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Driving Forward Change: Enhancing Midwifery Professional Autonomy at Hospital X,

Abu Dhabi, United Arab Emirates (UAE)

Name

Institution

Course

Professor

Date
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Abstract

This scoping review aimed to identify strategies to enhance professional autonomy in

midwifery practice. Some countries typically treat midwifery as an autonomous health

profession, while others never recognize it. Autonomous midwifery practice creates a viable

environment where professionals can provide evidence-based, high-quality, and up-to-date

care from pregnancy to postpartum. The main focus of this study, Hospital X, conducted a

survey that uncovered various shortcomings in midwifery professional autonomy and patient

care provisions. Using Lewin's change management model as guidance, the hospital

implemented the proposed change. Professional autonomy is a significant factor influencing

the success or failure of midwifery practice worldwide. Autonomy, as used herein, can affect

the midwife-led care model by enhancing or reducing the overall job satisfaction score. The

process of facilitating maternity care entails making critical and informed decisions. Limiting

midwives' professional autonomy can adversely affect the continuum of care. Data and

information were extracted from 20 articles to reveal various thematic areas, including the

qualities of a midwife, the nature of client-centered care, continuity of care, the impacts of

autonomy on midwifery practices, and the role of leadership in facilitating organizational

change. Implementing the ICEM, the midwives' model of care, and providing training to the

midwives is bound to resolve the inherent midwifery issues at Hospital X. Over time, the

hospital will experience improved patient care. Ethical performance is bound to improve as

healthcare personnel and midwives at Hospital X gain skills and knowledge regarding culture

and its implications for healthcare.

Contents
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CHAPTER ONE: INTRODUCTION................................................................................................5

1.1 An introduction to the research topic and the research report...............................................5
1.2 Research Topic in the Context of the Organization.................................................................5
1.2.1 Rationale for the Study.......................................................................................................6
1.3 Critical Reviews of the Literature............................................................................................7
1.4 An Overview of the Change Framework..................................................................................8
1.5 Research Aims, Objectives, and Questions............................................................................10
1.6.1 Research Aim....................................................................................................................10
1.6.2 Research objective............................................................................................................10
1.6.3 Research questions............................................................................................................10
1.6 Summary and Conclusion.......................................................................................................10
CHAPTER TWO: A SYSTEMATIZED SCOPING REVIEW METHODOLOGY.....................12
2.1 Introduction to the Chapter....................................................................................................12
2.2 An Overview of The Scoping Review Methodology...............................................................12
2.2.1 Title....................................................................................................................................12
2.2.2 Introduction/Rationale.....................................................................................................12
2.2.3 Review Question(s)...........................................................................................................12
2.2.4 Inclusion Criteria..............................................................................................................13
2.2.5 Search Strategy.................................................................................................................14
2.2.6 Sources of Evidence Selection..........................................................................................14
2.2.7 Data Extraction.................................................................................................................17
2.2.8 Analysis of the Evidence...................................................................................................18
2. 3 Discussion and Conclusion.....................................................................................................30
CHAPTER 3: REVIEW OF LITERATURE...................................................................................32
3.1 Introduction.............................................................................................................................32
3.2 Review Questions.....................................................................................................................32
3.3 Table of Characteristics...........................................................................................................33
3.4 Presentation of Themes...........................................................................................................33
3..4.1 Perceived Professional Autonomy in Midwifery............................................................33
3.4.2 Midwifery scope/role expansion to foster greater autonomy for midwives..................34
3.4.3. Barriers to midwifery Professional autonomy and autonomous decision-making......37
3.4.4 The role of leadership and change management in enhancement of professional
autonomy....................................................................................................................................39
3.4.5 Fostering leadership in the midwifery profession...........................................................40
3.4.6 Best practices for improving professional autonomy and job satisfaction in the
midwifery profession.................................................................................................................41
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3.5 Summary and Conclusion.......................................................................................................41

CHAPTER 4: IMPLEMENTATION AND EVALUATION PLAN...............................................43
4.1 Introduction.............................................................................................................................43
4.2 Gap Analysis.............................................................................................................................43
4.2 Impact Analysis........................................................................................................................44
4.4 Review of multidisciplinary teams and strategic planning...................................................46
4.5 Leadership and advocacy........................................................................................................47
4.6 Evaluation, Monitoring, and Continuous Improvement.......................................................47
CHAPTER 5: DISCUSSION AND CONCLUSION.......................................................................50
5.1 Introduction.............................................................................................................................50
5.1.1 Research project aims.......................................................................................................50
5.1.2 Research project objectives..............................................................................................50
5.1.3 Research project questions...............................................................................................50
5.2 The Key Contributions of the Study for Change...................................................................51
5.3 Findings....................................................................................................................................52
5.4 Limitations and Implications..................................................................................................53
5.5 Areas for Future Research......................................................................................................54
Grantt Chart..................................................................................................................................55
References......................................................................................................................................57
Appendices.........................................................................................................................................66
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CHAPTER ONE: INTRODUCTION

1.1 An introduction to the research topic and the research report

Healthcare uncertainties are complex and may stem from the complexities of patient

care, a lack of professional autonomy, unpredictable treatment outcomes, and the

unpredictability of future outcomes (Stephens & Lazarus, 2024). Autonomy, a central focus

of this thesis, refers to individuals' ability to make uncoerced and well-informed decisions.

Professional autonomy in midwifery practice demonstrates that midwives can control or

determine the standards for executing their duties and responsibilities while strictly adhering

to midwifery regulations, training, and education. Hospital X presents a scenario where

professional autonomy in midwifery encounters significant setbacks. The Midwifery

Satisfaction Survey results obtained from Hospital X show that midwives' ability to act on

professional judgment regarding patient care plans is way below benchmark values (see

Appendix 2). The survey established that midwives cannot modify their daily practices to

meet patient needs. Midwives must obtain approval from physicians before conducting lab

investigations. They cannot exercise their professional judgment when looking after low-risk

patients. Under such circumstances, providing timely and efficient patient care, enhancing

continuity of care provisions, and delivering the highest quality patient care are challenging.

There is a need to implement an effective leadership and management approach to address

the gaps in midwifery practice at Hospital X. Deductively, an effective organizational change

is required to enhance midwifery's professional autonomy. This research report aims to

propose and implement effective organizational change through a change framework and

leadership.

1.2 Research Topic in the Context of the Organization

To gain critical insights into the nature of professional autonomy within midwifery

practice and consequently identify the current impacts or consequences for an organization
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like Hospital X, qualitative research is necessary. Professional autonomy is essential to

professional development because it promotes employees' comfort and freedom. Zychová et

al. (2023) opined that autonomy reinforces the intrinsic value of work by enabling employees

to execute their responsibilities in a way that reflects their preferences and judgment, hence

enhancing job satisfaction in the long run. Most people agree that professional autonomy has

a significant impact on midwives' professionalization. Healthcare uses the concept of

midwifery to describe the knowledgeable, compassionate, and skilled care provided to

newborn infants, childbearing women, and families across the continuum (Davis &

O'Connell, 2023). A midwife's role includes organizing, planning, and providing care during

the postnatal period, according to the midwife-led care model (Perdok et al., 2016).

Vermeulen et al. (2023) argue that there is a positive correlation between job satisfaction and

professional autonomy. Professional autonomy can significantly impact the subjective well-

being of an employee and the entire organization (Pandey et al., 2021). A lack of professional

autonomy can lead to job dissatisfaction and low staff retention rates. As a cornerstone of

professional practice, midwives' professional autonomy must be improved to fulfill their

comprehensive role in healthcare sufficiently.

1.2.1 Rationale for the Study

The impetus to conduct this qualitative inquiry into professional autonomy in

midwifery practice arose because Hospital X needs a comprehensive plan to increase

autonomy and decision-making. According to the Obstetric Departmental Midwife

Satisfaction Survey results, Hospital X is presumably experiencing significant problems due

to a lack of sufficient autonomy among the midwives. Practically, a central thinking and

attitude towards this study came from those results, as they accurately illustrated the current

state of affairs as far as midwifery's professional autonomy is concerned at Hospital X.

Hospital X should implement specific measures to sufficiently resolve the inherent issues and

subsequently improve the staff's satisfaction level through enhanced professional autonomy.
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1.3 Critical Reviews of the Literature

A lack of autonomy in health care settings, such as obstetric units, can exacerbate

existing problems within the continuum of care. This implies that individuals in an obstetric

unit do not independently make critical decisions. They constantly await directives from

management regarding handling of specific tasks or issues (Niles, 2019). Zychová et al.

(2023) noted that critical thinking and being confident are unattainable when the staff has

subtle control over decision-making. Poor decision-making processes at Hospital X would

significantly decrease a midwife's skills and confidence. The problem is even worse when

obstetric policies are ineffective in effecting any change (Clemons et al., 2020). It is,

therefore, essential to ensure that specific guidelines and regulations address the issues

directly impacting the obstetric department to enhance the staff's autonomy in the long term

(Mivšek et al., 2021). Deductively, the need to achieve autonomy should guide Hospital X's

initiatives where necessary. Limited professional autonomy among hospital-based midwives

has negative implications for midwives' job satisfaction and well-being, as Zychová et al.

(2023) articulated. Hospital-based midwives tend to experience a decrease in autonomy due

to technological obstetric interventions, leading to an increase in stress.

Hospital X, one of the biggest hospitals in the UAE (United Arab Emirates), should

consider reviewing work-related responsibilities that hinder midwives from providing

appropriate care and implementing effective change through leadership and management.

Leaders and organizational management play a critical role in implementing change

management projects. Effective leadership and management provide a clear direction for the

organization, set an appropriate tone for the proposed change, and guide employees where

appropriate. According to Musaigwa's (2023) study, leadership roles in change management

include formulating a change vision, securing support from key stakeholders, strategizing the

change, and creating a supportive environment for the proposed change. As articulated by
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Onyekwere et al. (2023), the management of change improves an entity's ability to adapt

promptly, assists in building a process-driven culture, and increases the success of critical

deliverables in the project. Leaders and managers have critical roles in change management.

Their obligations include creating a sense of urgency, building the guiding team,

communicating with stakeholders for buy-in, getting the vision right, and empowering critical

players in the project to take action. Hospital X needs effective leadership and a management

approach to sufficiently facilitate the proposed change relating to professional autonomy in

midwifery practices.

1.4 An Overview of the Change Framework

The planned research aims to produce several positive outcomes, such as improved

timely patient care and enhanced midwife satisfaction, by promoting midwifery professional

autonomy at Hospital X. In this case, Lewin's change management model was selected as the

most appropriate change framework for this work. In the 1940s, Kurt Lewin, a German-

American psychologist, developed a change management model that today's world utilizes to

support organizational change (Amina et al., 2022). Healthcare settings typically use Lewin's

change management theory to understand human behavior in terms of patterns of resistance

to change and change itself (Harrison et al., 2021). Lewin's force field analysis, or Lewin's

change management theory, encompasses three major phases, including unfreezing, change,

and refreezing (Burnes, 2020). Lewin's force field analysis aims to identify factors hindering

change, pinpoint static forces, and recommend viable forces to drive or foster the expected

change.

During Lewin's first phase, the unfreezing stage, the change management team will

identify challenges associated with the problem and take strategic measures to reduce

restraining forces and strengthen driving forces for change. Healthcare organizations, such as

Hospital X, should identify and engage key players or stakeholders who would influence the
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planned change. Hospital X conducts a comprehensive stakeholder engagement to

communicate ideas, build involvement, enhance the internalization of each milestone of the

change process, and develop a sense of continuation (Chudyk et al., 2024). Ideally, the

facilitator, the Unit Manager of the Labor Ward at Hospital X, should communicate with all

stakeholders, including managers, frontline nurses, and the hospital's administration.

Establishing an open and honest line of communication at this stage ensures trust and security

while implementing the proposed change.

The stage of change, also known as the moving stage, is a period for implementing

the actual change. In this case, the moving (change) phase will entail developing a trustful

relationship, providing a comprehensive awareness of the change process, and working

continuously with the stakeholders to reflect the changing situation better. The researcher will

focus on establishing and maintaining healthy clinical relationships. At this level, the

researcher will strengthen professional leadership in midwifery and ensure strict alignment of

education and regulation with the International Confederation of Midwives (ICM) standards.

Promoting midwives' professional autonomy, according to Vermeulen et al. (2023), should

equally involve improving professional leadership in midwifery by forging constructive

partnerships across societal, political, and inter-professional domains.

The final stage, refreezing the changed practice, focuses on solidifying, reinforcing,

and strengthening the newly implemented changes. This stage aims to establish the changed

practice as a new norm. In this scenario, Hospital X's organizational culture will integrate the

ethical principles of midwifery and initiatives to enhance professional autonomy. These

improvements are anticipated to foster greater autonomy for midwives, support expedited

decision-making processes, and reduce physician dependence. Hence, this planned research

intends to employ the pragmatic and widely implemented Lewin's three-step (1940) change

management model as the basis for empowering obstetric services.

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1.5 Research Aims, Objectives, and Questions

1.6.1 Research Aim

This research aims to investigate the role of leadership and management in driving

forward effective change at Hospital X to enhance midwifery professional autonomy. The

study aims to investigate and interrogate midwives on aspects of autonomous practice, as

well as examine their perspectives on the concept of autonomy.

1.6.2 Research objective

This study will look at strategic solutions to address the concerns raised by the

Obstetric Departmental Midwife Satisfaction Survey about the midwife's professional

autonomy at Hospital X.

1.6.3 Research questions

The following questions will guide the study;

1. What factors influence midwives' perceptions of autonomy, and how can we improve

their professional autonomy?

2. What obstacles might hinder efforts to enhance midwives' professional autonomy?

3. How does leadership influence midwives' autonomy?

4. What international best practices or models could Hospital X implement to enhance

midwives' professional autonomy and satisfaction, and what potential effects might

these changes have on patient care?

1.6 Summary and Conclusion

Professional autonomy is a significant factor influencing the success or failure of

midwifery practice worldwide. Autonomy, as used herein, can affect the midwife-led care

model by enhancing or reducing the overall job satisfaction score. The process of facilitating

maternity care entails making critical and informed decisions. Limiting midwives'

professional autonomy can adversely affect the continuum of care. According to Hospital X's
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Obstetric Departmental Midwife Satisfaction Survey results, midwives still need to achieve

professional autonomy. A change management leadership team will be required to work on an

intensive plan to address the shortcomings of a lack of autonomy in the hospital obstetric

unit. Lewin's change management model, which advocates for unfreezing, changing, and

freezing, forms the basis of the proposed change management framework.

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CHAPTER TWO: A SYSTEMATIZED SCOPING REVIEW METHODOLOGY

2.1 Introduction to the Chapter

Attaining enhanced professional autonomy in midwifery requires a healthcare

organization to implement appropriate strategic approaches. This study aims to implement

effective organizational change through a change framework and leadership. In this case, I

am focused on addressing a gap identified in a departmental satisfaction survey: perceived

professional autonomy for midwives and patient care provisions.

2.2 An Overview of The Scoping Review Methodology

2.2.1 Title
“A scoping review of professional autonomy in midwifery practice at hospital X”

2.2.2 Introduction/Rationale
A systematized scoping review methodology will be used to sufficiently fulfill this

study's objectives. The rationale for using a systematized scoping review methodology in this

study is its ability to establish the consistency of scientific findings in articulating the subject

matter.

2.2.3 Review Question(s)

The scoping question will be, "What are the impacts of a lack of professional

autonomy for midwives providing midwifery services at the obstetric unit at hospital X?"

The review will seek to address the following sub-questions:

1. What are the perceptions held by midwives regarding professional autonomy?

2. What factors influence midwives' professional autonomy?

3. What impact does professional autonomy have on midwives' job satisfaction and

well-being?

4. What are the challenges to professional autonomy for midwives in Hospital X's

obstetric unit?
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Key Words

- Professional autonomy in midwifery is perceived

- Midwifery's scope of practices

- Autonomous decision-making in midwifery

- Leadership's impact on fostering professional autonomy

- The scope and role of midwifery are expanding to enhance professional autonomy

2.2.4 Inclusion Criteria

Parameter Inclusion Criteria Exclusion Criteria

Concept Concepts within the scope of Standards of care

midwifery practice

Study focus Midwifery practice No description of midwifery

standards practice standards

Articles Full text articles published Articles published before

in English: 2020 to date 2020

Context International publications in International publications

English language with no English language

Participants Midwives (registered Doctors and nurses

midwives, nurse midwives,

endorsed midwives,

advanced midwife

practitioners, and privately

practicing midwives)

Types of sources All articles and published Blogs, magazines

materials, such as reviews,

opinion papers, texts, and

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primary research

2.2.5 Search Strategy

In May 2024, we conducted a comprehensive systematic search across various

databases and information, including Sage Journals, Biomedical Center (BMC), MEDLINE,

PubMed, ScienceDirect, and CINAHL, to identify articles on midwifery's professional

autonomy. The text words in the titles and abstracts of the articles identified for this report

and the index terms used to describe the articles were used to develop a complete search

strategy for the Web of Science, the Directory of Open Access Journals (DOAJ), and ERIC.

The search strategy, including all identified keywords and index terms, was adapted for each

included database or information source. The reference list of all included sources of

evidence was screened for additional studies. Studies published in English, including those

published since 2020, were included to ensure that the information obtained is up-to-date,

reliable, and valid.

2.2.6 Sources of Evidence Selection

The sources selected were up-to-date (2020 to date) to ensure that the evidence

selection is up-to-date information. The chosen sources contained vital terms or concepts

used in this study. Another critical consideration during the sources' selection was the author's

authority regarding midwifery. A quick internet search helped establish the reliability of a

publication, author, or organization. Because such websites contain credible information, the

search considered URLs ending [Link] [Link]. During the evidence selection process, the

team initially identified relevant research articles or studies from various databases,

ultimately identifying 100 articles. Covidence software was used to facilitate the screening of

the articles.

The researcher independently carried out the search strategy, screening abstracts, full-

text articles, and titles for inclusion. Using the JBI manual, the researcher created a critical
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data extraction sheet to compile the content. Key features extracted from the data charting

process included study design, study aims and purposes, methodology and methods,

population and sample size, author, intervention type, and year of publication. Theoretical

background, reliability, type of instrument, dimensions, and items, theoretical background,

and response scales were used to evaluate the data extraction instruments.

The PRISMA flowchart below was used to illustrate the evidence selection process;

Identification of articles/studies via databases

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Articles/Studies removed before

screening:
Identification Duplicate records removed (n =
Articles/Studies identified from*: 5)
Databases (n = 100) Records marked as ineligible by
automation tools (n =5)
Records removed for other
reasons (n =10)

Articles/Studies screened
(n =80) Articles/Studies excluded**
(n = 5)

Screening

Articles/Studies sought for

retrieval Articles/Studies not retrieved
(n = 75) (n = 10)

Articles/Studies assessed for

eligibility Articles/Studies excluded:
(n = 65) Reason 1 (n = 14)
Reason 2 (n =12)
Reason 3 (n =19)
etc.

Articles/Studies included in
Included
review
(n = 20)

2.2.7 Data Extraction

The researcher exhaustively utilized a data extraction approach to systematically

synthesize and critically cross-examine the data gathered for the study “Driving Forward

Change: Enhancing Midwifery Professional Autonomy at Hospital X, Abu Dhabi, United

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Arab Emirates (UAE).” The researcher developed an appropriate Excel database to extract

essential information from the articles. The database development process took into account

various data extraction categories, as listed below:

 The Author(s)

 Year the article was published

 The article's title

 Publisher

 Purpose/Objective

 Study Design

 Key findings

 The article's relevance to the report is noteworthy.

2.2.8 Analysis of the Evidence

[Link] Research Question 1
What factors influence midwives' perceptions of autonomy, and how can we improve their

professional autonomy?

Table 1: Included Studies (n)= 6

Article 1

Author and Year the Article Vermeulen et al. (2023)

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Published

Title of the Article How Do Midwives View Their Professional Autonomy,

Now

and in Future?

Publisher MDPI (Multidisciplinary Digital Publishing Institute)

Purpose/Objective They sought to explore the views and perspectives of the

Belgian midwives regarding their autonomy.

Key Findings Midwives want to be respected and recognized within

and outside of the maternity care settings.

Relevance of the Article to Highlights midwives' perceptions about their professional

the Report autonomy

Article 2

Author and Year the Article Chakraborty et al. (2023)

Published

Title of the Article Validating midwifery professionals’ scope of practice and

competency: A multi-country study comparing national

data to international standards

Publisher PLOS ONE

Purpose/Objective The study sought to identify and explain the most

universally applicable midwifery professional tasks and

the widely recognized reference standards.

Key Findings Self-reported competencies and midwifery scopes of

practice vary significantly, posing critical threats to the

validity and reliability of global standards.

Relevance of the Article to The study reveals that midwives can use the complexity

the Report of behaviors and skills in the ICM (International

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Confederation of Midwives) competencies as a

benchmark for assessing workforce competency. Such a

conclusion is critical in providing insights on facilitating

midwifery scope and role expansion to foster greater

autonomy for midwives.

Article 3

Author and Year the Article Zychová et al. (2023)

Published

Title of the Article Job autonomy as a driver of job satisfaction

Publisher Central European Business Review

Purpose/Objective Sought to examine age, education, job satisfaction, and

gender differences in job autonomy.

Key Findings There is a positive relationship between job satisfaction

and job autonomy.

Relevance of the Article to Highlights job satisfaction as a major influence of

the Report professional autonomy

Article 4

Author and Year the Article Zolkefli et al. (2020)

Published

Title of the Article Autonomy and its impact on midwifery practice

Publisher British Journal of Midwifery

Purpose/Objective To cross-examine the definitions of autonomy, articulate

the key features of midwifery, and review the

implications of autonomy on midwifery practice

Key Findings Autonomy is normally linked to informed choices.

Autonomous midwife shares key qualities or attributes

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such as the ability to think critically and confident,

among other skills and knowledge.

Relevance of the Article to Highlights capacity for decision-making as a critical pre-

the Report condition that can be used to expand the scope of

midwifery

Article 5

Author and Year the Article Hajiesmaello et al. (2022)

Published

Title of the Article How professional quality of life is influenced by

perceptions of empowerment in midwives

Publisher British Journal of Midwifery

Purpose/Objective The study analyzes midwives' motivations and

perceptions regarding the quality of their working lives.

In addition, the study sought to identify empowerment

strategies and motivational factors that would

significantly facilitate its development and maintenance.

Key Findings Midwives’ perceptions hold that soliciting expertise,

advice, and support from provincial health authorities,

community members, family, and colleagues enhances

their commitment and adaptability to work.

Relevance of the Article to Information regarding what motivates them will be

the Report critical in answering research question one. The “love for

profession,” lack of support, and work overload were

highlighted as factors affecting midwives’ perceptions

towards professional autonomy.

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Article 6

Author and Year the Article Vermeulen et al. (2023)

Published

Title of the Article Key Maternity Care Stakeholders’ Views on Midwives’

Professional Autonomy

Publisher Multidisciplinary Digital Publishing Institute (MDPI)

Purpose/Objective It explored the views of maternity care stakeholders on

Belgian’s midwives’ professional autonomy

Key Findings An autonomous midwife is experienced, competent,

adequately educated or committed, assures qualitative

care, and efficiently collaborates with all stakeholders.

Relevance of the Article to The article will assist in understanding the nature of

the Report midwives’ professional perspective as understood by a

third party, in this case, the maternity care stakeholders.

[Link] Research Question 2

What obstacles might hinder efforts to enhance midwives' professional autonomy?

Table 2: Included Studies (n)= 6

Article 7

Author and Year the Sangy et al. (2023)

Article Published

Title of the Article What obstacles might hinder efforts to enhance midwives'

professional autonomy?

Publisher Elsevier

Purpose/Objective Its aim was to synthesize evidence on facilitators and barriers to

the implementation of midwife-care for childbearing women from

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perspectives of care providers and recipients.

Key Findings Findings from this study suggested that sustained and adequate

funding for midwife-led care programs is a major problem.

Relevance of the The article identifies inadequate funding as a major obstacle to

Article to the Report attaining optimal professional autonomy within the midwifery

practice.

Article 8

Author and Year the Mtegha et al. (2022)

Article Published

Title of the Article Challenges experienced by newly qualified nurse-midwives

transitioning to practice in selected midwifery settings in northern

Malawi

Publisher Springer

Purpose/Objective The study sought to analyze transition experiences of nurse

midwives who are newly employed and starting to practice

midwifery.

Key Findings Findings indicated that lack of confidence and skills, theory-

practice gap, workplace conflict, and inadequate resources are

some of the factors affecting various midwifery units.

Relevance of the The challenges articulated in this article will help the researcher in

Article to the Report gaining critical insights into the barriers towards attaining

maximum professional autonomy in midwifery practice.

Article 9

Author and Year the Wangler et al. (2022)

Article Published

Title of the Article Measuring job satisfaction of midwives: A

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scoping review

Publisher PLOS One

Purpose/Objective The study aimed at collating, describing, and analyzing

instruments utilized in research to evaluate job satisfaction among

midwives in hospital settings.

Key Findings Job characteristics such as autonomy, work-life balance, and the

significance of midwifery are underrepresented in instruments for

determining job satisfaction level of an individual.

Relevance of the The study highlights autonomy as a major aspect that can be used

Article to the Report to enhance job satisfaction for midwives.

Article 10

Author and Year the Bogren et (2020)

Article Published

Title of the Article Midwives’ challenges and factors that motivate them to remain in

their workplace in the Democratic Republic of Congo—an

interview study

Publisher Springer

Purpose/Objective Investigated the factors motivate midwives and challenges

affecting their work life

Key Findings Professional pride, utilization of midwifery skills for good

outcome, and sustaining viable relations with community and

women were some of the factors motivating midwives to keep

working under unfavorable environment. Lack of vital resources,

poor organizational culture, and insecurity were identified as

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major challenges.

Relevance of the The challenges highlighted in the study have direct impact on

Article to the Report midwives’ professional autonomy

Article 11

Author and Year the Pare and Samuelsen (2021)

Article Published

Title of the Article Balancing professional autonomy and authority at the margins of

a fragile state: Front-line health workers’ experiences in Burkina

Faso

Publisher Taylor & Francis

Purpose/Objective Aim at examining how health workers cope with poor motivation

and difficult working conditions.

Key Findings The professional authority of health workers is always challenged

even though they enjoy a certain degree of professional autonomy.

Relevance of the Helps in understanding the implications of challenging health

Article to the Report worker’s authority on professional autonomy.

Article 12

Author and Year the Davis and O'Connell (2023)

Article Published

Title of the Article The full potential of midwives will only be realized when

midwifery has professional autonomy

Publisher Australian College of Midwives (Women and Birth)

Purpose/Objective Sought to examine the growth and development of midwifery

profession from an historical perspective.

Key Findings Categorizing midwifery under nursing field reinforces and equally

reflects inequalities experienced by midwives’ professional

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autonomy

Relevance of the The researcher will gain tangible information on the issues

Article to the Report affecting midwives’ professional autonomy

[Link] Research Question 3

How does leadership influence midwives' autonomy?

Table 3: Included Studies (n)= 6

Article 13

Author and Year the Eri et al. (2020)

Article Published

Title of the Article Models for midwifery care: A mapping review

Publisher European Journal of Midwifery

Purpose/Objective Reviewed theoretical models for midwifery scare

Key Findings Salutogenic focus in care, midwife-woman relationship and

woman-centeredness

Relevance of the Article This study will enable the researcher to understand the role of

to the Report the midwifery partnership model, a critical aspect of

leadership, in enhancing midwives’ professional autonomy.

Article 14

Author and Year the Adcock et al. (2022)

Article Published

Title of the Article What do midwifery leaders need in order to be effective in

contributing to the reform of maternity services?

Publisher Australian College of Midwives (Women and Birth)

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Purpose/Objective Sought to examine what is needed by midwives in leadership

positions to execute positive reforms in maternity services.

Key Findings Maternity reforms are attained changing the current culture,

creating strategic relationships, and implementing evidence-

based maternity care.

Relevance of the Article The article highlights the importance of leadership attributes

to the Report enhancing midwives’ autonomy in their respective positions.

Article 15

Author and Year the Obata and Iriyama (2023)

Article Published

Title of the Article Development and validation of a professional autonomy scale

for Japanese midwives.

Publisher Nagoya Journal of Medical Science

Purpose/Objective The study sought to develop a professional autonomy scale that

can be used by midwives for the purpose of career

advancement and education in Japan.

Key Findings The professional autonomy scale can be utilized to evaluate

professional autonomy for midwifery education and that of the

Japanese midwives.

Relevance of the Article Provides a framework for evaluating professional autonomy in

to the Report midwifery practice from a leadership perspective.

Article 16

Author and Year the Ngabonzima et al. (2020)

Article Published

Title of the Article Influence of nurse and midwife managerial leadership styles on

job satisfaction, intention to stay, and services provision in

 27

selected hospitals of Rwanda

Publisher Springer

Purpose/Objective Sought to examine midwives’ managerial leadership styles how

this nexus affects their service provision and job satisfaction.

Key Findings A participative leadership style, a directive leadership style,

and supportive leadership style were identified as the major

managerial leadership styles used midwives and nurses.

Relevance of the Article Helps in understanding the role and implications of managerial

to the Report leadership on midwifery practices as well as the professional

autonomy of nurses.

Article 17

Author and Year the Usman (2020)

Article Published

Title of the Article Transformational Leadership and Organizational Change: In

the Context of Today’s Leader

Publisher International Business Education Journal (IBEJ)

Purpose/Objective It sought to analyze the effectiveness of transformational

leadership in driving organizational change in the

contemporary world.

Key Findings Findings indicate that transformational leadership has the

capacity to facilitate organizational change in the modern

world.

Relevance of the Article The insights gained herein will help the researcher understand

to the Report the impacts of leadership on midwives’ autonomy.

Article 18

Author and Year the Tedla and Hamid (2022)

 28

Article Published

Title of the Article Leadership in Healthcare Organizations: A Retrospective Study

Publisher International Journal of Health Sciences

Purpose/Objective This was a retrospective study that examine leadership in

healthcare organizations

Key Findings Appropriate leadership can assist in resolving the ever-present

challenges, barriers, and complexities in healthcare industry.

Relevance of the Article A critical analysis of this study will help in understanding the

to the Report role of leadership in the healthcare and how effective

leadership can be utilized to enhance professional autonomy in

midwifery practice.

[Link] Research Question 4

What international best practices or models could Hospital X implement to enhance

the professional autonomy and satisfaction of midwives, and what potential effects might

these changes have on patient care?

Table 3: Included Studies (n)=5

Article 19

Author and Year Sandall et al. (2024)

the Article

Published

Title of the Article Midwife continuity of care models versus other models of care for

childbearing women

Publisher Wiley
 29

Purpose/Objective The study sought to provide a comparative analysis of the impacts of

midwife continuity of care models

Key Findings Midwife continuity of care models were associated with more

positive experiences compared to other models of care.

Relevance of the The research will utilize the findings from this study to decide

Article to the whether to recommend the midwife continuity of care models for

Report Hospital X or not.

Article 20

Author and Year Wei Qi et al. (2020)

the Article

Published

Title of the Article Fostering Interprofessional Patient-centred Collaboration in

Healthcare through CPD: Our Learnings from the PARTNER

Programme

Publisher Taylor & Francis

Purpose/Objective The article focused on discussing the experiences associated with the

PARTNER program, a continuing professional development (CPD)

initiative that promotes interprofessional collaboration.

Key Findings CPD programs like the PARTNER program can be utilized to

promote patient-centered practice and interprofessional collaboration

during the management of chronic diseases.

Relevance of the CPD programs articulated in this study can be applied and

Article to the implemented by Hospital X to foster collaboration in the obstetric

Report unit, resulting to enhanced professional autonomy.

 30

2. 3 Discussion and Conclusion

Data and information were extracted from 20 articles to reveal various thematic areas,

including the qualities of a midwife, the nature of client-centered care, continuity of care, the

impacts of autonomy on midwifery practices, and the role of leadership in facilitating

organizational change. Interprofessional collaboration and education are critical to creating

and perpetuating a safe learning environment. Continuous professional development and

lifelong learning can be essential to improving an individual’s performance in the healthcare

setting. Midwife-led continuity of care requires collaboration and transparent cooperation

among the key stakeholders. Competence is also a critical aspect of midwifery practice.

Competency, skill, and knowledge should form the foundation of a collaboration between

midwives and obstetricians.

 31

CHAPTER 3: REVIEW OF LITERATURE

3.1 Introduction

Professional autonomy implies that midwives can control or determine the standards

for midwifery practice, education, and regulation in their respective healthcare settings.

Evidence-based, responsive, safe, and compassionate midwifery entails considering the needs

of the mother, her infant, or her family. The topic, "strategies to enhance professional

autonomy in midwifery practice," aligns precisely with the tenets of a scoping review.

Fundamentally, a scoping review provides the researcher with a detailed framework that

illustrates the evidence used rather than focusing on identifying the best available evidence. A

scoping review was utilized herein because it creates room for answering more specific

questions about professional autonomy and midwifery practice. The scoping review will

allow the researchers to gain critical insights into the research questions and objectives. In

essence, this literature review will examine ways to improve midwives' professional

autonomy, identify obstacles to enhancing autonomy, review the effects of leadership on

midwives' autonomy, and articulate the most suitable international models for improving job

satisfaction and independence.

3.2 Review Questions

1. What factors influence midwives' perceptions of autonomy, and how can we improve

their professional independence?

2. What obstacles might hinder efforts to enhance midwives' professional independence?

3. How does leadership influence midwives' autonomy?

 32

4. What international best practices or models could Hospital X implement to enhance

midwives' professional autonomy and satisfaction, and what potential effects might

these changes have on patient care?

3.3 Table of Characteristics

3.4 Presentation of Themes

3..4.1 Perceived Professional Autonomy in Midwifery

People generally view autonomy as a crucial component of human development and

well-being. Socially, autonomy reflects an individual's capacity or ability to exercise self-

governance and self-determination (Rost et al., 2023). The tenets of self-determination theory

anchor autonomy in this case, stating that individual differences and social contexts are

essential in facilitating different types of motivation, such as controlled and autonomous

 33

(Ryan & Vansteenkiste, 2023). Self-determination theory (SDT) holds that humans have three

primary psychological needs: competence, relatedness, and autonomy (Ryan & Deci, 2022).

In this case, autonomy represents an individual's willingness to endorse a specific behavior

and make a specific choice without intervention. An individual might feel controlled or

compelled in a situation without autonomy. An individual's social environment, which

includes health care professionals, family, culture, friends, or co-workers, usually influences

their autonomy (McClure & Leah, 2021). Supporting someone's autonomy involves

acknowledging his or her preferences, providing a rationale for a specific behavior, and

avoiding pressuring or controlling an individual to act in a specific way. In this case, the

social environment, intrinsic motivation, and social contexts can all have an impact on

midwives' perceptions of autonomy.

Variations in clinical decision-making among midwives exist due to various factors

such as managing uncertainty, experience of earlier adverse events, perceptions of risk, and

understanding of the boundaries of psychological birth (Daemers et al., 2017). In an obstetric

unit, the organization's culture typically shapes clinical decisions, collaborative efforts among

professionals, and the source of knowledge utilized (Zondag et al., 2022). For instance,

personal experiences, the concept of woman-centeredness, and the overall conditions in a

healthcare setting typically shape the decisions made by most midwives (Vermeulen et al.,

2023). Furthermore, personal values, an organization's leadership style, and workplace

culture can all have a significant impact on midwifery practices as a whole.

3.4.2 Midwifery scope/role expansion to foster greater autonomy for midwives

Educational paradigms, contextual situations, policy frameworks, and societal

perceptions intertwine and complicate midwifery autonomy. Perdok et al. (2016) argued that

combining the current training with maternity care professional education would attract

tangible merits in the long run. Interprofessional training helps individuals develop
 34

professional competence, uphold interprofessional respect, and develop a collaborative

attitude toward clients (Sonmezer, 2021). International professional entities like the ICM and

the International Labor Organization have been critical in redefining the nature of professions

such as midwifery. Chakraborty et al. (2023) observed that the ICM's operational standards

typically aim to improve midwives' competency by fostering continuous skills and

knowledge acquisition. To improve the level of autonomy in an obstetric department,

Hospital X should strategize and ensure strict adherence to the directives issued by such

global entities. Strict adherence to such standards of operation creates room for enhancing the

autonomy of midwives (Vermeulen et al., 2023). The overall goal is to eradicate issues related

to workers' underpayment and midwives' undervaluation. However, midwives must enroll in

advanced courses or further education to improve their competency, work-related experience,

and skills.

Strengthening the inherent leadership in midwifery practice can lead to solid

professional autonomy. The International Confederation of Midwives guided midwifery

leadership, identifying six significant principles: clinical leadership, operational leadership,

political strategic leadership, education, regulation, and research (Sattar et al., 2023). In this

case, strengthening leadership implies that the management will have the capacity to

challenge the status quo, inspire significant others, and demonstrate compassion (Jackson et

al., 2021). Adcock et al. (2022) observed that midwifery leaders must possess essential skills

and knowledge to significantly contribute to maternity care. Midwifery leaders should initiate

and facilitate maternity care reforms by providing unwavering support for healthcare

executives, developing opportunities, and fostering effective relationships (Obata & Iriyama,

2023). As articulated by Vermeulen et al. (2023), strengthening professional leadership would

be essential to fostering midwives' professional autonomy. Enhancing midwifery autonomy

would entail forging partnerships across societal, inter-professional, and political domains.
 35

Developing and implementing a comprehensive formal professional course on

leadership styles for midwives would significantly enhance their autonomy. According to

Ngabonzima et al. (2020), proper nursing and midwifery leadership could increase employee

retention due to improved job satisfaction. Usman (2020) explicitly designed

transformational leadership to enhance management quality. In this case, transformational

leadership would significantly redefine midwifery practice, improving autonomy and job

satisfaction. As Tedla and Hamid (2022) articulated, effective leadership plays a critical role

in addressing public challenges, maximizing human potential, and providing quality services.

Skillful and competent leaders, in this case, would guide a specific healthcare organization,

ensuring the midwifery profession's autonomy. When supported and developed appropriately,

midwifery leadership can strengthen and shape the profession.

The medicalization of birth is a significant factor that negatively impacts midwives'

professional autonomy. Medicalization is defined herein as the overuse of medical

interventions even when dealing with low-risk childbirths and pregnancies. According to

Spina's (2023) study, medical-scientific advances have led to a significant improvement in

maternal care. Unfortunately, such an advancement has led to the development of

medicalization. Surgical childbirth is a valid example of medicalization. Addressing the

medicalization of birth should entail reorganizing the current pregnancy and childbirth paths

in an attempt to de-medicalize them (Miani et al., 2020). Medicalization of birth is a

significant issue affecting the utility of autonomy within the midwifery sphere (Kirkham,

2020). Because of medicalization, it becomes difficult for midwives to make the most

feasible decision. Despite the medicalization of processes like childbirth, menstruation, and

pregnancy, they remain normal and natural.

Experiences, values, backgrounds, needs, and beliefs typically shape women's

attitudes towards some natural processes, such as pregnancy and childbirth. Addressing
 36

medicalization should involve promoting natural childbirth processes. Hashemi et al. (2020)

argued that creating a culture for natural childbirth would entail elevating the role of

midwives and convincing expectant mothers that vaginal birth is natural. The ultimate

objective is to prevent treating childbirth as a disease or health risk, necessitating clinical

interventions (Zwier, 2020). This is based on the assumption that many women prefer clinical

interventions when giving birth because they think that it is a sign of modernity. It is

recommended that holding childbirth festivals and engaging celebrities would influence a

cultural tilt towards natural childbirth. In the long run, midwives will enjoy enhanced

autonomy in making critical decisions regarding childbirth.

3.4.3. Barriers to midwifery Professional autonomy and autonomous decision-making

Mental stress, fatigue, and unnecessary aggressiveness are some aspects that illustrate

the possibility of having an unsupportive organizational system. Individuals working in an

unsupportive or poor organizational culture tend to feel isolated, unwanted in the workplace,

worthless, and inadequate. People treat a poor organizational culture as a long-term obstacle

to achieving autonomy (Bogren et al., 2020). An unfavorable management approach,

insufficient work-related security, and an ineffective remuneration approach all suggest that

anchoring the entity in an unsupportive system is necessary. Clemons et al. (2021) argued that

midwives are more likely to feel underappreciated when the payment approach could be more

favorable.

Political unrest, social conflicts, and the need for power can devastate midwifery.

According to Sangy et al. (2023), political unrest tends to interfere with a country's smooth

running and operation of midwifery-led programs. Furthermore, in such situations, the fear of

potential consequences always clouds decision-making. In addition, Perera et al. (2023)

argued that gaps in training and education are attributable to insecurity, political conflicts, and

social unrest in society. Meanwhile, Bogren et al. (2020) affirmed that executing midwives'
 37

duties in an insecure environment is relatively challenging. Such societal events tend to

establish and perpetuate an unfavorable work climate, eventually affecting an individual's

performance (Pare & Samuelsen, 2021). A case example is a situation where bandits have

taken over a specific area. This automatically restricts midwives' movements in that area.

Continuous, unstable security and long-term conflicts have instilled fear in many midwives.

Lack of resources and financial barriers have redefined the nature of midwifery

practices, as well as midwives' professional autonomy. Mtegha et al. (2022) remarked that

most midwives, especially in developing countries, use outdated industry resources such as

standards and practice guidelines, jeopardizing their overall outcomes and services.

Vermeulen et al. (2023) observed that strengthening the midwifery profession often requires

valuable resources. Therefore, requiring more critical resources weakens the profession

(Wangler et al., 2022). Davis and O'Connell (2023) demonstrated that a lack of resources and

equipment is often attributable to inadequate funding for midwifery programs.

The chronic shortage of midwives has been a significant problem in midwifery

practice, negatively affecting the profession's autonomy. The workforce shortage often forces

most midwives to work 24-hour shifts at their facilities (Adatara et al., 2021). Work overload

is usually stressful and impacts an individual's autonomy in delivering effective care

(Muchiri, 2022). Workforce shortages challenge midwives wishing to further their studies or

conduct evidence-based research. Midwives, especially those in rural areas, have limited

access to in-service opportunities, which hinders their progress towards attaining autonomy.

Adatara et al. (2021) argued that midwives in rural areas tend to attend few to no in-service

training courses compared to their peers in urban centers. Under such circumstances,

improving their skills and knowledge cannot be challenging. Besides, these midwives need to

improve their competence to deal with the challenges associated with staff shortages and

unpredictable working conditions, as Bogren et al. (2020) examined. In addition, a lack of

 38

suitable patterns of midwifery workforce management negatively impacts midwifery's

autonomy. The available resources, human input, and level of competence commonly

influence their decision-making process.

Access to essential consumables and critical needs often helps an midwives’ efforts to

attain professional autonomy. The lack of access to such critical resources makes it easier for

midwives to fully perform their iterative midwifery care (Bloxsome et al., 2021). Such

circumstances often force them to improvise and use only limited resources, leading to poor

care outcomes. Midwives tend to feel neglected or unrecognized by the clinic managers for

the poor supply of critical supplies needed to facilitate optimal midwifery

practices. Disparities between the content they learned in school and the process of

discharging care in a healthcare setting are more likely to occur for newly qualified nurse-

midwives. Hospital management guidelines challenge them even though they have acquired

sufficient knowledge and skills in class (Mtegha et al., 2022). Gustafsson et al. (2023) found

that midwifery students find it challenging to fulfill all professional competencies due to the

conspicuous differences between clinical practice and theory during their clinical placements.

Such a theory-practice gap is typically attributable to the use of technology within healthcare

settings and a need for more autonomy.

3.4.4 The role of leadership and change management in enhancement of professional

autonomy

A robust leadership style in midwifery allows for partnerships across societal,

international, and political domains. Such partnerships are highly beneficial to midwives'

professional autonomy. Eri et al. (2020) conducted a mapping review, which illustrated that

midwives typically use a midwifery partnership model to enhance their relationship with

women. As a leadership approach, this model prompts midwives to work collaboratively with

women while valuing them as individuals and acknowledging their liberty to make
 39

independent decisions regarding their care and the care of their infants. In a midwifery

partnership model, midwives collaborate to make decisions while maintaining autonomy.

Empowerment in midwifery is defined as providing psychological support, facilitating

relevant training, and allocating social resources to enable midwives to deal with challenges

effectively. A robust leadership approach involves empowering midwives to decide to attain

universal health coverage. Effective leadership empowers midwives and other professionals

by supporting innovation and creativity, enabling nurses to practice midwife-led care

optimally, and providing a positive work environment. Adcock et al. (2022) argued that

creating a positive workplace culture provides a viable environment for empowering

midwives and enhancing their autonomy in the workplace. Besides, midwives' leadership has

influenced midwife-led care and encouraged the development of decision-making skills,

which are essential in fostering evidence-based maternity care and sustaining strategic

relationships.

3.4.5 Fostering leadership in the midwifery profession

An organization or profession can promote leadership to provide vision and

significantly inspire others toward achieving a common goal. Leadership in midwifery plays

an essential role in building trust and influencing positive change. Developing leaders and

managers from within provides an opportunity to enhance managerial and leadership

capacity, as articulated by Jarrett (2020). To increase midwifery autonomy, intensive efforts

must be made to promote leadership within the profession. The process should include

encouraging midwives to take leadership roles in midwifery at regional, national, or

international levels. Deductively, midwives holding influential positions in the healthcare

system are more likely to fight for and promote professional autonomy within the midwifery

profession.
 40

3.4.6 Best practices for improving professional autonomy and job satisfaction in the

midwifery profession

Hospital X could adopt international best practices to improve midwives' professional

satisfaction and autonomy. However, this study will focus on two primary models: the ICEM

(International Code of Ethics for Midwives) and the midwives' model of care. The

International Code of Ethics for Midwives strives to enhance the standard of care through

education, development, and the appropriate use of professional midwives. The model

addresses midwives' ethical mandates and responsibilities in promoting the well-being and

health of infants and women (International Confederation of Midwives, 2024). The

International Code of Ethics for Midwives provides a legal framework for developing and

perpetuating midwifery relationships, encourages evidence-based practice, highlights critical

midwives' responsibilities, and lays the groundwork for advancement in midwifery practice

and knowledge.

Hospital X can equally rely on the midwives' model of care, which strives to reduce

technological interventions, provide individualized education to mothers, and monitor their

well-being during the childbearing cycle. Sandall et al. (2024) argued that the midwife's

model of care strives to promote continuity of personalized care, improvement of

relationship-centered care, and utilization of parent-infant dyads. Ideally, this model is a time-

intensive and relationship-intensive strategy, even though it encourages an individual's

autonomy in childbearing. Some of the benefits of the midwifery model of care and practice

include lower stillbirth rates, improved perinatal outcomes, and fewer chances of baby loss.

3.5 Summary and Conclusion

Implementing the ICEM, the midwives' model of care, and providing training to the

midwives is bound to resolve the inherent midwifery issues at Hospital X. Over time, the

hospital will experience improved patient care. Ethical performance is bound to improve as
 41

healthcare personnel and midwives at Hospital X gain skills and knowledge regarding culture

and its implications for healthcare. Besides, strict adherence to the code of ethics will provide

a comprehensive foundation for forming partnerships where midwives share critical

information, leading to informed decision-making in response to the ever-evolving care plan.

The literature underwent a critical analysis, revealing various thematic areas. This

case established that aligning education and regulations with the ICM's standards,

strengthening leadership in midwifery practice, and addressing the medicalization of birth

could enhance the midwives' professional autonomy. Various factors hinder efforts to enhance

midwives' professional autonomy, such as the theory-practice gap, an unsupportive

organizational system, political instability, inadequate funding for midwifery programs, a

shortage of the midwifery workforce, limited in-service opportunities, and logistical

challenges. Furthermore, research has shown that leadership significantly impacts midwives'

professional autonomy by empowering them, forming partnerships, and fostering leadership

within the midwifery profession.

 42

CHAPTER 4: IMPLEMENTATION AND EVALUATION PLAN

4.1 Introduction
Hospital X needs the conceptualized literature to address the underlying issues

affecting midwives' professional autonomy. This chapter aims to discuss the implementation

and evaluation of the recommended change.

4.2 Gap Analysis

A comprehensive analysis of the literature review reveals various gaps in autonomous

clinical decision-making with low-risk pregnant women. Equally, there are significant

hindrances to midwives' professional autonomy in patient care, reflecting gaps in patient care

provisions and experiences and midwives' satisfaction. Findings from the data collected

regarding the current practice indicate specific gaps in midwifery practice and the

achievement of professional autonomy.

Limited Autonomy and

Barriers

Influence of Leadership on
Midwifery

Enhanced Midwifery
Professional Autonomy
Recognition and
Professionalism

Interprofessional
relationships and
collaborative practice

Policy and regulatory

framework
 43

4.2 Impact Analysis

The profession of midwifery and its autonomy thereof is normally impacted by a wide

range of factors. Vermeulen et al. (2023) argued that that professional autonomy of midwifery

practice is experiencing issues that would eventually culminate to, or lead to the inability of

midwives to execute their roles or make effective decisions. Vermeulen et al. (2023), using

Belgian midwives as a case study, argued for implementing strict protocols to enhance

professional autonomy among midwives. Another study by Vermeulen et al. (2023) revealed

persistent knowledge gaps regarding midwives' professional autonomy. It is recommended

that the empowerment of midwives worldwide resolve the inherent problem.

Leadership can redefine the trajectory of change in midwifery practices. Empowering

midwives, forming partnerships, and promoting leadership within the midwifery profession

can have a long-term impact on midwives' professional autonomy (Hewitt et al., 2021).

Leadership's influence on problem-solving and decision-making is evident as a critical

thematic area. Strong leadership is usually associated with better patient outcomes, efficiency

in health care, and effective treatment processes (Terkamo-Moisio et al., 2022). In this case,

healthcare leaders, or midwife leaders, should constantly strive for improvement while

staying abreast of industry changes, trends, and developments. On the other hand, midwives'

performance and overall quality of care are generally correlated with leadership approaches

such as the autocratic style.

Midwives' recognition and professionalization play an essential role in enhancing

their autonomy. Previous research on the subject matter demonstrates that society generally

needs to pay more attention to highly competent midwives, resulting in enhanced recognition

of their efforts (Prosen, 2022). In this case, a lack of adequate compensation can equally

demoralize midwives, leading to diminished morale and low productivity in the long run.

Ideally, autonomy is critical in midwifery because it tends to influence decision-making and

 44

exert control over an individual in a predetermined situation. Knowledge and skills such as

confidence are essential in enhancing autonomy in midwifery practices (Ball et al., 2022).

Overall, valuing and acknowledging midwives' contributions and expertise in society

provides a strong foundation for improving professional autonomy in the long run.

Enhancing autonomy in health care, particularly in midwifery, necessitates exclusive

involvement in collaborative practice. As examined herein, collaborative practice entails

providing healthcare services in collaboration and cooperation with two or more social care

providers or healthcare providers. McDonald's (2022) generally encourages midwives to

foster and maintain positive interprofessional relationships to enhance their autonomy and

satisfaction. Previous studies indicate that other healthcare professionals within a hospital or

healthcare setting can subject midwives' autonomy and decisions to intense scrutiny (Feeley,

2023). In this situation, challenging midwives' decisions and independence are more likely to

obstruct or negatively affect an individual's job autonomy. Fostering mutual respect and

encouraging effective collaborations can significantly improve patient care while also

assisting midwives in achieving independence.

The maternity standards and specific policies should facilitate raising the status of

midwives and supporting them to work autonomously. The International Confederation of

Midwives provides a comprehensive framework for promoting regulatory mechanisms within

the midwifery profession (Mattison et al., 2020). Most global standards for midwifery

regulation are generic and serve as a benchmark for standardized midwifery practices. As an

international organization, the critical obligation of ICM is to enhance the high quality of

midwifery care while redefining the scope of practice to improve the autonomy of midwives

(Chakraborty et al., 2023). Besides, the philosophy of midwifery care holds that providing

person-centered care, being committed to self-regulation, demonstrating professional

knowledge, and illustrating leadership skills are critical to enhancing autonomy in midwifery.
 45

Midwifery typically employs policies to fortify the profession, addressing crucial aspects

such as leadership, education, financing, workforce management, and innovation.

4.4 Review of multidisciplinary teams and strategic planning

A multidisciplinary team review or Task Force will be formed to take on the roles of

leadership and management in implementing effective change management. The Task Force

will solely be responsible for developing targeted initiatives and strategies, such as policy

adoptions, training and educational programs, and organizational reforms, among others, to

foster enhanced midwifery professional autonomy and autonomous decision-making at

Hospital X. Results-based policy dialogue processes will be utilized to gain support and

strengthen the current midwifery workforce. Adaptation policies and measures will be

developed by engaging the state and other relevant stakeholders in midwifery practice. The

overall goal is to critically analyze the current landscape of policies by discussing the needed

adaptations to systems, plans, legislation, and strategic measures.

Facilitating a broad engagement of stakeholders, including educational institutions,

national ministries, private sector employees, international financial institutions, development

partners, and regulatory bodies will be critical in this case. Data from strategic plans, national

health worker documents, workforce forecasting, and health labor market analysis will be

used to fill gaps identified in midwifery practice. Formulating evidence-informed policy

solutions at this juncture provides an opportunity to make informed decisions regarding a

paradigm shift in the midwives' working conditions, leadership approach, and professional

regulation.

The process will entail establishing a Task Force that incorporates the hospital's

stakeholders, including midwives, physicians, and nursing leadership. The task force's role in

this scenario is to spearhead the recommended change. As the unit manager of the labor ward

at Hospital X, I will be the only researcher conducting this study. I will be leading this change
 46

with effective leadership. My collaborative and transformational leadership styles will be

utilized to lead this change. Ideally, I will be critical to team development and collaboration

while co-chairing the task force.

4.5 Leadership and advocacy

Enhancing midwives' professional autonomy should involve fostering

interprofessional collaboration, increasing public awareness, prioritizing midwife-led

continuity of care, and advocating for policy reforms, as articulated by Vermeulen et al.

(2023). In addition, the literature revealed barriers hindering midwifery's professional

autonomy, such as the theory-practice gap, an unsupportive organizational system, political

instability, inadequate funding for midwifery programs, a shortage of midwifery workforce,

limited in-service opportunities, and logistical challenges.

4.6 Evaluation, Monitoring, and Continuous Improvement

A Theory of Change (ToC) will provide a comprehensive evaluation and assessment

of the social change at Hospital X due to Kurt's change management model interventions.

The theory of change serves as a methodological tool, illuminating the causal pathway

associated with specific activities. It will help the research identify viable solutions and

strategic measures to address the problems preventing midwifery from attaining professional

autonomy. The implementation plan will be evaluated using the Kirkpatrick model. The

Kirkpatrick model, a globally recognized evaluation method, typically assesses learning and

training programs against four significant aspects: learning, behavior, reaction, and results.

Similarly, we usually use this model to determine the changes or successes of an

implementation plan. Here is an overview of how this model will evaluate the

implementation plan in this particular case:

Level 1: Reaction: The objective of this evaluation is to determine whether the

learners, in this case, midwives, found the overall training or organizational change relevant,
 47

engaging, and favorable to their midwifery profession. Data and feedback will be collected

using an after-training survey in which the midwives will be requested to rate their

experiences regarding the implemented changes. This level plays an essential role in

soliciting opinions and information from the participants regarding the program's value. The

information obtained herein is typically used to evaluate the program's effectiveness or

change, justify its continuation, and identify potential improvements.

Level 2: Learning: The objective of this level is to determine the extent to which the

participants have acquired and internalized the intended knowledge, attitudes, and skills

provided via the training or program implementation. The training executives or the plan's

implementation manager are responsible for assessing whether the training objectives have

been met satisfactorily. Please keep in mind that you can complete this evaluation level by

conducting pre- and post-event assessments. A pre-event survey allowed the researcher to

conduct a comparative analysis of what transpired before and after program implementation.

It usually serves to demonstrate the extent of change or its absence.

Level 3: Behavior: This level's role is to assess the impact of the implemented change

on an individual or a group of people. It involves evaluating changes at the workplace by

determining whether the participants have changed their behavior. Measuring behavior entails

conducting interviews, providing opportunities for the team members to utilize the skills

gained in a real-life scenario, and recording observations. It is essential to note that change

does not necessarily mean that the program could have been more effective in causing any

change. Sometimes, a lack of behavioral change can indicate the current cultural conditions

and processes that promote an ideal environment for attaining the desired change.

Level 4: Results: Key performance indicators (KPIs) typically measure an

organization's outcomes against its inherent learning objectives. This phase aims to obtain

tangible results regarding employee retention, improved efficiency and quality, and increased
 48

morale. In this scenario, the organization implementing the change calculates the return on

investment (ROI) to determine its ultimate value.

Various fields and environments can utilize the highly flexible and adaptable

Kirkpatrick Model. The model allows the researcher to continually gather feedback and

critical information to determine the effectiveness of the implementation plan in causing a

predetermined change (Cahapay, 2021). However, the primary role of the Kirkpatrick Model

is to evaluate and consequently analyze the results of an educational, learning, and training

program.
 49

CHAPTER 5: DISCUSSION AND CONCLUSION

5.1 Introduction
5.1.1 Research project aims
The research project aimed at identifying strategies needed to enhance professional

autonomy in midwifery practice. To fulfill this aim, the researcher utilized a scoping review

methodology to summarize previous studies and disseminate the research findings. The

process involved establishing an equilibrium between breadth and feasibility, utilizing an

iterative approach to choosing studies, and extracting data. The study aimed to identify

strategies for enhancing midwives' professional autonomy, the factors that shape their

perceptions of autonomy, the obstacles to professional independence, and the impact of

leadership on midwives' independence. Previous studies were conducted to expound on these

critical objectives.

5.1.2 Research project objectives

This study sought to look at strategic solutions to address the concerns raised by the

Obstetric Departmental Midwife Satisfaction Survey about the midwife's professional

autonomy at Hospital X.

5.1.3 Research project questions

Four major research questions guided the study. It sought to answer the questions below:
1. What factors influence midwives' perceptions of autonomy, and how can we improve

their professional autonomy?

2. What obstacles might hinder efforts to enhance midwives' professional autonomy?

3. How does leadership influence midwives' autonomy?

4. What international best practices or models could Hospital X implement to enhance

midwives' professional autonomy and satisfaction, and what potential effects might

these changes have on patient care?

 50

5.2 The Key Contributions of the Study for Change

Strengthening global midwifery is critical to infant and maternal outcomes. It is a

comprehensive process that involves raising awareness of the essential role of midwifery

services in society. This should align with the Millennium Development Goals (MDGs), such

as MDG 4, MDG 5, and MDG 6. Reducing child mortality globally is one of the critical

objectives of the United States. MDG 5 seeks to improve maternal health by improving

access to effective interventions and good-quality reproductive health care (Larionova, 2020).

Meanwhile, SDG 6 focuses on combating malaria, HIV/AIDS, and other significant

diseases by increasing the availability of ART (antiretroviral therapy) globally. Ideally, the

need to strengthen midwifery at the global level aligns with the Millennium Development

Goals. In this regard, working collaboratively with the ICM would ascertain that women have

sufficient access to midwifery care during the continuum of pregnancy. Globally, we expect

midwifery associations and midwives to provide education and care for newborns, as well as

advocate for a situation that allows midwives to fully practice their profession.

Also known as 'Caseload Midwifery,' Midwifery Group Practice (MGP), in this case,

refers to a caseload midwife who is responsible for providing a known midwife to facilitate

the childbirth process and postnatal care. Caseload midwifery plays an essential role by

increasing the probability of having safer birth outcomes, encouraging natural delivery, and

attaining better breastfeeding outcomes for the infant (Hewitt et al., 2024). Higher

satisfaction ratings for antenatal care, home-based postpartum care, and intrapartum care

strongly correlate with caseload care. On the other hand, caseload midwifery allows

midwives to share experiences related to specific challenges that impact midwifery practices

and the more prominent healthcare fraternity (Vasilevski et al., 2021). The MGP has various

benefits, including safer birth outcomes and greater birth satisfaction. The MGP may have

additional benefits, such as:

 51

 Shorter post-delivery hospital stays.

 It improved breastfeeding outcomes.

 Enhanced prevention of postnatal depression.

 Factors influencing clinical decision-making

Various factors, such as knowing the evidence, the patient and person, the

environment, and yourself, often affect clinical decision-making. Knowing the evidence base

and subject area allows researchers to identify patterns and possible outcomes of midwifery

practices. A clear understanding of the patient's experiences with illness, preferences, and

current care needs helps an individual make an informed decision regarding a specific subject

matter. Besides, awareness of and recognition of team dynamics within an entity is essential

in the decision-making process. Various research studies have identified various aspects that

influence midwives' clinical decision-making. People typically expect midwives to be

essential as protectors and promoters throughout pregnancy. Core skills in a decision-making

process include teamwork, evidence-based approaches, pattern recognition, and

communication skills.

5.3 Findings

The planned research employed a mixed-methods approach to address gaps identified

in midwifery autonomy and patient care provisions at Sheikh Khalifa Medical City Hospital.

Given that the research was conducted at Sheikh Khalifa Medical City and only midwives

and patients in the obstetric department will be considered, it means that by that approach, a

large potential population will not be considered; therefore, a purposive sampling strategy

will be used. Analysis of the inferential and descriptive statistics will be used for surveys, and

a thematic analysis approach will be utilized to analyze the interview data, which will involve

identifying common patterns and themes often appearing in participants' accounts. The data

will be transcribed, and a themes table will be developed to allow for systematic data analysis
 52

through attribution to a series of common themes. The thematic overview will align with the

research questions and highlight the themes and overall trends.

Since the researcher is an insider in the healthcare industry and unit manager of the

labor ward at Sheikh Khalifa Medical City, this provides unique circumstances for data

collection and objectivity. Because an insider's viewpoint can sometimes influence the study

process, ethical issues are paramount. Since the researcher is also an insider in the

organization under investigation, it is considered unethical; therefore, transparent disclosure

enables the participant to participate in the study with all the necessary information to make

an informed decision. Furthermore, we will obtain and apply informed consent to

participation, protect participant privacy, and ensure data anonymity. We have yet to obtain

participant consent, as this step will take place during the participant recruitment stage. Ethics

considerations focusing on anonymity, informed consent, and full disclosure will be applied

to ensure the integrity of the research. Furthermore, we will obtain official ethical approval

from the Sheikh Khalifa Medical City ethics committee before initiating the planned study,

which includes surveys and interviews. So far, the research concept and the use of midwifery

satisfaction survey data have received organizational approval.

5.4 Limitations and Implications

The culture and context of autonomy, including the scope of autonomous midwifery,

vary from one nation to another or from one setting to another. The reviewed literature

illustrates various preconditions to enhance autonomy in midwifery practices. However, the

most conspicuous precondition is the midwives' decision-making ability. A collaborative

approach is necessary to ensure that the decision-making process takes into account the views

and inputs of other midwives or women. Midwives bear responsibility and accountability for

the decisions they make. Besides, critical thinking, self-awareness, confidence, collaborative

skills, and competence are essential as far as the midwifery profession is concerned.
 53

5.5 Areas for Future Research

Studies focusing on neonatal care should be conducted to unearth the standards of

care and how these standards impact professional autonomy. Equally, future studies should

focus on investigating critical aspects of reproductive health, such as childbirth, menopause,

and menstruation, in order to position them within the realm of midwifery and autonomy.
 54

Grantt Chart

Steps/Time Status Notes

The researcher to Obtain Organizational Approval Obtained on (n.p.) See Appendix 1

from Nursing Manager

The hospital to conduct an Obstetric Departmental Completed on 2023

Survey on Midwife Satisfaction

Release of the statistical analysis of the Midwife Completed in 2023 See Appendix 2

Satisfaction Survey

The researcher is to obtain ethical consent through Scheduled for Draft survey and

the Hospital X Ethics Committee to conduct a September, 2024 interview

patient satisfaction survey on midwifery care in questions are in

the unit and to interview midwives. Appendix 3

The researcher will conduct the patient satisfaction Scheduled in

survey and conduct interviews with stakeholders September/October,

on identified gaps (focusing on autonomy and 2024

decision-making gaps identified).

The researcher is to complete statistical and Date December, 2024

thematic analysis.

The researcher is to compile the analyzed data January 2025

(from surveys and interviews) and create

comprehensive reports.

Facilitate meetings and review data with the February 2025

nursing manager and senior hospital leaders.

The researcher is to spearhead the development of March 2025

a task force consisting of a disciplinary team, unit

 55

representatives, and OBGYN leaderships.

The task force is to address gaps identified in the May to October, 2025

comprehensive reports from the data collection

and analysis and propose appropriate and

achievable changes applying Lewin’s change

framework, e.g., related reforms such as decision-

making (e.g., placing lab investigations),

opportunities for increased autonomy, policy

adaptations, training identification, e.t.c.

The researcher, serving as the unit manager of the October 2025 to

labor ward, is to implement the determined October 2026

changes with the support of the nursing manager

and the task force.

The researcher is to evaluate and analyze the November/

impact of the change by replicating the baseline December2025

survey, replicating the patient satisfaction survey,

and interviewing midwives to measure the impact

of the change in the Midwifery Satisfaction

Survey and patient satisfaction.

 56

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Appendices

Appendix 1: Organizational Approval from Nursing Manager

[Insert the Approval Here]

 66

Appendix 2: Enhancing Midwifery Professional Autonomy at Hospital X, Abu Dhabi

1. Can you describe your current level of professional autonomy in your role as a

midwife at Hospital X?

2. What factors do you believe influence your perception of autonomy in your role?

Select all that apply

a. Hospital policies and protocols

b. Leadership and management support

c. Access to continuous professional development

d. Interdisciplinary collaboration

e. Patient demographics and expectations

f. Legal and regulatory frameworks

3. What obstacles have you faced in trying to enhance your professional autonomy?

Select all that apply

a. Lack of support from management

b. Insufficient time due to workload

c. Lack of access to further education and training

d. Rigid hospital policies and protocols

e. Cultural and societal perceptions of midwifery

4. How does leadership within Hospital X impact your professional autonomy and how

can it be improved?

5. Can you share examples of international best practices or models that could enhance

midwifery autonomy and satisfaction? How do you think these could impact patient

care?

6. In your opinion, what changes could Hospital X implement to improve professional

autonomy and midwife satisfaction? Select all that apply

 67

a. Enhancing leadership and management support

b. Revising hospital policies to increase decision-making power

c. Providing more opportunities for professional development

d. Improving interdisciplinary collaboration

e. Adopting international best practices in midwifery care

7. How likely are you to recommend hospital x as a workplace for midwives seeking

professional autonomy? [Rating with values 1-10]

8. What specific support or resources do you need to overcome the obstacles to

professional autonomy?
 68

Appendix 3: Midwifery Care Patient Satisfaction Survey at Hospital X, Abu Dhabi

1. How would you rate your overall satisfaction with the midwifery care you received?

a. Very satisfied

b. Satisfied

c. Dissatisfied

d. Very dissatisfied

2. Select all that apply: What aspects of the midwifery care were most important to you?

a. Professional autonomy of the midwife

b. Communication with the midwife

c. Midwife's ability to make independent decisions

d. Support and guidance provided by the midwife

e. Overall patient care and empathy

3. How effectively did the midwife communicate with you regarding your care and

treatment options?

a. Very effectively

b. Effectively

c. Ineffectively

d. Very ineffectively

4. Did you feel that the midwife was able to make independent decisions regarding your

care?

a. Yes, definitely

b. Somewhat

c. Not really

d. Not at all
 69

5. What, if any, obstacles did you perceive in the midwife's ability to provide care

autonomously?

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………..

6. In what ways do you think midwifery care at Hospital X could be improved?

………………………………………………………………………………………………

………………………………………………………………………………………………

……………………

7. How likely are you to recommend the midwifery services at Hospital X to a friend or

family member? [Rating with values 1-10] ………….

8. Did the leadership (e.g., senior midwives, department heads) seem to support the

midwife's professional autonomy?

a. Yes, definitely

b. Somewhat

c. Not really

d. Not at all

9. Select all that apply: What international best practices or models do you think should

be implemented to enhance midwifery care at Hospital X?

a. Greater professional autonomy

b. Better communication and support from leadership

c. Continuous professional development for midwives

d. Increased patient involvement in care decisions

e. Implementation of evidence-based practices

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