Tuesday, November 17, 2015

Bullies in the Birth Profession: Shining light on a dirty little secret

I recently read the article "I loved being a midwife but bullying, stress and fear made me resign." The things that the midwife/author said evoked such a feeling of sadness.  As I began to consider the phenomenon of bullies, I understood that bullies are in every part of life.  But there is a part of me that asks, "Why maternity care?  We are better than that!".

Identifying the Bully Tactics
While bullies exists in nearly every part of life, the way in which bullies work varies.  In a 2009 article in the Journal of Perinatal Education, Susan Hodges says this about bully tactics: 

Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient's self-esteem while enhancing the abuser's sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

Work place bullies
As the coordinator of one of the first hospital-based doula programs in the United States in the
mid-1990s, I experienced first hand bullies in the workplace.  A nurse manager would say things to me like (after a difficult labor ending in a cesarean), "Well, your doulas didn't do their magic this time." or "Don't let your doulas whisper in the labor room, I know they are talking about me."  As Hodge points out, we are socialized to see health care professionals as trustworthy and demonstrating professional behavior.  No one would expect a nurse manager in labor and delivery to act with such disdain. Or at least I didn't.

Peer bullies
Bullying takes place between midwives, childbirth educators, doulas, lactation - really anyone in any profession!  Fellow birth researcher from Australia, Carolyn Hastie wrote about how peer bullying can take a dark turn:

"Jodie was one of those 'bright young things' that older, cynical midwives knowingly smile at each other about and comment how they were like that once. Enthusiastic, passionate about her work, talented and committed to learning as much as she could about her chosen profession, Jodie was equally committed to improving the situation for the women and babies in her care. Jodie went to every conference and workshop possible within the limitations imposed by shift work and rosters. Those of us who knew Jodie were aware of the difficulties she experienced as she sought to influence practices and improve care for women and their babies in the institution in which she worked. Instead of support, interest and encouragement from the institution and its management, Jodie met hostility, criticism and intimidation. Comments such as 'what would you know, you are only a new graduate, I've been doing it this way for "x" number of years' were common responses to her suggestions and ideas based on her rapidly accruing knowledge. Jodie developed a deep sense of isolation and despair. Gradually her confidence was shattered. Continued criticism and disparagement led her to doubt her value and abilities."

Bullies to patients/laboring women
Verbal and physical abuse of laboring women is a reality.  Examples of bullying in the birth room includes beginning procedures without informed consent, not stopping the procedure when asked for information by the laboring mother or her support team, misrepresentation of medical situations, and threats such as "if you don't do this, your baby will die."  In a true bully situation, this lack of informed consent and listening to the patient may contribute to the high rate of interventions and traumatic birth experiences, according to Hodges.

Side effects of bullying
Some adults who are targets of bully tactics can compartmentalize such behavior and deal successfully with it.  Others may experience physical illness, psychological depression and permanent debilitation, such as what happened with Hastie's story of Jodie the midwife.

But the side effects of bullying can be much more wide spread.  According to an article in The Clinical Teacher, the UK's NHS has shown that bullying can undermine the effectiveness of the workplace environment, and have serious implication on the delivery of care.

What can you do?
First, be aware of the behaviors of a bully.  If you witness a bully scenario between a health care person and patient, remind the patient that they have the right to change nurses or other health care person.  If you are a childbirth educator or doula who typically sees women prior to them going into labor, let them know about the rights of childbearing women and also about informed consent. Additionally, become familiar with the Mother-Friendly Childbirth Initiative from the Coalition for Improving Maternity Services - particularly the portions that deal with normalcy of the birthing process, empowerment and autonomy.  Lastly, find out about any grievance policies involving the parties.  Reach out to administrators or organizational governing bodies for assistance.

If you are the object of a bully situation, be mindful of your actions, your words and your tone. Do not antagonize the bully, stay with the facts and after the interaction, have someone with whom you can debrief. Bullies practice their behavior for many reasons including cultural, social, family and personal history or the desire to have power over persons perceived as weaker.  Understand the difference between bullying and harassment plus identify strategies that work for you to get you through the situation(s).  Take care of you.

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