Midwifery Practice in Zones of Danger

Many Certified Nurse-Midwives and Certified Midwives will seek employment with hospital corporate systems that may be new to them. During the hiring process, prospective new-hire midwives are introduced to most aspects of the hospital regime that the hospital is particularly proud of. During this quasi-courtship, the midwife is unlikely to discover the institution's dark underbelly until much later in their employment.

One of the brighter spots that might be presented during hospital hiring is the concept of teamwork, which the hospital will tout shamelessly without revealing any substance behind it. New clinicians are unlikely to experience a hospital's actual rendition of teamwork during the early stages of orientation.

Functioning Healthcare Teams

Ideally, healthcare teams function on platforms designed for interspecialty cooperation and open communication among providers with diverse backgrounds and training. The differing scopes of practice among participating team members are recognized as essential in patient emergencies. The expectation is to function smoothly without hierarchical drama or competition. It is, however, crucial that all providers participate in team training. In hospitals truly dedicated to team training, patients benefit when provider egos do not compete, and the team maintains a horizontal structure. This can facilitate accurate coordination of members' talents, experience, and background.

So, what do well-functioning care teams have to do with avoiding malpractice and other legal involvement? Just about everything. To function as a cohesive healthcare team, the following elements must be incorporated: trust, patience, empathy, and regular drills tailored to potential emergencies and the unique talents of the team's providers. Practice scenarios for emergencies must be regularly managed and debriefed. Everyone must know their role and scope in each situation and understand how every other team member will function.

Documentation of Team Training

Some hospital systems understand and respect the concept. Others are without a clue. Or they don't think that it is crucial. In hospital litigation, almost every inch of the medical record will be requested as potential evidence. Even if the hospital is not diligent about documenting team training, the lawyers prosecuting an injury case will be. They will search for evidence of team training that may be related to a patient injury and obtain it through document requests. The absence of team drills in vulnerable environments, such as OB, will bolster a plaintiff's case against the hospital, and discovery will be conducted to determine whether this lack of evidence can be developed for consideration by a jury.

If you have never had the experience, it might be informative and enlightening for you to contemplate how truly unhealthy cultures of care and dysfunctional care teams operate:

Illegitimate Team Training

During one unfortunate period of hospital employment, I participated in an OB Unit's fever dream of Critical Events Team Training (CETT) for the first time. Right away, the process was suspicious because the only "team participants" were the labor and delivery nurses and the certified nurse-midwives. No doctors, no residents, no NICU (neonatal intensive care unit), no unit secretaries, etc. Just the already warring factions of RNs and CNMs. In her questionable wisdom, the "OB Women's Services Director (RN)" considered this to be a legitimate team training for CNMs experiencing OB emergencies. Adding insult to injury, the RNs from the unit were assigned to run the training scenarios, impersonating patients that we would encounter. (The hospital did have a sophisticated “learning lab” with stations to practice appropriate shoulder dystocia pressures and other competencies, but the facilities were available for the residents only.)

Unknown to me, my scenario involved the dramatic appearance of a 28-week G1P0 with no prenatal care who presented to the triage unit in active labor. My "assignment" was to perform in this situation, alone (unrealistic scenario #1). I was directed to the triage room to await my fate when suddenly the door burst open. One of the more demonstrative OB RNs was wheeled into the room, crouched on hands and feet, riding the gurney like it was a surfboard (unrealistic scenario #2). To add to this drama, she was shrieking at the top of her lungs. Her "family" (two other RNs from the unit), accompanied the gurney, struggling to maintain straight faces.

As the concerned midwife, my first reaction was to calm the "patient" and reposition her for an examination. I began to ask the pertinent triage questions, but the "patient" would not stop yelling long enough to answer. Fetal monitoring was not going to happen. Her pretend family, in the meantime, was opening all the cupboards and rummaging through the drawers in the room (unrealistic scenario #3).

By this time, according to my taped (and failed) performance, I should have turned on the warmer, examined the patient, pulled out a precip tray, and called NICU, in that order. Yeah, but what about a crowning patient? Or a breech presentation? Indeed, in my years as a hospital CNM, I have never witnessed this behavior from a patient or a family member. My first instinct was to laugh because the entire training was a farce. It was later that I realized it was a not-so-subtle effort to shame and humiliate. It was a lot of fun for the RNs.

In retrospect, I should have pressed the emergency button and actually called for security, bringing this “critical event” to a halt. Although I hate to admit it, I did learn something from the experience. Obviously, team training is not a joke. Nor should it present an opportunity to make a fool of someone. It certainly was not a proper opportunity to learn anything valuable regarding emergency patient care.

Dangers of Poorly Conducted Team Training

In the wrong hands, poorly conducted training exercises can be traumatic. Institutions that refuse to take these exercises seriously, or allow only one provider group to run them, can ruin the experience for someone who is there to learn. If there is a preexisting unhealthy dynamic between provider groups, it can become ridiculous. Training fiascos, like this one, might also allow individuals with negative agendas to inflict abuse and waste everyone's time.

"The clinician operating in isolation is now seen as undesireable in health care - a lone ranger, a cowboy, an individual who works long and hard to provide the care needed, but whose dependence on solitary resources and perspective may put the patient at risk".1 Given the uncoordinated state of care by groups of people who have not devevloped team skills, it is not surprising that some clinicians report that team care may actually increase medical errors. High-performing teams are now widely recognized as essential for creating patient-centered, coordinated, and effective health care delivery.2

Mutual Respect Among Team Members

Finally, team members must learn to appreciate one another's talents and accept that one type of training or perspective is not superior to others. Team members can be taught to rely on one another to recognize and avert failures, regardless of where they are in the medical care hierarchy.3

In a healthy culture of care, legitimate training is useful and thought-provoking, potentially encouraging bonding among different providers. If an entire group of providers supports one another with a common goal of preparing for something useful, the exercise can become what it is intended for: preparation for disaster, not the creation of one. Unfortunately, my "training exercise" did not enhance cooperation, expertise, or excellence in patient care; it merely embedded resentments.

Hospital Department Dysfunction - A Trial Lawyer’s Dream

In litigation, legal professionals are adept at uncovering hospital department dysfunction through simple discovery, while accounting for the tendencies toward negligence that reside in unhealthy cultures of care. Absence of hospital team training may also bolster a medical injury case, and attorneys can pursue this approach to convince a jury of hospital negligence.

As midwives, if you find yourself in this type of environment, run, don't walk,lk to your next professional opportunity. Ugly cultures of care become embedded over time and rarely rehabilitate, despite recruitment and hiring campaigns for the "best talent.” If you cannot vacate such an environment, self-preservation and maintaining legal integrity may require "rising above the stress" through self-care, enhanced focus, and dedication to your calling, as well as meticulous documentation of training activities, both on- and off-the-record.

1 Mitchell, P., Wynia, M., Golden, R., et.al. Core Principles & Values of Effective Team-Based Healthcare. Institute of Medicine OF THE NATIONAL ACADEMIES. October 2012.

2 Ibid. p. 2,3

3 Ibid. p. 5

http://www.midwivesontrial.com