Intra-specialty Cooperation: Cultures of Care Revisited

Enhancing Teamwork While Staying in Your Lane

Labor and Delivery Nurses-NICU Nurses

Although there are other specialty members crucial to an effective team, these 4 specialties of maternal/infant care collectively illustrate a hierarchy of care which should reflect a superior care dynamic dedicated to the health and safety of pregnant mothers and their infants: Doctors at the top (considered top-tier care), Midwives in the middle (mid-level care), and Labor and Delivery/NICU RNs on the bottom (not named, but generally representing a lower level of care). In regard to effective teamwork and best care, this model is a reflection of failure in American maternity-care delivery, underscored by U.S. standing compared to maternal and infant mortality rates of other industrialized countries around the world.

-Doctors-

-Midwives-

-Labor and Delivery/NICU Nurses-

Let’s consider the flow of communication, interaction, cooperation, and respect up and down a vertical model such as this. At the turn of the 20th century, a newly designated specialty of physician care, Obstetrics, sprang forth from Johns Hopkins Hospital, it’s leader, Dr. Joseph DeLee, who famously claimed invention of obstetrical forceps (although generations of Chamberlain barbers and metal-smiths would disagree).

At this point in time, vilification of midwifery, supported and advertised by JHH birthing specialists, effectively eliminated this once-trusted specialty as a safe choice for women from the middle and upper echelons of American society.

Campaigns maligning midwifery were especially effective in allowing budding obstetricians to claim professional superiority; saving American mothers from the lethal condition known as pregnancy. Care for the socioeconomically disadvantaged was acknowledged as a societal requirement, and skilled midwifery had nearly always met the maternal needs of families considered to be lower class. However, with the burgeoning profile of “obstetrics”, efforts to eliminate midwifery, for even this segment of American society, was eventually successful. (Refer to: What Happened To Midwifery in America)

In regard to a hospital-based model of care, in these early times, there were only two levels of care to consider: dominant physician care and subservient nursing care. Nurses with midwifery skills were not a significant presence in most hospitals. The physician was king, emperor, and dear leader. Nursing plans of care were non-existent. Doctors’ orders were the rule and unquestioned.

Over time, registered nurses transitioned from hospital-based schools of nursing conferring certificates, to Bachelor’s, Master’s and Doctoral degrees earned from colleges and universities. Although nursing may not (yet) be on equal footing with physicians, in regard to societal respect, the profile of nursing continues to elevate, with the doctor-nurse dynamic transitioning from what it was at the beginning of the 20th century.

And then, with the vision and conviction of nursing professionals, midwifery made a comeback, forging a professional presence in hospital-based care. Certified Nurse-Midwives became members of hospital medical staff, practicing as independent, qualified providers of maternal care, and specializing in the normal processes of pregnancy, labor, and birth, among other capabilities. It was a somewhat demoralizing and painful process, early on, and it still is, to a certain extent.

In dysfunctional cultures of hospital care, the role of the CNM can be stressful. With a strict physician hierarchy of hospital care, CNMs/Cms are caught in the middle, with distrust and disdain flowing both ways. An absence of communication, collegiality, and respect between nursing, midwifery, and medicine can create a very uneasy dynamic, varying elements of hostility may color relationships and the overall working environment.

In certain situations of hospital care, negative attitudes can flow from nursing to midwifery, in one direction, and from medicine to midwifery, in the other. Depending on the culture of care in certain hospital corporate environments, certain relationship dynamics may be more problematic than others.

Physicians may graduate from residency with an ingrained attitude toward midwifery that is reflected in automatic distrust and avoidance. Where and how these attitudes develop is a mystery, as many of the most ardent anti-midwifery physicians have never known or worked with nurse-midwives.

It has been speculated among midwives that there must be a course in medical school or residency that hammers dark and dangerous images into recently-formed doctor brains regarding the myriad evils of midwifery. Midwives have never initiated turf wars in the delivery of maternity care, but too many physicians have never been interested in reading the memo.

Despite nurse-midwifery foundations in nursing, labor and delivery RN’s can be overtly disdainful and suspicious of nurse-midwives. Certain behaviors, such as circumventing the midwife and directly consulting the physician for orders, is not unusual. Passive-aggressive behaviors can flow both ways. It is an interesting and, sometimes, stressful dynamic. Again, hostile working environments for nurse-midwives seem to be directly proportional to unhealthy cultures of care in certain labor and delivery units. Of course, conflicts can also be personality-driven.

In a healthy culture of care, the above-mentioned difficulties may be few and far between. Care providers with differing models of care, can learn to understand scope of practice, appreciate cooperation in delivery of patient care, and improve outcomes by combining the best of their individual backgrounds, training, and education. They respect boundaries and reject traditional hierarchies of care. By respecting each group’s scope of practice, they may be able to come together as a cooperative maternal care team. This kind of cooperation looks good on paper but is often difficult to achieve based on historically established prejudice and dysfunctional cultures of care. Providing best care takes vision and effort but can only improve productivity and patient care.

For clinicians, a busy labor and delivery deck can be incredibly stressful, tempers may flare, egos are wounded and interpersonal relationships may suffer, along with healthy outcomes for the patients. Naturally, there are certain hospital cultures where dedicated, positive working relationships are a baseline expectation.

Differing provider specialties can work together effectively, achieving common goals for excellent patient outcomes. Dedicated teamwork, absent a rigid hierarchy of care welcomes and respects the inputs of all provider specialties involved. Positive working environments seem more likely to thrive in hospital settings when a horizontal, teamwork driven model of care has been ingrained in the care culture.

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Intra-specialty Cooperation: Cultures of Care Revisited

Foundations For Legal Certified Nurse-Midwifery/Certified Midwifery Practice and Boards of Nursing