie’s assessments, Nadine was 7 centimetres dilated, contracting 3 in 10 for 60 seconds and was “struggling to cope”. Therefore, Millie felt it necessary to discuss the next steps of a caesarean section with Nadine and her husband. The necessary paperwork was gathered and to be completed indicating consent for the procedure. The premedication has also been prepared and left with midwife Cassie. Handover was complete and midwife Millie wished the best for Nadine. Cassie took the liberty of reading through Nadine’s antenatal notes and her birth plan which she went over to discuss with Nadine. They discussed all of the options and Cassie carefully listened to Nadine’s thoughts and requests. She strongly wanted a vaginal birth using Entonox and controlled breathing. However, she was feeling disempowered, and thought her body couldn’t do it on her own. Midwife Cassie decided to support this woman. She went and spoke with her senior supervisor to advocate for Nadine and her choice for a vaginal delivery. After explaining her rationale behind her decision, Cassie’s senior supervisor approved of this decision and commended her courageous attitude. With a positive attitude, Cassie said, “this is a new day and we’re going to have this baby!”. Cassie assessed the situation, clinical need and history determined no risk to Nadine or her baby. Nadine was taken off CTG and was intermittently auscultated after every contraction. Cassie encouraged Nadine to mobilise and use the birthing ball and try different birthing positions. A calm and less clinical environment was created by dimming the lights and allowing Nadine to tune into her body and labour. About two hours later, post vaginal examination conducted with consent, Nadine was fully dilated and actively pushing, having the baby naturally and safely.

In order to reinforce and omit repetition, Walker & Avant (2005) suggest five additional model cases. These include invented, borderline, contrary, illegitimate and related cases. A contrary model case would follow the same scenario as above, however, with a different outcome after handover. This indicates the absence of the defining attribute of courage. It demonstrates what the concept is not (Walker & Avant, 2005).

…Handover was complete and midwife Millie wished the best for Nadine. Cassie took the liberty of reading through Nadine’s antenatal notes and her birth plan which she went over to discuss with Nadine. She strongly wanted a vaginal birth using Entonox and controlled breathing. However, she was feeling disempowered, and thought her body couldn’t do it on her own. Midwife Cassie reiterated that the clinical decision was with the consideration of her and her baby’s best interest. Nadine felt as if she didn’t have a choice and agreed to the caesarean. The paperwork was completed and Nadine was prepared to be taken to theatre. Nadine was accompanied by her partner. In theatre, the spinal anaesthesia procedure was unsuccessful. A general anaesthetic was decided by the doctors as it was indicated on the CTG that there was fetal distress and decelerations. After the caesarean section, Nadine missed out on bonding with her baby and early skin-to-skin contact. This caused difficulty to establish breastfeeding and a strong bond with her baby. During the postnatal period, Nadine was diagnosed with postpartum depression.

It should be highlighted that the case studies above do not contain any identifiable factors. Therefore, all names and portrayals are fictional. Antecedents are events or incidents which must be present before the occurrence of the concept (Walker and Avant, 2005). Thus, the antecedents of moral courage entail rationalism, individual excellence, acquiring academic and professional qualification, support, and internal and external barriers (Sadooghisal, 2016).

Professional excellence is an outcome of moral courage and it includes creating peace of mind, the nurse’s proper functioning and decision making and providing a provision of professional care.

Therefore, this can be related to the model case by presuming Cassie is a highly qualified and knowledgeable midwife who is able to rationalise and support her decisions. She is able to identify the ethical dilemma and decide to advocate for Nadine. It is demonstrated what could potentially occur if the antecedents had not occurred in the above contrary case. Ferrell & Coylle (2008), state that in order for a healthcare professional to be able to advocate for a patient, one must experience some level of suffering or ‘loss of control’.

Additionally, Maguire et al (2000) strongly advocate courses include training surrounding leadership, decision-making and teambuilding. This training could potentially allow junior midwives to develop qualities that can be linked with courage which must be pursued as deliberately as the acquisition of clinical skills and knowledge.

Consequences are the events or incidents that occur as the outcome of the concept (Walker & Avant, 2011). The fundamental consequence of courage is enabling midwives to make an ethically correct decision for the women that are being cared for and advocating for them. Furthermore, from training proposed by Maguire et al., (2000), potential consequences that ensure persistent improvement in care standard could be qualities including the demonstration of inter- and intraprofessional working, advocating women’s choices and the priority of care needs.

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Antecedents and consequences help to further enhance the defining attributes. The provision of courageous care and incrimination of midwives can often be affected by a number of reasons. Mollart et al., (2013) propose a major burden midwives are faced with is burnout or work-related stress. It was discovered that the way in which midwives dealt with ‘burnout’ was influenced by long shifts, looking after more women with complex psychosocial issues and working many years in the profession.

Additionally, an evident association was seen between friction with supervisor, doctor as well as with other midwives. This could be related to a lack of courage. Therefore, support systems must be present to ensure all healthcare professionals provide care (Hewison et al., 2016) as this in turn promotes a healthy and caring environment for everyone and more importantly, the patients.

A factor that has an increasing influencing on the delivery of courageous care is time restrictions. Hall (2013) suggests that midwives have more cases that are complex to oversee, an increased workload and have a higher birth rate which can be a strain from ambition timescales, lack of midwives and overstretched resources.

Taking into consideration these factors, it can be foreseen that a healthcare professional will be challenged to provide courageous care if necessary and be able to take time to advocate for the patient under their care.

Empirical referents are indicators that are used to measure the occurrence of the concept to validate its existence (Walker & Avant, 2011). In short, the defining attributes should reflect the empirical referents. However, it should be acknowledged that this is not always the case as abstracts concepts may not always echo the defining attributes. Courage is a concept that has an elaborate amount of different as aspects. Therefore, making it challenging to defined due to its plethora of interpretations.

Woodward (2004) presented a study developing a measurement of courage. The Courage Scale assesses a person’s reported willingness to act in meaningful situations where he or she is experiencing the fear that results from a sense of vulnerability. In such situations, there may be the stark realization that control is lost, commitment is wavering, and the challenge presented will likely lead to failure.

Although there is a lack of research and literature into courage in the clinical area of midwifery, it is still considered a fundamental virtue. Could courage be the basis of different virtues such as advocacy or empowerment? Although not as prominent as compassions or communication, these keywords are still imbedded into the code stating “encourage and empower people to share in decisions about their treatment and care” or “act as an advocate for the vulnerable, challenging poor practice…” (NMC, 2015).

Enquiry Based Learning (EBL) Reflection:

Enquiry Based Learning (EBL) is a reflective task which was used in order to guide our presentations and will be studied thoroughly.

EBL magnifies one’s analytical skills and critical thinking development (Savin-Baden, 2003). Additionally, it inspires an individual to actively be a part of their own personal learning (Prosser & Trigwell, 1999) and it boosts team building and collaborations (Albanese & Mitchell, 1993).

A wide range of model of reflections have the potential to be used within the EBL process. For this essay, the reflections will be formatted as Driscoll’s Model of Reflection (1994) which incorporated three stages.


All students were directed to choose a concept that they considered interesting from the six C’s. We were all then put in groups based on our choice of concept. As the group came together, we drew our ideas together to prepare a concept analysis using Walker & Avant’s eight steps (2005). At our original meeting, we reflected on our ideas and assigned tasks to each other which we were personally interested in. As a group, we organised to meet on the slots allocated after lectures to confirm we were working up to the expectations we had set as a group and individually.

So What?

At first, the idea of the concept analysis was difficult to grasp. We chose to pursue a concept analysis in courage as we believed this concept is undervalued and overlooked yet vital within in midwifery. This proved to be challenging as we struggled to find suggestion literature to develop our concept analysis. Although not a central ethos, we believed courage is a fundamental virtue which overlaps with all the other remaining six 6’s (DoH, 2012). Additionally, we were further challenged as group due to members changing group. Therefore, we had to reconstruct our tasks a few times before we established our scaffolding as a group.

The EBL process allowed me to understand the significance of deadlines, a group member’s working speed and learning, and deadlines which may potentially influence the final product, in this case, the presentation (Carter, 2013). Furthermore, the EBL process has been an insightful task as I have understood that my work should always be accomplished and composed to a standard that allows for coherent teamwork as it can potentially hinder the work of the members in the group.

Now What?

To support our research in the light of lack of literature, additional model case studies would have aided in comparing and contrasting between the examples of model. This would have helped to test our attributed further. Throughout research, the concepts of empowerment and advocacy were came across on various occasions. To further test our attributes, we could have compared model cases of these concepts to further test our defining attributes.

I believe it would have been helpful to have researched what a concept analysis consists of to further our understanding. This would have allowed us to delegate tasks between the group according to our strengths and weaknesses.

The format of Driscoll’s Model of Reflection was easy to understand and reflect the process of putting together the presentation. It is essential to recognise that although reflective models differentiate from each other, they should have the same reflective outcome. Furthermore, all reflective models have strengths and weaknesses (Bulman, 2013).

Some may argue that Driscoll’s reflective model is too simplistic, however, I believe that all models are great but one will choose their own reflection model based on their own preferences and professional needs (Nakielski, 2005).


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