Working Relationships in Midwifery Practice: Clinical Encounters of the Dysfunctional Kind: Part 2
Relevance For Practice: What the Experts Say
Situation
Unfortunately, the long history of friction between CNMs and RNs on labor and delivery will probably not resolve any time, soon. Accept that this dysfunctional dynamic may remain inherent in the culture of care on many L&D Units. Unhealthy cultures of care transcend State lines and territorial boundaries, existing in many hospital labor and delivery units in the United States.
Familiar issues, of course, are the state of relations between registered nurses and certified nurse-midwives. Since the first nurse-midwives showed up in American hospitals, there has been tension, animosity, and an unfortunate lack of teamwork. Many historical issues persist, one being persistent communications breakdown and disrespect.[1]
Nurses and CNMs have more difficult relationships between them than either group has with obstetricians. After decades of association on Labor and Delivery units across America, nurses often fail to understand midwifery education, scope of practice, or the CNM role in healthcare. Nurses have always been in the position where physicians provide the care orders. Discovering that they would need to take orders from CNMs, nurses became resentful at best, and suspicious at worst, leading to varying forms of nursing sabotage against midwives.[2] Passive-aggressiveness formed the basis of these relationships. Today, differing issues such as philosophical disagreements regarding labor, birth, safety, and pain management are consistent points of conflict. Lack of respect and poor communication flows both ways.
Between obstetricians, nurses, and midwives there are situations where professional roles and responsibilities overlap. Nurses have expressed that they expected different things from midwives, despite familiarity with obstetrical practice. Disregard from CNMs was felt to be harder to take than from the doctors, due to the shared “roots” between nurses and midwives. Likewise, CNMs have reported feeling overt disrespect from nurses due to midwives’ roles as providers. Again, having to take orders from CNMs ( “aka other nurses”) was hard for labor and delivery RNs to swallow.[3]
Nurses have reported tension when: “CNMs aren’t acting like midwives”, e.g. requesting that the nurse bring a patient juice or a clean gown. The nurses’ attitudes were: You’re the midwife, do it yourself. As a result of honest reflection, nurses admitted that they weren’t as annoyed if the same request came from a doctor. In healthcare, there is a necessity for constant collaboration. However, some nurses struggle with mutual respect, asserting that midwives are no smarter than they are.[4] Attitudes of indignation and disrespect toward midwifery also included the belief that nurse-midwives exhibit superior behavior because they are “advanced practice” nurses. Certified nurse-midwives held similar attitudes toward nurses, claiming that negative encounters with nursing detracted from the midwives’ abilities to provide good care and advocacy for their patients.[5] Relations have been strained for decades due to personality clashes, hierarchical issues, power imbalances, and extremely poor communication. Not the ideal atmosphere for laboring patients.
Expectations/Duty:
Certified Nurse-Midwives and Labor and Delivery RN’s each have an absolute legal and moral duty to maternity patients and unborn infants, but not necessarily to one another in a legal sense. In a perfect world, efforts to resolve conflict should be prioritized. However, you will not see this in the average labor and delivery environment. Civility and mutual cooperation between nurses and CNMs should be a baseline expectation. For CNMs in hospital practice, there may be no one who is willing to facilitate this. Nursing grievances will be addressed by nursing administration. But who in the hospital administration is going to advocate for the CNMs/CMs and address the deeply ingrained resentments and conflicts between the specialties? Obstetrical hierarchies are not likely to touch it and nursing administration is not going to relate to, or stand with, the midwives.
The culture of care in hospital maternity settings is complex. It would seem that teamwork, communication, and collaborative relationships would be prioritized. Dysfunctional communications should be recognized and replaced with effective communication to ensure patient safety and quality of patient care[6] In regard to improving communications skills and supporting strategies, no clear answers are being proposed by hospital corporate entities. It’s no secret that increased job demands and unclear role perceptions lead to inter-professional conflicts. In sick cultures of care, there is a need to enhance and ecourage a healthy work environment.[7] [8] But healthy and functioning labor and delivery environments appear to be few.
There should be a baseline expectation for professionalism and cooperation between nurses and midwives to work together as colleagues. These aspirations are reasonable and can only enhance the quality of patient care. From a CNM/CM standpoint, potential solutions lie within their specific specialty; adherence to standards of practice, core competencies, and ethics. In especially difficult cultures of care, it is important not to lose sight of midwifery behavior that is consistent with duty and impeccable patient care. Collegial issues are draining, but with no real solutions for communication/respect issues on labor and delivery, midwives must direct their focus to the patient and do the best they can, absent any meaningful administrative support.
Professional Vulnerability and Inherent Legal Risk:
In a dysfunctional care environment, the risk of legal liability is high. It is obvious and predictable that communications and competent care are compromised. It is reasonable to expect that patient care will suffer. CNMs are in a position of straddling nursing and medicine in order to find a specific, self-contained, and respected, niche in maternal/child healthcare. Attempting to establish an identity that is separate from nursing and medicine has been consistently met with hostility and resistance.
The relationships between nurses and CNMs can be more difficult than between CNMs and obstetricians/anesthesiologists. Conflicting philosophies of care result in dysfunctional communications and disrespect among colleagues. Resolutions are hard to come by. Doctors, nurses, and midwives frequently discover that they are unable to work as partners.[9]
Sixty percent of medical errors are the direct result of communications breakdown. Despite viewing childbirth as a normal, physiological event, the labor and delivery unit is considered a potentially high risk area. The process of delivering an infant is unpredictable. Situations can change instantly . Dedicated team approaches to care are difficult when all participating professionals have probably learned contrasting styles of decision-making and enter the environment of childbirth with drastically different communications skills. In acute situations of childbirth, hospital midwives sometimes feel invisible due to rigid hierarchical structures that have been established over time in many hospitals.[10]
Balancing Personal Life and Career
For CNMs, balancing personal life responsibilities to partners, children, and their own self-care can be significantly stressful. With competing desires to take care of their families and clients, many midwives have left full-scope midwifery for less demanding work responsibilities.
A significant source of stress for CNMs/CMs is the fear of litigation. When interviewed, many midwives have described the difficulty of practicing in fear of medical-legal ramifications. They have expressed that a component of their daily work stress level included their fear of a lawsuit, despite applying principles of best evidence. “Litigation might end my career, even though I have done the best job that I can do.”[11]
Again, significant issues for midwives in hospital practice involve the demands of taking call and the sleep deprivation associated with mandatory on-call schedules. It has been suggested that improving sleep hygiene might improve inter-professional relationships and patient safety. [12] (Refer to: ACNM Position Statement: Fatigue, Sleep Deprivation, and Safety).
Potential Remedies/Protection:
There are no realistic answers. Improving working relationships needs to be a goal for all providers. For midwives, focus must be directed to the patients; mom and baby. Best advice from this author: Refuse to ignite or encourage tensions or animosity. Document situations or conflicts which have the potential to compromise patient care. Memorialize negative encounters that you feel are interfering with competent patient care. There is nothing improper or unethical about this. Document all contentious conversations as they occur.
You are in charge of your patient’s care and well-being. Having to function in the midst of poor working relationships is exhausting, and diverts your attention away from the care of your patients. In these situations, the risk of malpractice is significantly increased. Duty to the patient is paramount. Strive to maintain focus and the appearance of composure. Ideally, there might be some support from a charge nurse, but do not count on it. If necessary, activate an approriate chain of command. Consult with members of the hospital’s obstetrics department, human relations, or even risk management at the hospital. Go up a medical/obstetrical chain of command to voice concerns. Bypass nursing chain of command as this is not likely to be effective. Advocating for yourself and your patients takes inner strength, but by carefully documenting the issues, there is hope that someone from the higher levels of administration might take action. Again, it is important to speak up and make a record of all efforts to receive help.
There are plenty of suggestions for improving culture of care and patient safety, but these are frequently just empty platitudes or wishful thinking, without concrete plans for change. Statements which encourage the need for effective communication and teamwork being an ongoing process are really not expressing anything new.[13]
For now, if your workplace is significantly dysfunctional, stay calm and alert. Take care of patients, first. Document carefully, as care responsibilities will allow, on and off the medical record. Dysfunctional cultures of care can increase the risk for obstetrical care disasters from provider malpractice. If there is no avenue for help or support, consider leaving this environment.
I can do anything you can do, better. .
[1] Kennedy, HP PhD, CNM. et.al., Tensions and Teamwork in Nursing and Midwifery Relationships. Journal of Obstetric, Gynecologic & Neonatal Nursing. Vol. 37, Issue 4, July-August 2008, Pages 426-435.
[5] Erin M. Wright, CNM, DNP et.al., Midwifery Professional Stress and Its Sources: A Mixed-Methods Study. Journal of Midwifery and Women’s Health. Vol.63, No. 6, November-December 2018. p. 644.
[6] Wang,YaYa, et.al. International Journal of Nursing Sciences. Interventions to improve communication between nurses and physicians in the intensive care unit: An integrative literature review.2017 Nov 24. p.81-88
[7]Schmiedhofer, Martina et.al. Barriers and Facilitators of Safe Communications in Obstetrics: Results from Qualitative Interviews with Physicians, Midwives, and Nurses. J. Environ. Res. Public Health 2021, 18(3)915.
[8] Schmiedhofer, p. 426-435.
[9] Kennedy, HP et.al.
[10] Schmiedhofer, p.426-435.
[11] [12] Wright, Erin M. p. 646-647.
[13] Kennedy, HP et.al.
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