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Objective to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth. Design ethnography. Setting tertiary hospital in Australian city. Participants sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork. Findings women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence. Key conclusions informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices. Implications for practice as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.

Background: Aboriginal and Torres Strait Islander women, hereafter called Indigenous women, can experience a lack of understanding of their cultural needs when accessing maternity care in the standard hospital care system. Aim: To explore the lived experiences described by Indigenous women accessing labour and birth care in the standard hospital care system at a tertiary public hospital in South Australia. Methods: An interpretive Heideggerian phenomenological approach was used. Indigenous women who accessed standard care voluntarily agreed to participate in semi-structured interviews with Indigenous interviewers. The interviews were transcribed and analysed informed by van Manen's approach. Findings: Thematic analysis revealed six main themes: "knowing what is best and wanting the best for my baby", "communicating my way", "how they made me feel", "all of my physical needs were met", "we have resilience and strength despite our hardships" and "recognising my culture". Conclusion: Indigenous women in this study expressed and shared some of their cultural needs, identifying culturally unsafe practices. Recommendations to address these include the extension of current care planners to include cultural needs; Aboriginal Maternal Infant Care (AMIC) workers for women from rural and remote areas; AMIC workers on call to assist the women and midwives; increased education, employment and retention of Indigenous midwives; increased review into the women's experiences; removal of signs on the door restricting visitors in the birth suite; flexibility in the application of hospital rules and regulations; and changes to birthing services in rural and remote areas so women may not have to relocate for birth. Refereed/Peer-reviewed

Selecting the most appropriate methodology for research as a doctoral student is one of the most important yet difficult decisions. Not only should the methodology suit the research question, it is important that it resonates with the philosophy of one’s discipline and produces needed results that will contribute to knowledge. Interpretative phenomenological analysis (IPA) is an approach to qualitative enquiry. IPA seeks to explore how individuals make sense of their major life expe-riences and is committed to the detailed study of each particular case before moving to broader claims. In the field of midwifery, midwives work with women throughout pregnancy, childbirth and the early postnatal period, offering individualized care based on the unique needs of each woman. IPA aligns with this women-centered philosophy as it offers a methodological approach that considers the individual in a local context. By capturing context specific situations, IPA al-lows broad-based knowledge to be contextualized within a social and cultural context, producing relevant findings. Thus the access to IPA studies will enable midwives to better care for women and their families through understanding the experiences and perceptions of those in their scope of practice.This paper presents the theoretical framework leading to practical guidelines on how to conduct a doctoral-level IPA study, as experienced by the first author. It also addresses the advantages and challenges around utilizing IPA, illustrated through examples from the doctoral student’s study on the journey of exclusive breastfeeding in Australia. Refereed/Peer-reviewed

OBJECTIVE: To describe sleep, stress and compensatory behaviors in nurses and midwives. METHODS: The study included 41 midwives and 21 nurses working in Australian hospitals between 2005 and 2009. Participation was voluntary. All participants recorded on a daily basis their work and sleep hours, levels of stress and exhaustion, caffeine intake and use of sleep aids for a month (1,736 days, 1,002 work shifts). RESULTS: Participants reported moderate to high levels of stress and exhaustion on 20-40% of work days; experienced sleep disruption on more than 50% of work days; struggled to remain awake on 27% of work days; and suffered extreme drowsiness or experienced a near accident while travelling home on 9% of workdays. Age, perceived sleep duration and work hours were significant predictors of caffeine intake. About 60% of participants reported using sleep aids (about 20% reported taking prescription medications and 44% of nurses and 9% of midwives reported alcohol use as a sleep aid at least once during the study). Stress and workdays were significant predictors of sedative use. Overall, 22% reported being indifferent or mildly dissatisfied with their job. CONCLUSIONS: Sleep problems, high levels of stress and exhaustion and low job satisfaction are prevalent among nurses and midwives. The use of alcohol and sleeping pills as sleep aids, and the use of caffeine to help maintain alertness is also common. Nurses and midwives may use caffeine to compensate for reduced sleep, especially on workdays, and sleeping pills to cope with their daily work-related stress. OBJETIVO: Descrever sono, estresse e comportamentos compensatórios em enfermeiras e parteiras. MÉTODOS: O estudo incluiu 41 enfermeiras 21 parteiras em hospitais australianos de 2005 a 2009. A participação foi voluntária. Os participantes registraram diariamente as horas de trabalho, sono, stress e níveis de exaustão, cafeína e uso de ajuda para dormir durante um mês (1.736 dias, 1.002 turnos). RESULTADOS: Os participantes relataram de moderados a elevados níveis de stress e de exaustão em 20%-40% dos dias de trabalho; experimentaram distúrbios do sono em mais de 50% dos dias de trabalho; relataram esforço para permanecer acordado em 27% dos dias de trabalho; e sofreram sonolência extrema ou acidente perto de casa em 9% dos dias de trabalho. Idade, duração do sono percebida e jornadas foram preditores significativos da ingestão de cafeína. Aproximadamente 60% dos participantes relataram utilizar a ajuda para dormir: cerca de 20% relataram uso de medicação prescrita e 44% das enfermeiras e 9% das parteiras consumiam álcool como auxílio para dormir pelo menos uma vez durante o estudo. Estresse e dias de trabalho foram preditores significativos do uso de sedativos. Em geral, 22% relataram ser indiferente, ou ligeiramente insatisfeito com seu trabalho. CONCLUSÕES: Problemas no sono, estresse e exaustão elevados e diminuição na satisfação no trabalho são prevalentes. São comuns o uso de álcool e de medicamentos para dormir, e consumo de cafeína para se manter alerta. Enfermeiras e parteiras parecem usar a cafeína para compensar a redução do sono, especialmente em dias de trabalho, e usar soníferos para compensar o estresse diário. OBJETIVO: Describir sueño, estrés y comportamientos compensatorios en enfermeras y parteras. MÉTODOS: El estudio incluyó 41 enfermeras 21 parteras en hospitales australianos de 2005 a 2009. La participación fue voluntaria. Los participantes registraron diariamente las horas de trabajo, sueño, estrés y niveles de agotamiento, cafeína y uso de ayuda para dormir durante un mes (1.736 días, 1.002 turnos). RESULTADOS: Los participantes relataron de moderados a elevados niveles de estrés y de agotamiento en 20%-40% de los días de trabajo; experimentaron disturbios del sueño en más de 50% de los días de trabajo; relataron esfuerzo para permanecer despierto en 27% de los días de trabajo; y sofrieron somnolencia extrema o accidente cerca de casa en 9% de los días de trabajo. Edad, duración del sueño percibido y jornadas fueron predictores significativos de la ingestión de cafeína. Aproximadamente 60% de los participantes relataron utilizar la ayuda para dormir: cerca de 20% usaron de medicación prescripta y 44% de las enfermeras y 9% de las parteras consumirán alcohol como auxilio para dormir al menos una vez durante el estudio. Estrés y días de trabajo fueron predictores significativos del uso de sedativos. En general, 22% relataron ser indiferente, o ligeramente insatisfecho con su trabajo. CONCLUSIONES: Problemas en el sueño, estrés y agotamiento elevados y disminución en la satisfacción en el trabajo son prevalecientes. Uso de alcohol y de medicamentos para dormir, y consumo de cafeína para mantenerse alerta también es común. Enfermeras y parteras pueden usar la cafeína para compensar la reducción del sueño, especialmente en días de trabajo, y usar somníferos para compensar el estrés diario.

Investigations of mood and workload in health care settings have focussed primarily on nurses and junior doctors. Given the critical shortfall in the Australian midwifery workforce, and the specialised nature of midwifery as an occupation, it is important to understand how mood and workload are experienced by midwives. Twenty midwives (18F, 2M) in an Australian metropolitan hospital completed logbooks assessing daily fluctuations in subjective mood and workload. Participants also provided information about history of psychopathology and sleep quality. Results revealed that midwives were relatively stable in terms of mood but did experience increased fear and decreased happiness when at work. Further, workload factors significantly predicted mood at work. Specifically, when participants felt that their work was more demanding and frustrating and required more effort, or when they felt that they could not accomplish all that was expected, mood was negatively influenced. This supports the connection between workload and negative mood change in healthcare. Given the potential for mood to influence a multitude of functions relevant to safety, performance and psychosocial wellbeing it is important to understand the factors which influence mood, particularly in light of the current shortfall in the Australian healthcare workforce. Refereed/Peer-reviewed

Since the 1970s, men have been encouraged to actively participate in the childbirth process, resulting in a shared experience for couples. Nevertheless, after the baby is born, many fathers find themselves displaced, unsure of how to embrace the transition to parenthood. The shift in cultural practice and evolving needs of families calls for the recognition of fathers as well as mothers in the provision of midwifery services. Innovative strategies must be considered to enhance postnatal education that is father-inclusive and responsive to the needs of families in the 21st century. This article introduces one strategy created from an action research study conducted to develop, implement, and evaluate strategies to improve postnatal education for parents.

In this article, we discuss the use of critical medical anthropology (CMA) as a theoretical framework for research in the maternity care setting. With reference to the doctoral research of the first author, we argue for the relevance of using CMA for research into the maternity care setting, particularly as it relates to midwifery. We then give an overview of an existing analytic model within CMA that we adapted for looking specifically at childbirth practices and which was then used in both analyzing the data and structuring the thesis. There is often no clear guide to the analysis or writing up of data in ethnographic research; we therefore offer this Critical analytic model of childbirth practices for other researchers conducting ethnographic research into childbirth or maternity care. Refereed/Peer-reviewed

There is a paucity of information regarding Australian nurses' sleep and fatigue levels, and whether they result in impairment. Forty-one Australian hospital nurses completed daily logbooks for one month recording work hours, sleep, sleepiness, stress, errors, near errors and observed errors (made by others). Nurses reported exhaustion, stress and struggling to remain (STR) awake at work during one in three shifts. Sleep was significantly reduced on workdays in general, and workdays when an error was reported relative to days off. The primary predictor of error was STR, followed by stress. The primary predictor of extreme drowsiness during the commute was also STR awake, followed by exhaustion, and consecutive shifts. In turn, STR awake was predicted by exhaustion, prior sleep and shift length. Findings highlight the need for further attention to these issues to optimise the safety of nurses and patients in our hospitals, and the community at large on our roads.

Objective: to develop and validate national competency standards for midwives in Australia. This study was part of a commissioned national research project to articulate the scope of practice of Australian midwives and to develop national competency standards to assist midwives to deliver safe and competent midwifery care. Design: a multi-method, staged approach was used to collect data through a literature review, workshop consultations, interviews, surveys and written submissions in order to develop national competency standards for Australian midwives. Subsequently, direct observation of practice in a range of settings ensured validation of the competencies. Setting: maternity-care settings in each state and territory in Australia. Participants: midwives, other health professionals and consumers of midwifery care. Findings: The national competency standards for the midwife were developed through research and consultation before being validated in practice. Key conclusions: the national competency standards are currently being implemented into education, regulation and practice in Australia. These will be minimum competency standards required of all midwives who seek authority to practise as a midwife in Australia. It is expected that all midwives will demonstrate that they are able to meet the competency standards relevant to the position they hold. Implications for practice: the competency standards establish a national standard for midwives and reinforce responsibility and accountability in the provision of quality midwifery care through safe and effective practice. In addition, individual midwives may use the competency standards as the basis of their ongoing professional development plans. © 2006 Elsevier Ltd. All rights reserved.

Summary Objective to research the role of midwives in Australia from the perspectives of women and midwives. This study was part of a commissioned national research project to articulate the scope of practice of Australian midwives and to develop national competency standards to assist midwives to deliver safe and competent midwifery care. Design a multi-method approach with qualitative data collected from surveys with women and interviews with midwives. Setting participants represented each state and territory in Australia. Participants midwives who were randomly selected by the regulatory authorities across the country and women who were consumers of midwifery care and involved in maternity activism. Key conclusions midwives and women identified a series of key elements that were required of a midwife. These included: being woman centred; providing safe and supportive care; and working in collaboration with others when necessary. These findings were consistent with much of the international literature. Implications for practice a number of barriers to achieving the full role of the midwife were identified. These included a lack of opportunity to practice across the full spectrum of maternity care, the invisibility of midwifery in regulation and practice, the domination of medicine, workforce shortages, the institutional system of maternity care, and the lack of a clear image of what midwifery is within the wider community. These barriers must be addressed if midwives in Australia are to be able to function according to the full potential of their role.