Collegial Sabotage

One well-documented aspect of work stress that destroys a sense of well-being and confidence for hospital midwives is the aura of hostility and disrespect toward midwives on many labor and delivery units. It has been pervasive, malignant, and persistent within this environment since nurse-midwives took their places on labor and delivery units. Unhealthy cultures of care on obstetrical units have never, really, gone away. Scholarly papers and other research articles have reported it repeatedly. How it starts and continues to destroy professional working relationships has been studied, but remains unresolved. Some of the best attempts to understand the problem have ultimately failed.

Unhealthy Cultures of Care

Labor and delivery nurses are fairly consistent in their disdain for midwives, often joined by physicians, residents, and upper-level nursing management. Even Nursery/NICU nurses have joined in and may be openly critical of and resistant to midwifery care. Unfortunately, the health of the work environment influences midwifery performance. Although leadership can mitigate stress by improving workplace health, efforts to alleviate workplace stress have been inadequate. 1

Everyone who has attempted to study these interactions has been unable to propose any realistic solutions. In a 2008 study, attempts were made to bring nursing and midwifery together in a meeting of the minds. Tensions escalated to the point that the study leaders were forced to bring in outside professional mediators to intervene. In reviewing many of the articles on this subject, the same issues keep recurring. Although nurse-midwives have staffed hospital OB units for decades, it appears that nursing cannot accept a model of care it cannot relate to. Other studies of working relationships between nurses and midwives revealed that CNMs defined their occupational identities as separate from nursing, although both identified advocacy as essential to their roles. A distinct difference for the midwife was protecting patients from technological intervention. In addition, the author of one study found a more difficult relationship between nurses and CNMs compared with CNMs and physicians. In addition, it appeared that nurses did not understand midwives' training and often felt resentful, resulting in sabotage against the midwives (no details on the exact nature of the sabotage).2

When interviewed, nurses and midwives cited departures in philosophy and a bilateral lack of trust. Both nurses and midwives felt a mutual sense of betrayal. Midwives are often considered too "hands-off" regarding patient care, and the most fervent nursing criticisms suggested midwifery care to be dangerous. The nursing and midwifery scopes of practice are widely divergent. I doubt RNs or MDs could identify any items within the midwifery scope of practice. Territorial/turf skirmishes are the norm when the focus should be on united efforts to provide the best care.

Mutual trust between nurses and midwives is consistently lacking. Midwives claim that nurses tend to compete for control of the patient and openly disagree with CNM management, frequently in the patient's presence. Nurses accuse midwives of elitism, "acting as if they are better or smarter than the nursing staff. 3 Apparently, independent midwifery management was perceived as an insult to traditional nursing. Consistently, the two professions have difficulty finding a common ground. Nursery and NICU nursing also have turf issues. Cooperation and respect are a two-way street, where too few professionals can co-exist.

Professionals Acting Out

Before becoming midwives, many CNMs have worked as labor and delivery nurses. They have done what nurses do. They understand the nursing role, whereas RNs don't fully understand the CNM role or the model of care. Nursing may dismiss it outright, refusing to even consider the underlying basis for midwifery care. CNMs have claimed exhaustion from having to repeatedly defend their knowledge, care, and evidence-based practice rationale to colleagues who repeatedly reject it. 4 Making matters worse, nursing department leadership is often assigned to regulate and oversee the practice of CNMs, which is inappropriate for managing midwives.

On a labor and delivery unit, nursing administration can set a permanent tone of suspicion and negativity. A disdainful atmosphere, once established, is difficult to change. CNMs express frustration that they will only be accepted within established RN working environments if they can remember to "act like good nurses. 5 In addition, assigned CNM group "leaders" possess little power to support or defend the group. Sometimes, CNMs have little choice but to put their heads down and suck-it-up. Until they can't.

The Nurse in Nurse-Midwife

Is it possible that the "nurse" in nurse-midwife is part of the problem? Nurses feel betrayed by nurse-midwives, and midwives cannot escape their nursing backgrounds, which interferes with their ability to enjoy an elevated status as advanced practice providers. Medicine will never stop expressing superiority over nursing, extending their ingrained attitudes of superiority to "nurse"-midwives. This underscores the medical care class consciousness that has carried on for more than a century. No matter how degreed, dedicated, and experienced, nurse-midwives may always be "just nurses, not only to doctors and fellow RNs, but to society, as well.

The difficulties between nursing and hospital midwifery will persist until there is a collective change in perspective and attitude. From both sides. Dedicated teamwork requires an understanding and respect for each specialty's scope of practice and how they can complement one another. I consider the bottom line for rehabilitating the negative attitudes currently prevailing. The literature on effective teams in healthcare emphasizes the importance of respecting individual scopes of practice among team members. True specialty teamwork requires knowledge and dedication that some hospital systems and medical providers have not been ready to embrace, particularly because it involves a change in the status quo, attitudes, and a willingness to let go of outdated hierarchies of care. In the meantime, mutual respect should be a goal to strive for. Easy to say, but not easy to implement.

Fear of Litigation

Perhaps a healthy fear of litigation can be useful in chaotic settings, reminding nurses, midwives, and doctors that disrespect and animosity must not persist. Unhealthy cultures of care definitely pose a threat to competent patient care. Staff and administration might focus on the legal risks in dysfunctional, angry settings. Clearly, established animosity within health care systems provokes medical negligence, resulting in patient harm. When the care culture is ugly and teamwork is nonexistent, the trial lawyers rejoice. They have a much easier time making their case for negligent conduct. When providers are at odds, it is a defense team's nightmare to bring them together for trial preparation. Limited example:

- A mother and her infant have suffered injury due to nursing/midwifery negligence

- The medical records and deposition testimony reveal that the midwives and nurses were not coordinated, or in agreement with, the patient/infant plan of care

- An unhealthy culture of care will be flushed out and highlighted in pre-trial depositions and throughout the trial

- The plaintiff patient will probably be able to testify regarding bedside provider conflicts, in detail

- The patient care was predictably flawed because the providers were not working as a team

- Testimony regarding ways that the absence of teamwork and mutual cooperation jeopardizes patients and their infants

- Plaintiffs' counsel’s winning scenario: (a) midwife-resistant, seasoned L&D nurse plus (b) equally resistant, seasoned midwife = Inconsistent testimony - a litigator’s dream

- Clear gaps in communication resulting in negligent care

No More Nurses In Midwifery?

Midwifery may face a future in which former L&D nurses, at least, will have no interest in becoming midwives. No wonder. For others interested in a career in midwifery, one challenge is the requirement to study nursing before entering a certified nurse-midwifery program. Some believe that nursing education may somehow "taint" pregnancy and birth with an illness orientation, requiring midwifery students to "override the learned nursing role in order to make decisions aligned with a midwifery model of care.

Currently, individuals entering midwifery from backgrounds other than nursing can take on the CM (Certified Midwife) role. So far in the U.S., the absence of nursing education prevents individuals from engaging in midwifery hospital practice. That's not to say that practicing midwifery in homes and birth center settings is undesirable. Artists, teachers, musicians, and others might actually make better midwives, unburdened by the static traditions and attitudes of nursing and medicine.

1. Kennedy, HP, PhD, CNM. Tensions and Teamwork in Nursing and Midwifery Relationships. Journal of Obstetrical Gynecologic and Neonatal Nursing. Vol. 37, Issue 4. 2008 pg. 426-427.

2. Ibid. pg 427

3. pg. 431

4. pg. 433

5. Erin M. Wright, CNM, DNP et al. Midwifery Professional Stress and Its Sources. J Midwifery Womens Health. 2018; 63:660-667.

https://www.midwivesontrial.com