everyday encounters 26jun - qut...everyday encounters are ethical encounters and have potential to...
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Everyday Encounters of Everyday Midwives: Tribulation and Triumph for Ethical Practitioners
Joanne Helen Kinnane RN, Endorsed Midwife, B. Nurs (Hons)
This thesis is submitted in total fulfilment of the requirements for the degree of
Doctor of Philosophy
Humanities Research Program Carseldine Campus
Queensland University of Technology Beams Road
Carseldine, Queensland, 4034 AUSTRALIA
2008
i
KEYWORDS
ethics, midwifery, midwives, midwives’ stories, morals, narrative, narrative
research, midwifery ethics, profession, social practice
ii
ABSTRACT
Midwifery is a dynamic, ever changing, specialised field of nursing involving
the care of women and childbearing families. Clients are central to the
practice of midwifery and thus their well-being is the main focus of midwives.
So, it is not surprising that much of the relatively small body of midwifery
research is client focused. As a result, client perspectives have been studied
in a number of ways, regarding several aspects of midwifery care.
This research, however, aimed to consider midwifery from the midwives’
perspective by exploring the everyday encounters of everyday midwives who
are working in institutional settings, and identifying the ethical aspects of
those encounters. From the researcher’s standpoint, it is clear that midwives’
everyday encounters are ethical encounters and have potential to be either
beneficent or harmful. There was, however, uncertainty that midwives
recognized this “everydayness” of ethics. This research sought to clarify the
place of ethics within midwives’ everyday activities. A further purpose was to
ascertain how the ethics that entered into the encounters and activities
midwives participated in on a daily basis had affected their practise, their
profession and/ or themselves. In doing this, the intent was to broaden the
understandings of the ethical dimension of the practice.
A particular ethical approach was adopted for this project. It is a view of
ethics where persons have regard for, and responsibility toward, each other
(Isaacs, 1998). The fact that midwifery is a social practice was expected to
be significant in both the everyday encounters that midwives experienced
and the ethical responses to those encounters. Members of social practices
share an overall purpose and have a moral obligation or desire to practise
ethically. As they share a culture and a covenantal commitment to care for
those the profession seeks to serve – in a context of gift, fidelity and trust
(Isaacs, 1993; Langford, 1978), it was anticipated that midwives would,
generally, work in an ethically laden “world”.
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Narrative research offered an appropriate framework for investigating these
dimensions of midwifery practice. Many authors have noted the value of
story-telling for making sense, and illuminating the ethical features, of our
lives. It is, Kearney says, “an open-ended invitation to ethical …
responsiveness” (2000, p. 156). By enabling the participants to tell their
stories, rich, contextual narrative material was obtained. The researcher was
able to engage with both the participants and the stories as audience.
An introduction to the study is provided in Chapter One, while Chapter Two
explains both why narrative inquiry was chosen for this research project and
the framework that was utilised. The insights from the study are presented in
Chapters Three through Six. Each chapter considers the issues and
concepts arising from stories that involve midwives’ relationships and
interactions with a different group of people: midwives, institutions and
administration (“them”), doctors and families.
In Chapter Three different types of interactions between midwives and their
colleagues are explored. Some of the issues that arise are the importance of
understanding one’s own values and the place of ethics in practice, as well
as the need to “do ethics-on-the-run”. Many ethical concepts are evident
including autonomy, integrity and professional identity. Participants had many
negative experiences, and some conveyed feeling a lack of support,
threatened or overwhelmed. Conversely, some stories share very positive
images of mutual understanding where midwives worked together
empathetically.
Chapter Four looks at how managers’ interactions with midwives impacted
upon them and their practice. Unfortunately, this seems to be mostly
negative. The midwives convey a sense of feeling undervalued both
professionally and personally.
Doctors have their turn to interact with the midwives in Chapter Five. In this
chapter it becomes evident that doctors and midwives view birth from
different perspectives. The participants’ stories tell of challenging situations
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that alert us to the fact that normal, in the context of birth, is not as simple
and common place as one might think when doctors and midwives have to
work together. Wonderful, positive stories of midwives and doctors working
together told of the symbiotic relationship that these two groups of
professionals can have when the client is the focus.
The last of the insights chapters, Chapter Six, focuses on the relationships
midwives have with families. Interestingly, these are the people they spoke of
least, even though they are the people for whom the profession exists. Here
the concept of midwife as friend is discussed. Then, through their stories
some of the participants help us to learn how midwives work together with
their clients, care about them, not just for them, and how their past
experience has had a lasting impact on their practice.
Professionalism (or a lack of it) was implicated as a possible cause of some
of the participants’ concerns, as was the improper use of power. Both of
these concepts arose many times throughout the project. Chapter 7
discusses these issues in some depth.
The final chapter provides an overview of midwives situated within their
practice. An account is offered of how the participants see the future of their
practice and it is questioned if midwifery is, in fact, a social practice with
common goals. The thesis draws attention to the embeddedness of ethics in
the everyday practice of midwives, and to the vital role that relationships play
in midwifery practice. This suggests the need for a relational, contextual
ethics approach if the practice is to flourish.
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TABLE OF CONTENTS
KEYWORDS i
ABSTRACT ii
TABLE OF CONTENTS v
LIST OF TABLES xi
GLOSSARY OF MIDWIFERY TERMS xii
STATEMENT OF ORIGINAL AUTHORSHIP xv
ACKNOWLEDGEMENTS xvi
PREAMBLE 1
CHAPTER 1: INTRODUCTION 2
Background. 3
Ethics 4
What is a Midwife? 5
Who are Midwives? 8
Mostly Female 9
Mostly Older People 9
How Many? 9
What do Midwives Do? 10
The Current State of Affairs 12
Summary 13
CHAPTER 2: NARRATIVE RESEARCH 15
Introduction 15
Towards Narrative 15
Drawing Closer to Narrative 18
Narrative Approaches in Research 23
Narrative 25
What is a Narrative? 25
Features of Narrative – Jerome Bruner 28
Narrative diachronicity 29
Particularity 29
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Intentional state entailment 30
Hermeneutic composability 30
Canonicity and breach 31
Referentiality 31
Genericness 32
Normativeness 32
Context sensitivity and negotiability 32
Narrative accrual 33
Narrative and Nursing 33
Nurses and the Law 34
Storytelling for teaching 35
Nursing leadership/ administration/recruitment 36
Narrative and Midwifery 37
Storytelling for Teaching in Midwifery 37
Enriching research findings 39
Narrative to critically reflect and examine practice 42
Client Stories 43
The Moralness of Narrative 44
Narratives are reconstructions of past events 46
Stories are composed and interpreted hermeneutically 46
Engagement 47
Transmission of culture, religious practices, traditions, morals,
values and beliefs (Geanellos, 1996)
47
Communication of knowledge and skills 47
Problem solving 48
Attention arousal, engagement and community 49
Evaluative and moral frameworks are provided 49
Listening 49
Summary 50
Procedure 50
Ethical Clearance 50
Recruitment 51
Participants 53
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Inclusion Criteria 53
Reasons for Inclusion Criteria 53
Exclusion Criteria 54
Number 54
Demographics 54
Gender 54
Age 54
Work Area 55
Years of Experience 55
Consent 55
Confidentiality and Anonymity 56
Non Disclosure of Names 56
Storage 56
Female Pronoun 57
Pseudonyms 57
Essential Omission 57
Collecting and Collating Narratives 57
Narrative Material 57
Setting 58
Interviews 58
Transcription 60
Editing 60
Becoming Immersed in the Narratives 61
Listening 61
Reading 62
Computer Software Analysis 63
Interpretation 64
Plausibility 65
Time Frame 68
Difficulties/ Limitations 68
Equipment Failure 68
Interview Environment 69
Long Gaps 69
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Self Selection 69
Transcribing Errors 70
Researcher Bias 70
Conclusion 72
CHAPTER 3: MIDWIVES AND MIDWIVES 75
Introduction 75
Setting the Scene 76
Look After Your Client My Way 77
From the Literature 84
The Challenge 85
Sharing the Load 87
Ethics on-the-run 90
Look After My Client Your Way 92
Can the Code Help? 95
Collegial Relationships and Professional Development 100
Listen to Me 104
You Can Manage on Your Own 111
Conclusion 114
CHAPTER 4: INSTITUTIONS/ ADMINISTRATION AND MIDWIVES
116
Introduction 116
What is Team Midwifery? 119
On the Up Side 121
For the clients 121
Maternal and Neonatal Outcomes 122
For the Midwives 123
In-between 124
What Were We Thinking? 125
“Forced Rotation” 128
What Can We Make of This? 132
Education and Training 143
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Education is the Midwife’s Responsibility 144
Not all Midwives Seem to Agree 145
Should Support be Offered by Management? 146
Staffing Constraints 150
Conclusion 157
CHAPTER 5: DOCTORS AND MIDWIVES 159
Introduction 159
Keeping Things Normal 162
Unwanted Intervention 163
Managed Labour 168
Assisted Births 177
Triumph 179
Stuck in the Middle 181
Instrumental Inaccuracy 182
Need to Know 187
Working Together 191
Conclusion 193
CHAPTER 6: FAMILIES AND MIDWIVES 195
Introduction 195
Midwives as “Friends” 196
Working together, working with 201
Caring for versus caring about 204
When the past impacts on the present 208
Wrong place, wrong time 214
Conclusion 218
CHAPTER 7: “THIS PROFESSIONALISM” AND “POWER STRUGGLE” 220
Introduction 220
Being Professional 221
Setting the Scene 221
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Profession 224
Practice 226
“Goods” 230
Summary 232
Professional 232
The Professional Health Care Provider 234
Virtues 237
Integrity and Identity 240
Care 244
Compassion 246
Courage 246
Generosity 247
Trustworthiness 247
Other Virtues 248
Principles 248
Summary 249
Power 250
Conclusion 257
CHAPTER 8: CONCEPTUALISING MIDWIFERY PRACTICE
258
Introduction 258
Midwives and their Practice 261
Future of the Practice 263
Narratively Speaking 266
Social Practice with Common Goals? 268
It Is Not All Bad 270
Conclusion 271
POSTSCRIPT 273
APPENDICES
Appendix A: Introductory Letter – Large Private Hospital 275
Appendix B: Information Sheet for Participants 276
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Appendix C: Participant Response Sheet 278
Appendix D: Introductory Letter – Smaller Public Hospital 279
Appendix E: Advertisement for Participants at Large Public Hospital 280
Appendix F: Covering Letter for Recruiting Participants at Large Public Hospital 281
Appendix G: Consent Form 282
References 279
LIST OF TABLES Table 1: Features and Functions of Stories 28
Table 2 Names of Nodes and Number of Interview Segments in Each 64
xii
GLOSSARY OF MIDWIFERY TERMS (as utilised in this thesis)
Accoucheur: a person who assists a woman during childbirth
Active Third stage: managing the birth of the placenta actively, by giving the
woman an injection of a hormone and/ or pulling gently on the cord. The
hormone injection causes the uterus to contract firmly, encouraging the
placenta to separate from the wall of the uterus. It may also reduce bleeding.
Traction on the cord can physically assist separation and removal of the
placenta, but carries risk of haemorrhage and is rarely, if ever, done by
midwives.
Antenatal: before birth. Often used when speaking of the period of
pregnancy prior to labour or a pregnant woman eg: she was antenatal.
Augmentation: assisting labour once it has commenced. It is invoked if
progress is slower than anticipated.
Breaking Waters: also known as membranes rupturing or rupturing the
membranes. This is when the sac surrounding the baby in utero is broken
and the fluid escapes. It can happen spontaneously, which is the ideal. It is
also done by midwives and doctors using a special instrument to induce,
augment or speed up labour.
D.I.C.: Disseminated intravascular coagulation. A rare but extremely serious
blood clotting disorder that occasionally arises as a complication of childbirth
and in other seriously ill persons.
Early labour /latent phase of labour: the first stage of labour when
contractions are characteristically mild and short. The cervix dilates from zero
to four centimetres during this stage.
Endorsed Midwife: a registered nurse who has undertaken at least one year
of further training in either a hospital or at university, and gained the
necessary qualifications to have his or her registration endorsed as
competent to practise midwifery.
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Epidural: a form of anaesthetic or pain relief given by injecting medication
into the epidural space around the spinal cord, usually in the lower back
Fundus, fundal: the top of the uterus
ICN: Intensive Care Nursery. A special ward for very ill and premature
babies. Only tertiary hospitals have ICNs.
Induced/ induction: the process of having labour started artificially.
Commonly a three step process involving application of hormone gel onto the
cervix, breaking the waters, and inserting a syntocinon drip.
IUFD: Intrauterine foetal death. When the baby dies before being born.
Liquor: the fluid that drains out after the waters have broken
Multipara/ multip/ multi: terms used to refer to a woman who has had a
baby before. Multipara is the correct word, but it is usually shortened in
everyday usage by midwives and doctors.
Obs: observations. This includes temperature, pulse and blood pressure, but
depending if the mother has had her baby yet, also encompasses a
combination of the following: blood or fluid loss, contractions, fundal height,
position of the baby, pain, stitches, breast fullness and integrity, foetal heart
rate, mood
Palp: abbreviation for palpation. A part of an abdominal examination in which
a midwife assesses the position and well-being of the baby
Physiological third stage (expectant management): when the mother is
allowed to birth the placenta on her own, utilizing the surge of hormones her
body provides when, having had a normal labour, her healthy newborn is
allowed skin to skin contact and to suck at the breast. Interventions, including
medicated pain relief, interfere with the normal hormonal responses.
Postnatal: after the birth of the baby
Primip1/ primigravida: a woman pregnant with her first baby
Primip/ primipara: a woman who has had her first child. Note that the
abbreviated term, “primip”, that midwives frequently use, can refer to a
primigravida or a primipara.
Prostaglandins/ prostins/ prostaglandin gel/ prostis: the hormonal gel
that is used to induce labour
1 Although it is technically incorrect, midwives often used the term “primip” to refer to a primigravida as well as using the same term to refer to a primipara.
xiv
Puerperium: the first six weeks following the birth of a baby, during which
time the uterus is returning to its pre-pregnant state
Registered Nurse: a person who has undergone three years of training,
passed the relevant assessments, and been accepted by and entered onto
the registry of a regulatory board such as The Queensland Nursing Council.
Resus/ resuscitation: the process of reviving a person. In the case of a
newborn, the degree may be very minor (in need of a little suction or oxygen)
or complete (in need of cardiac massage).
Resuscitaire: a special piece of equipment designed for the resuscitation of
newborn babies
Rupturing membranes: see breaking waters
Scalp electrode: a small wire that is passed vaginally and attached to the
baby’s head to obtain an accurate reading of the baby’s heart rate during
labour
SCN: Special Care Nursery. A special ward for sick and premature babies
that require a high level of care, but are not as seriously ill as those in ICN.
Shoulder dystocia: difficulty birthing the baby’s shoulders
Syntocinon/synto/oxytocic: hormone given to cause or increase
contractions for or during labour. It is also used to cause the uterus to
contract strongly after the birth to assist separation of the placenta and
reduce bleeding.
Syntometrine: a mixture of syntocinon (see above) and another medication,
ergometrine. The ergometrine helps to constrict blood vessels and thus may
further reduce bleeding.
xv
STATEMENT OF ORIGINAL AUTHORSHIP
“The work contained in this thesis has not been previously submitted to meet
the requirements for an award at this or any other higher education
institution. To the best of my knowledge and belief, the thesis contains no
material previously published or written by another person except where due
reference is made.”
Signed:…………………………………….
Date:………………………………………..
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ACKNOWLEDGEMENTS Many people have assisted, supported and encouraged me throughout the
years of this research. I would like to acknowledge and express my sincere
gratitude to the following people:
My principal supervisor, Mr. David Massey, whom I have dubbed “the
supervisor from heaven”. Support, guidance, wisdom and encouragement
are but a small portion of his gift to me. He has been my advocate, advisor
and friend through challenging times.
Dr. Ruth Elder, my Associate Supervisor, for words of encouragement and
advice.
Dr. Angela Cushing, for encouraging me to do this PhD. I will never forget
you asking me, the day I handed in my Honours Thesis, when I was going to
start.
All the midwives who participated in this research. You are amazing and I
want you to know how much you are appreciated. You gave so much more
than your time.
Special thanks are due to the doctors and nurses at the Prince Charles
Hospital in 2001. Without them, I would have died without completing this
degree. Also, my many other doctors, and the staff at the Wesley, Brisbane
Private, and Princess Alexandra hospitals have worked very hard to keep me
in reasonable health since. Thank you. Gratitude of particular magnitude is
due to LeeAnne, Leanne, Leesa and Lisa (at Brisbane Private), Leanne and
Tod. You know who you are. Not only do you care for my health on a regular
basis, but you listen to me ramble about my thesis endlessly for hours.
xvii
Quantum Technology, Freedom Scientific and their staff. They provided me
with invaluable advice, assistance and software without which I could not
have completed this thesis. WYNN Wizard steered me back on track.
Dr. Lorraine Venturato and Dr. Jillian Brammer who have been constant
supporters throughout the project, always going the extra mile even when
they were under pressure themselves. Thank you so much.
Dr. Lindsay Henderson, for making the transition to a new school so
pleasant.
Dr. Isabella Taylor, who is always there at the end of the phone when the
going gets tough. I know you really understand.
All my fellow PhD candidates and the staff of the Humanities Program. The
collegial support and discussion makes it easier, more pleasant and possible.
My church family, Stafford Salvation Army Corps, a constant source of
practical and prayerful support.
The security guards at QUT, who enabled me to work many late nights and
weekends safely.
My colleagues at work, who have encouraged me every step of the way,
and my friends who have shown interest in my work and understood my lack
of sociability. Robin Turnbull deserves an extra big thankyou for the
tremendous assistance she gave in checking my references.
My family, who have helped me in every way conceivable to reach my
goals throughout my life. I am indebted to you for your loving support and
encouragement.
Lastly, I want to acknowledge my God. He is the alpha and omega, the
beginning and the end. He was there when I set out to commence this PhD
and He is here at the end. I thank Him for His steadfastness and help.
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PREAMBLE
Stories are of crucial importance to our development, well-being and the
functioning of our society. Before we are born we hear stories; in the first
weeks of life babies practise interacting with those around them (even
mouthing), beginning to learn the art of storytelling; and in every aspect of
our lives we use stories. Ochs and Capps have said that stories are a
“central proclivity of human kind” (2001, p. 2). They are so much a part of our
being, who we are and who we are becoming, we cannot help telling them.
Some stories have been told many times, for they are eminently tellable.
Other stories wait for an audience. They may wait patiently, or they may cry
out for a hearing, but they wait. Needing a forum to be heard, they have little
choice. This thesis provided such a forum for the stories that were waiting,
while also welcoming stories of the first type. All of our stories are worthy of a
hearing and every story is valuable, or it would not have become a story in
the first place – but I am getting ahead of myself now.
Acknowledging that stories are valuable, and because midwives are natural
storytellers and stories are inherently ethical, narrative has been used at all
stages of this research project. In keeping with this narrative approach, used
throughout the research project, a storied account is provided in the pages
that follow. The audience is invited to engage with the research as they read
and add their own interpretations to the research and the stories within.
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CHAPTER 1 INTRODUCTION
Everyone needs a midwife.
Anonymous
It seems only fitting that this thesis, the culmination of my narrative research
project, should begin with a story. This brief, personal story has some
significance for the project. One day, early in the university year, I was
privileged to give a poster presentation of my work-in-progress during the
University’s postgraduate orientation day. It was refreshing and most
enjoyable to participate in discussions about my study and the interest shown
by the many staff members and students was very encouraging. Many
people seemed to appreciate hearing about narrative, ethics and midwifery.
Then, a young man came by. He said just a few words. I cannot remember
them exactly, but they were very similar to this: “Everyone needs a midwife –
even if they are not going to have children. After all, everyone was born”. At
that moment I had a new realisation of the importance not only of my own
study, but also of all midwifery research.
Virtually every person in Western society will have contact with a midwife and
thus an interest in the practice of midwifery. Just how vital can a practice be?
How important is it that we find out as much as we can about the practice,
that we understand midwives and midwifery? What if midwives do not
understand themselves? How does this young man in front of me perceive a
midwife? What would he expect of me if his partner were birthing right now?
Questions flashed through my head. Some had passed through my mind
before, others had not, but they all suddenly had a new dimension. It is not
that they were any more real, but they were now so much more important. If
some matter affected even one person it required attention, but midwives
were going to be in contact with everyone. Everyone.
3
This thesis is about narrative, ethics and midwifery. Being discrete, yet
inseparable, they invite investigation. Narratives are inherently moral, ethics
is embedded in midwifery, and midwives are narrative beings. Each of these
will become clearer as we move through the thesis. Midwives are involved in
situations that have an ethical component on an everyday basis (Dalby,
1993; Kwan, 1993). Each time an ethical encounter arises, there is a need for
a choice, judgement or decision to be made. There is also an opportunity to
display an excellence of character – or otherwise. Although these choices
and deliberations are often minor, sometimes even subconscious, others
require considerable thought, reflection and even heartache, as is
demonstrated in some of the participants’ stories in the project. Ethics has
been a concern of midwives for a very long time. Perhaps the earliest
evidence of midwifery ethics is that recorded in the Bible when two midwives
refused to carry out the King’s orders to kill boy babies born to the Hebrew
women they assisted (Wilday, 1989). Ethical considerations remain an
important aspect of midwifery practice today.
Background On entering a Bachelor of Nursing Program as a registered nurse in 1992, I
was rather naïve when it came to “nursing ethics”. After completing three
ethics units, this was to change significantly. I became acutely aware of the
importance of the ethical aspect of nursing practice and recognized the
urgent need for a greater awareness and understanding of its relevance to,
and place within, the profession. This motivated me to expand my knowledge
of nursing ethics and gave me a desire to inspire others to do so too.
Whilst sharing with midwifery colleagues during inservice programs at my
workplace, I discovered that many were unaware of the relevance of ethics to
everyday practices. Also, several midwives expressed concerns and doubts
over situations they had been in and/ or decisions they had made –
sometimes many years earlier. Some actually said that they wondered if they
had made a “good decision” (morally) and expressed uncertainty about their
response to the situation. Others were concerned because legal constraints
4
had caused them to make a decision that they “knew” to be “wrong”
(morally). Isaacs (1993) and Gastmans, Dierckx de Casterle and Schotmans
(1998) have noted that nursing is a moral activity, so it is not surprising that
there was such an interest in dealing with ethical issues in practice. There
seemed, however, to be a lack of ethical acumen. They did not know how to
“do” ethics.
Ethics Midwives are required to make frequent decisions in their everyday practise
that almost always involve an “other” in some way, and thus they comprise
an ethical encounter 2 (Isaacs, 1996; J. Thompson and H. Thompson, 1996).
At each of these encounters there are opportunities for “good” or “bad”
decisions to be made, which may, accordingly, lead to benefits or harms. It is
vital, therefore, that midwives be aware of the consequences of actions and
responses within and to their encounters. These encounters and their
outcomes impact on themselves, their clients and their practice.
The terms “ethics” and “morals” are often used interchangeably. There are
different approaches to ethics and morality, some of which suggest this
should not be the case. Ethical theory, for example, refers to a thinking,
reflective process – a more philosophical approach to ethics, whereas
morality applies to the more everyday, socially acceptable ideas of what is
right and wrong, or “good” and “bad” behaviour within a particular community
(Beauchamp and Childress, 1994). It is, in these terms, possible to think of
ethics as a thinking endeavour, and morals as a doing endeavour.
Beauchamp and Childress tell us, however, that “ethical and moral are …
construed as identical in meaning” (1994, p. 5). For this reason, in this
project, the terms can be understood to have the same meaning and refer to
the same domain.
2 That is, there is an ethical component to the encounter. The encounter may be “good” or “bad”.
5
There are many theories and philosophical approaches to ethics. Deontology
focuses on duties, whereas teleological theories (the most common of which
is utilitarianism) are concerned with the consequences of actions (Johnstone,
1989). Nursing and midwifery have traditionally drawn their ethical
understandings from bioethics. Principlism, very commonly taught to nurses
in ethics courses, frequently uses four principles (autonomy, beneficence,
non-maleficence and justice) to guide people in their ethical thought,
discussion and decision making (Beauchamp and Childress, 1994;
Johnstone, 1989 ). This project called for a different approach to ethics.
Given the nature of midwifery practice and the settings in which it is
practised, a people focused, relational, context specific understanding was
required to make sense of the situations that the midwives presented.
The midwives in this thesis take us to some of their workplaces and share
roles which may be unfamiliar to other people. It will be helpful, and is
important, therefore, to have a sound understanding of what a midwife is,
who midwives are and what they do. This will be outlined below.
What is a Midwife? Midwives have a central role in this thesis. The definition adopted by the
International Confederation of Midwives (2005) is a good starting point to
reveal what a midwife is. This broad definition is widely accepted by
midwives and other health professionals around the (developed) world.
6
International Confederation of Midwives
Definition of the Midwife
A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care. A midwife may practise in any setting including the home, community, hospitals, clinics or health units. Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia
While some people have no concept at all of what midwives are or do, most
do have an idea. That is, they know that midwives deliver babies. It would be
wrong, however, to confine our understanding of a midwife to this limited
description. I would first of all like to correct a myth. Most babies do not
actually need to be “delivered”. Some gentle guidance provided by a midwife
is often of assistance. This guidance may be physical, emotional, or verbal,
and could be given to mother, father or baby. In a normal, healthy labour and
birth, midwives assist women to birth their babies, they don’t deliver babies.
Lysne (2006) asks us to imagine we are a woman in labour in the
countryside, 200 years ago. Now-a-days we are blessed with better hygiene,
and excellent back-up if there are complications, but it seems to me, in a
normal labour, not much has changed. She says,
7
This midwife/friend is there for you and the moment you see her, you
relax and prepare for the coming hours. You know she is well-practiced
and has laboured with many women.
…
After birth, your child would be placed on your stomach, and you would
have plenty of time to bond Lysne, 2006, p.48 (italics added)
Another misconception is that midwives only assist women to birth their
babies.3 Midwives are trained to care for women and the foetus/ neonate
throughout all the stages of pregnancy and birth, from conception, throughout
pregnancy, labour, birth and the puerperium. This is made very clear in The
Australian College of Midwives definition of a midwife.
Definition of a Midwife
“…a health professional who, in partnership with a woman, provides specialist care, education and support during pregnancy, birth, postnatal and the early parenting period. Midwives believe that pregnancy and childbirth are normal and significant life events for women and their families and respect and support this transition. Midwives work in many settings including hospitals, birth centres and the community. Midwifery care includes the detection of complications in mother and baby, the referral to other specialists as needed, and the initiation of necessary emergency care. Midwives also have an important role in health counselling and the provision of information to women, their families and the community. Registration as a midwife is dependant upon successful completion of a recognised midwifery education program and, continuing demonstration of the necessary knowledge, skill and experience to provide safe and professional midwifery care.”
Australian College of Midwives Incorporated [ACMI] (n.d.)
There is much debate about the appropriateness of midwives who, either by
choice or necessity, “refuse” to work in all the different areas of midwifery.
Many administrators and, indeed, many midwives, claim that all midwives are
qualified to work in all fields of midwifery and should thus be both able and
willing to work wherever they are assigned. This assertion will be explored in
more detail in Chapter 4. 3 I am a midwife myself, and it is many years since I have been with a woman as she birthed her baby, and it is unlikely that I will, by design, ever be with another during this most amazing life event.
8
Many people are aware that midwives (in Australia) are also Registered
Nurses. This means that they have completed three years of either hospital
training, or a three year university degree, before going on to complete at
least one further year of education and training (hospital or university trained,
depending on their “vintage”), to become a midwife. Whilst this is true of the
vast majority of currently practising midwives in Australia, it is also possible to
become a “Direct Entry Midwife”, by studying a course that will qualify a
person to be a midwife, but not a registered nurse. Direct Entry Midwifery
courses are being re-introduced in recent times to encourage people into the
profession.
The “four defining characteristics of what it means to be a midwife” that
Walsh and Steen (2007) suggest provide a succinct summary. Midwives are
autonomous, and this autonomy also makes them accountable and
responsible. They are in tune with normality – the physiological processes of
pregnancy and birth. Holism enables the midwife to be “with women”, to truly
engage with her and have a relationship which is meaningful within the
context. Lastly, women-centredness is, they say, “axiomatic” – it is, without
question, what midwives are focused on (2007, p. 320).
Who are Midwives? Oftentimes it can be very helpful to go back to the basics. I think this is the
case when trying to understand what midwifery is all about. If we look at the
meaning of the word “midwife” in various languages, it is enlightening. In
English, Portuguese and Spanish it means “with woman”. The Portuguese
and Spanish use the word “Comadre”, whereas in English we use the word
“midwife” (Sullivan, 2002).” With woman” is such a wonderful way to describe
being a midwife; a woman has a companion to travel with her, along side as
she is becoming, and then becomes, a mother. Her partner is not left out,
though not central, as they all work together and a new family is formed.
Sullivan (2002) also shares that ancient Jews, the French and some
Germans called the midwife “the wise woman” (sage-femme or weise frau).
9
Perhaps we could combine these two traditional meanings and claim that
midwives are wise because they walk with women through their pregnancy,
labour, and birth, guiding and assisting when and where needed, with the
benefit of sound professional knowledge and training? Their wisdom enables
them to know when their help is needed, their being there enables them to
give it, and their knowledge enables them to provide appropriate care and
seek further assistance when needed if complications arise. If the latter
occur, they indicate that labour is no longer normal and it is, therefore,
outside midwives’ domain. At this juncture midwives’ collaboration with
obstetricians is crucial to the well-being of mother and infant. Working with
obstetricians and other health professionals is a vital aspect of being a
midwife.
There are some rather interesting facts to note about midwives. They differ
from the general nursing population. This is not only in what they do, but also
in who they are.
Mostly Female A traditionally female profession, nursing has attracted an increasing number
of men over recent decades. Despite this, midwifery remains an
overwhelmingly female profession, with barely a token representation of male
nurses entering into the specialty. Just 1 percent of midwives in Australia,
who were working in midwifery in 2004, were male (The Australian Institute of
Health and Welfare [AIHW], 2006). In contrast to this, 8.7 percent of the
Australia-wide general nursing workforce was male (AIHW, 2006).
Mostly Older People Midwives in Queensland are an aging population. In 2004, the average age
of a midwife in Queensland was 43.1 (AIHW, 2006). The average age of a
registered nurse is fairly similar; 44 for Queensland (AIHW, 2006).
How Many? Numbers of midwives in the workforce are falling. It is likely that the reasons
for this are multi-factorial, and this thesis will shed some light on some of
10
these factors. The aging of midwives is, of course, a contributing factor. In
2005 there were 10,227 nurses endorsed to practise as a midwife in
Queensland. In 2006, this number fell to 9,950 (QNC, 2006, p.11). Of this
group, there were 66 midwives endorsed to practise in Queensland in
2006/07 who were not also registered nurses. Naturally, not all those who are
endorsed to practise as a midwife are actually working as midwives. Many
hospitals rely on Agency (temporary) staff, especially at busy times, and are
often unable to find suitable staff when required due to a shortage of
midwives (anecdotal). It is natural that the numbers of registered nurses
would be somewhat higher than those of midwives. In Queensland in 2004
there were 34,901 employed registered nurses (AIHW, 2006).
What do Midwives Do?
Much of this has been covered already under the heading “What is a
midwife?” and much more will be discovered as you read through this thesis.
The list below, quoted directly from the Australian College of Midwives
(ACMI, 2006), is just a beginning. It even seems that they acknowledge this,
as they say “Midwifery services include…”, implying that there is more. When
we are dealing with people, there is always so much more, which is why this
thesis is also about ethics. First, however, let us read what midwives do.
Midwifery services include…
• Assessments and care throughout pregnancy. This includes arranging
any necessary blood tests or investigations.
• Information and education either individually or in groups.
• Support and professional care throughout labour and birth, in a place
the woman chooses.
• Support advice, and professional care for the newborn and infant
• Support, advice and assistance with breastfeeding and the transition
to parenting
• Consultation with an obstetrician or other health professional if
complications arise at any time during pregnancy, labour, birth or the
weeks following.
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Midwives…
• Focus on women’s health needs, expectations and aspirations
• Recognise each woman’s social, emotional, physical, spiritual and
cultural needs.
• Encourage every woman, with information and support, to take
responsibility and make informed decisions for herself, her baby and
her family
ACMI, 2006, retrieved 07.01.08 from
http://www.acmi.org.au/ForWomen/Whatdomidwivesdo/tabid/323/Default.aspx
It is most important to recognise all these roles of midwives. As has already
been mentioned, many people within the community, and even many
childbearing families, are of the misguided belief that midwives only deliver
babies. The birthing process, usually, comprises just one day. The many
other, varied and important roles of midwives are often not recognised as
being midwifery roles. Yet, midwifery knowledge and skills are necessary for
the provision of appropriate, safe care during this time.
Another fact that is worthy of noting is that nowhere in any definition or list
does it say that efficiency or economics are primary goals of midwifery.
These could relate to time or finance, but they are not the goals of a midwife
or their profession. Sadly, they are frequently the goals of a business or an
institution, and this can be seen to cause difficulties for the professionals that
work in those situations. Walsh and Steen affirm this, saying that midwives
working in large maternity hospitals “have little autonomy, are under constant
surveillance and pressure to increase productivity” and they “vote with their
feet” (2007, p. 321). O’Connor, writing of the situation in New Zealand, says that “midwifery is a
profession under pressure” (2006, p. 18). She points out a few of the
reasons, including the aging midwifery population, the diminishing numbers
and the heavy workloads – not helped by the first two factors. Happily,
midwives in New Zealand enjoy more independence in their practice than
their counterparts in Australia, but it seems many of the pressures are the
same. It is time for midwives to reflect on their practice and there is an urgent
12
need for researchers to investigate the social and ethical aspects of the
profession.
The Current State of Affairs Midwifery research, as a separate field from nursing research, is a relatively
new field in academia, and this is particularly so in the case of midwifery
ethics. The amount of published research specific to midwifery remains quite
small (Reid, O’Reilly, Beale, Gillies and Connell, 2007). Not surprisingly,
therefore, research incorporating midwifery, ethics and narrative is scarce.
Until the last decade, narrative research in nursing (not just midwifery) was
uncommon. The irony of this is encapsulated by Råholm (2008).
Stories have a central place in human lives and yet they occupy a
peripheral place in the published literature on nursing education,
research and practice. Narratives have an ethical dimension because
they also reflect notions of hope, joy and the good life.
Råholm, 2008, p. 70
Narrative has become increasingly popular as nurses in both clinical and
academic areas have come to appreciate its usefulness for teaching, learning
and enhancing practice. Interest in narrative is growing rapidly and,
consequently, the body of narrative based research is expanding (Råholm,
2008) with each year seeing more papers published.
Short narrative articles, often written in the first person, can now be found in
midwifery journals on a regular basis. Recent examples include a story of a
student midwife’s observations of the interaction between her colleague and
the grieving mother whom she was counselling (Gould, 2007); a recounting
of a friend’s experience when she had responded to an obstetric emergency,
and “saved the baby’s life, and probably the doctor’s reputation” (Bates,
2007, p. 25); a mother’s story of her choice for private care (Bannon, 2007)
and a student midwife telling her audience of her experiences (Spence,
2007). All of these stories offer opportunities to midwives to learn through the
experiences of others. Magill-Cuerden (2007) related a story that she had
heard. It contained a sentence that stood out. The sentence was: “you never
13
forget the midwives and how they were towards you. That remains with you
and affects you forever” (Magill-Cuerden, 2007, p. 534). This conveys a
strong message to midwives and affirms the value of listening to stories. As a
midwife I found the story-teller’s words incredibly sobering. They brought into
focus very clearly just how important, how crucial, it is that we treat our
clients the “right” way. We need to be good, ethical, professional midwives.
Midwifery research utilising narrative is also easily sourced, although not
plentiful. A series of three articles discusses the setting up, benefits and
outcomes of a midwifery project in Lancashire, England (Byrom and Downe,
2007; Flemming and Downe, 2007; Flemming et al., 2007). Sleutel, Schultz
and Wyble (2007) examined participants’ narrative comments in order to
learn more about factors that might affect the intrapartum care they provide
to their clients, in either a positive or negative way.
There are also examples of narrative being used to explore ethical issues.
Coles (2007) questions the ethicality of what she calls “recreational”
ultrasound scans (scans during pregnancy for non-medical reasons). The
appropriateness of the care received by a Jehovah’s Witness client who
suffered a postpartum haemorrhage is discussed by Porter (2007). Complex
ethical issues can present when an expectant mother has sickle cell
anaemia, and these are explained and the surrounding issues are given
consideration by Zack-Williams (2007).
Summary These recent examples demonstrate the increasing interest and awareness
of both narrative and ethics in midwifery but, at the same time, also alert us
to the limited amount of research available in the area4. There seems to be
little research into the personal and professional experiences of midwives,
and how these might impact upon, or what effect they might have on,
themselves, their practise and/ or the profession5.
4 The literature referred to is not an exhaustive review, but representative of recent literature in the field. 5 Sleutel, Schultz and Wyble’s (2007) study is a notable exception.
14
This research aimed to shed some light in these areas by exploring the
ethical aspects and implications of the encounters that midwives shared in
their narratives, and focused on the social practice of midwifery and everyday
activities of midwives. As members of a social practice, midwives seek a
common goal – to care for those for whom the profession exists – mothers,
babies and childbearing families. Isaacs (1993) says that this would be in the
form of a covenantal commitment in the context of gift, fidelity and trust. W.
May (2000) claims a stronger covenantal commitment, aligning it to a
religious commitment, and says it would be with a sense of gift, fidelity and
moral obligation that a professional would care for his or her client. This type
of practice is inherently ethical or, at times, ethically problematic6. The
embeddedness of ethics within the everyday experiences of everyday
midwives invited investigation.
As I have previously indicated, everyone is affected, at some time, in some
way, by midwifery practices. It is, therefore, both necessary and important
that our shared understandings of midwives and their practice be enhanced
and illuminated. This has the potential to be enriching and beneficial for
people both inside and outside of the profession. In the next chapter the
value and appropriateness of narrative inquiry for this research will be
explicated.
6 Indeed, in this project, some of the midwives found themselves in situations where it was difficult or impossible to practise what they believed to be “good” midwifery.
15
CHAPTER 2 NARRATIVE RESEARCH
Unlike other forms of communication, stories are a safe way to convey
messages that engage the affective domain rather than only the
cognitive. Capitalizing on the art and the craft produces a powerful
potential to create memorable legacies.
Yoder-Wise and Kowalski, 2003, p. 41
Introduction Deciding how to “go about” one’s research is frequently a matter of great
consternation. I learned this not from books or journals, and not only from my
own personal experience of reading and poring over “methodology” tomes
and “how to” texts, but from tea room conversations and university corridors,
discourse at conferences and workplace discussions. It seemed as though
almost every person that had entered into a “serious” research project – that
is, a project that would be meaningful in some way to someone beyond
themselves – spends weeks, or even months, deciding on the most
appropriate way to approach and undertake their research project. This is,
perhaps, one of the reasons why methodology chapters have a tendency to
simultaneously fill the writer with awe and the reader with expectation. The
how of this research is now to be explained, and it holds great importance to
both the researcher and the reader. Neither can make sense of the research
without understanding what follows in this chapter.
Towards Narrative The purpose of this research was to explore where ethics fitted in midwives’
everyday practice, and to ascertain what impact the ethical encounters that
midwives experienced might have on the midwives themselves, their practice
and/ or their profession. I believed the best way to gain insight into these
areas of interest was to seek illumination from midwives themselves. So in
order to gather information and gain enhanced understandings about these
aspects of midwifery my starting point was to seek a methodology that would
16
allow midwives to express themselves in some way. Originally focus groups
were considered, allowing midwives to discuss topics of interest to the group.
Some sort of thematic analysis would then be employed to analyse the
transcripts of the focus group interviews.
These were very embryonic thoughts, and there was little certainty that this
type of research would answer the questions I hoped to address. That is,
what sort of ethical encounters do midwives have, what impact/s do ethical
encounters have on midwives, and what effect might these have on their
practice and midwifery? Whilst investigating the possibility of using focus
groups, I naturally came across and reviewed a number of research articles
in the literature. The narrative research articles immediately caught my
attention.
Narratives are frequently referred to as stories. They are the stories we tell,
and I, like many others, use the words narrative and story interchangeably.
Stories are commonplace in our lives, and have been used to convey
important matters such as cultural and moral norms for eons. This is affirmed
by Geanellos who tells us that “Storytelling is embedded in the origins of
humankind and preceded written communication by centuries” (1996, p. 28).
The conveyance of history, morals, behavioural expectations, and laws –
everything depended on oral communication, and stories were a valuable,
community based and often enjoyable means of passing on this important
knowledge (Colwell, 1991; Davidhizar and Lonser, 2003; Yoder-Wise and
Kowalski, 2003). If stories were of value before the written word, they must
surely still be worthy of respect and appreciation now, perhaps even more so.
Some have suggested that nurses’ stories have been undervalued. A striking
example of this is found in the research undertaken by Chiarella (2000). She
found that nurses’ stories had been “silenced” in legislation and case law,
and that this has had a significant impact on not only how nurses are viewed,
but also on their ability to effectively care for their patients in some cases.
She found that doctors were accepted as being able to speak for nurses, and
noted that this resulted in a failure to recognise the fact that nursing work was
17
unique and different. In the cases she examined, from 1904 to 1999, nurses
were rarely given voice, unless the case involved only nurses. Narrative
research is suited to give voice to the voiceless and vulnerable, and nurses
often fall within this group (Maher, 2003). Stories are certainly worthy of
attention. Storytelling is an art that needs to be rediscovered, revitalized and
given more prominence within nursing (Yoder-Wise and Kowalski, 2003).
Narrative research had aroused my interest. Three facts were now at the
forefront of my mind. One: stories are used to convey important things. Two:
my midwifery colleagues were (and are) frequently engaged in the act of
storytelling. It seemed to be how they debriefed, worked through problems,
conveyed and learned new knowledge, shared joys and challenges,
information and advice, and showed interest and support in each other’s lives
(personal experience). Three: it seemed that stories could have much to
offer. Narrative inquiry and analysis was definitely worth further investigation.
Narratives have enjoyed an ever-increasing presence in research in the last
two decades, although this is not quite as strongly evident within the nursing
literature as in some other fields. Frid, Öhlén and Bergbom (2000, p. 695) tell
us that nursing’s interest in, and use of, narrative research is “essentially
new” compared with the social sciences. It has been exciting for those
interested in narrative research to see the publication of journals specific to
the area emerging. These include periodicals such as Narrative Inquiry (John
Benjamins Pub. Co., 1998) and Narrative (Ohio State University Press,
2003), amongst others. The importance of this resurgence of narrative is
conveyed powerfully by Sandelowski, who states, “Mourning the devaluation
of narratives as sources of knowledge, and emphasizing the moral force,
healing power, and emancipatory thrust of stories, scholars across the
disciplines have (re) discovered the narrative nature of human beings” (1991,
p. 161).
Frid, Öhlén and Bergbom (2000) were informing us well when they stated
that narrative research was “essentially new” in nursing in 2000. At that time,
a search for narrative research articles in nursing was a difficult task. It is
18
clearly evident that nursing scholars and clinical nurses since then have been
embracing narrative, and its benefits and uses (Maher, 2003). A brief search
of the literature in early 2007 yielded more than a dozen nursing articles
already published that year which have embraced narrative in some way
(see, for example; Eriksson and Svedlund, 2007; Hardy, Titchen and Manley,
2007; Kelly and Howie, 2007). Although it could be successfully argued that
some of the literature that one finds when doing such searches is not actually
narrative research, it is none-the-less a good indication of the rapidly
increasing interest in narrative within nursing scholarship.
Drawing Closer to Narrative As already mentioned, my interest in narrative research had been aroused,
as obviously was that of a great many other folk. I found that narrative
research was “in harmony with the ‘deep interest’” I brought to the research,
which van Maanen (cited by Emden, 1998a, p. 30) tells us is an important
aspect when deciding upon an appropriate approach for one’s research
project. It made a lot of sense. Midwives love to talk and I was very happy
and willing to listen. I wanted, very much, to learn about their everyday
experiences as midwives. Being able to engage with them and hear their
stories was an ideal way for me to be able to do this. Further, it presented an
opportunity to gain a deeper and broader understanding than other methods
such as questionnaires could provide.
Some nursing scholars have identified the desirability and advantages of
using stories with the profession. Geanellos informs us that “untold stories of
nursing are lost opportunities to pass down knowledge and skill, to transmit
culture and practice, to explore the teachings and learnings of the stories,
and to preserve their contextual, historical and socio-political meanings”
(1996, p. 28). Boykin and Schoenhofer assert that nurses’ stories are “an
exquisite source for understanding” and they “call to mind the commonalities
of nursing situations as well as the beauty and uniqueness of each” (1991, p.
246). More recently, Diers has said that “the intricate notion of ordinariness
as the social contract in nursing simply cried out for forms of expression that
19
could find the wonder, the glory, and majesty of nursing, that might require
not so much description as scriptural prose or poetry” (2004, p. 315). It would
be difficult to express the importance of stories in a manner more fittingly
than these nursing scholars have done. Kennedy, Shannon, Chuahorm and
Kravetz (2004) also affirm the value of utilizing stories in nursing research.
They assert that stories inform social policy, give both nurses and clients
voice, provide a means to solving clinical problems, and they also are a way
in which diversity can be better understood. Not only do stories call out from
nursing, nursing calls out for stories. These authors tell us that there are
many invisible aspects of nurses’ work, and stories allow these to be seen.
Stories allow us to formulate individual ideas and approaches that are most
suited to the specific context in which we are situated (Kennedy et al., 2004).
Koch (1998) provides an extensive list of the capabilities of stories, some of
which are mentioned above, as Kennedy et al. (2004) drew upon her work. In
addition to these, she draws our attention to their ability to: make us “proud
practitioners”, research health related matters, be therapeutic, lead to
organizational change, give voice to those that are in marginalized groups,
provide understanding to address diversity and more (1998, p. 1183).
Narratives can also assist health care leaders to understand their staff and
shape nursing culture (Smeltzer and Vlasses, 2004).
With the benefit of these understandings, it is clear to see that the
opportunities that stories offer us ought to be utilised for the betterment of the
profession. In fact, bearing these thoughts in mind, it would clearly be wrong
not to use the stories that midwives and nurses have to offer. Midwives’
stories are rich and wonderful resources, generously given, and frequently
shared. They provide moral guidance and direction and offer many
opportunities to individuals, and the profession as a whole, to gain insight
and understanding. Untold stories are indeed lost opportunities, and some
stories are just waiting for an opportunity to be told, eager for an audience.
Sometimes, when one story is told, another hears his or her own story within
the story being recounted, and is pleased that their own story has at last
20
been shared. This was the case when Diers (2004) was instrumental in
attaining publication of a friend’s story in a prominent nursing journal about
being a nurse in Vietnam. Many other nurses identified with the story as “it
was the first time someone had validated their experience in mainstream
nursing print” (Diers, 2004, p. 327). Someone had at last told their story.
Similarly, an audience member had her decision to continue breastfeeding
validated when another woman’s feeding experience was shared at a
conference (Behrmann, 2005). Within this research, it is quite possible that
one or many of the participants’ stories may resonate so well with a reader
that it could well have been their own. This can be significantly meaning-
making for all parties – participant, researcher and audience, and is just one
of the many benefits narrative, and thus narrative research, offers. Known as
verisimilitude, it is also one of the ways the value of a narrative research
project can be judged7.
Roof questions if we have not, with all our sophisticated research methods,
moved beyond storytelling. As if, perhaps, storytelling is a little too basic and
we can surely do much better than that. It was a reflective question though,
and he goes on to answer it himself, saying “stories have great capacity to
bring things together, to sharpen the focus, to help us see things differently”
(Roof, in Emden, 1998a, p. 32). Stories are thus learning tools. Although
there are many other forms of research that could be utilized, Roof affirmed
the relevance and importance of narrative when he drew attention to its great
capacity. One of narrative’s strengths is the fact that it is somewhat basic, in
the sense that we all utilize it from a very early age. Everyone can identify
with a storied account.
Although, in the sense mentioned, narrative is basic, it is by no means
simple. Quite to the contrary, stories are remarkably complex. Every story we
tell is very real to us, coming from within, making us who we are as it
7 Verisimilitude, discussed by Connelly and Clandinin (1990), Bruner (1991), Massey (2007) and others, is when narrative is life like, seeming to be true. Bruner tells us that we cannot be sure that narrative is about what actually was, but at the same time it applies to the “narrative truth”, and thus constitutes or creates reality rather than referring to it. If something has verisimilitude, it “rings true”.
21
emerges, still remaining our story; yet now also shared. It is no longer just
our story. As it is shared and interpreted by an “other” (or many “others”), it
inevitably changes, and it has now been given away to become part of a
greater story – part of other people’s stories, part of a family story, part of a
community’s story; but at the same time, kept, remaining our story, albeit a
changed one.
Very significantly for my project, narrative is inherently ethical (Abma, 1999;
Frid, Öhlén and Bergbom, 2000; Sandelowski, 1991). I hold a particular
interest in the ethical aspects of midwives’ experiences and the fact that their
stories themselves are inherently ethical resonated with the purpose of the
project. This particular aspect of narrative was one of the most significant
factors in my project utilizing narrative at all stages. Stories enable us to
make sense not only of our own lives but also of life itself. They are meaning
making, but more than that, they construct our lives (Josselson, 1996;
Emden, 1998a; Bruner, 1997). Bruner says that “we constantly construct and
reconstruct a self to meet the needs of the situations we encounter, and do
so with the guidance of our memories of the past and our hopes for the
future”. This, he says is “rather like making up a story about who and what
we are, what has happened and why we are doing what we are doing” (2003,
p. 210). In short, we are using story to construct our life.
Moralness is an integral part of stories. The term moralness is being put
forward as an alternative to “ethicality” hoping (and believing) that midwives
will be receptive to the terminology. In my personal experience, many
midwives have shied away from the term “ethics”. Although they are very
interested in ethical concepts such as personal, professional and client
autonomy, respect for persons, responsibility, confidentiality, honesty and
truth, for many, ethics appears to be relegated to Codes of Conduct and
academics. The term, “moral”, however, seems to have a more accessible
and acceptable sense of right and wrong, knowing and doing what you
22
believe in, and being something you do, rather than something someone else
is an expert in and midwives just manage to look upon from the edge.8
Every story involves an “other”. J. Thompson and H. Thompson tell us that
“Wherever you have two or more people, you have a moral situation” (1996,
p.36). In telling a story, the storyteller aims to engage the other, wanting them
to understand and share the feelings that they have (Colwell, 1991). This
desire to engender empathy and understanding is a moral activity, as is the
apparently simple act of endeavouring to involve the audience, regardless of
whether they be physically present or anticipated to be present later, as in
the case of a book or a piece of artwork. No-one tells a tale to an empty
room. Although it is often not a conscious act, prior to conveying, or as they
convey their story, a storyteller interprets and reconstructs their story (Bruner,
1991). During these processes, beliefs and values will necessarily affect the
outcome of the story-as-told, which may, as a result, be different from the
events as they occurred and even change over time. Further, stories are
often jointly composed, through a process of negotiation. Ochs and Capps
(2001) discuss how narratives can develop in everyday conversation and are
negotiated through the contributions of two or more interlocutors. The
moralness of stories, which I regard as being of considerable importance to
this project, will be explored in greater detail later.
With ethics being a significant focus in my research, the moralness of
narrative made it an ideal mode of discovery for this project.9 In adopting a
narrative research approach, my primary interest was not the stories
8 Having said this, I would, however, like to acknowledge that I have been conscious of an exponentially increasing awareness of ethics amongst midwives in recent years (both what it is and its place within the practice) in the hospitals I have frequented as staff, researcher and visitor. 9 Implied in this section is the unstated “fact” that stories are spoken. Whilst this is true of some, perhaps even most, stories, some remain unspoken, waiting for an audience; whilst others are expressed in different ways, such as through sculpture, painting, poetry, music, film and various other media that allow and enable persons to express themselves. Anyone who has been fortunate enough to experience some of these, either from within or without, knows how powerfully they can and do express stories, be they real or imagined. In the case of this project, however, the stories of the midwives involved were expressed verbally, through conversational talk, and later, in the transcriptions, became written stories.
23
themselves, but what the stories revealed about the midwives and their
experiences, particularly the ethical aspects – or what I refer to as the
moralness of the stories. This project was thus situated within the narrative
research tradition.
Narrative Approaches in Research The boundaries of narrative research are not at all clear. The format is
different from author to author and there seem to be no standard, agreed-
upon ways as to how to conduct a narrative study or analyse narrative
material. Many narrative researchers, including Connelly and Clandinin
(1990), Emden (1998a) and Riessman (1993), have noted this diversity.
Researchers have drawn from vast and varied research approaches and
incorporated them into their narrative research projects, others have
incorporated narrative into their projects that are, perhaps, more at home in
another methodological framework. Some have used narrative at the “data”
collection stage of their research (collecting stories), others use narrative
analysis (Frid, Öhlén and Bergbom, 2000). Examples of other approaches
used with narrative include ethnography (Charmaz, 1999), grounded theory
(Charmaz, 1999), interpretive interactionism (Baker and Daigle, 2000), and
phenomenology (Emden, 1998a). Whilst I had been seeking clarification,
these projects, incorporating many different research approaches as well as
narrative, rather clouded narrative as a methodology.
The above authors, and many others, have indeed shown that it is not only
possible, but frequently valuable, to utilize narrative in conjunction with
another research method. Sense can be made from these studies, and it
certainly makes sense to perform this type of research. For me, however, this
seemed to detract from the true value of narrative itself. Emden noted that
“the spirit of narrative enquiry is perhaps best nurtured by a mature
appreciation of multiplicity and difference” (1998b, p.39). Narratives do not
need the support of another methodology.
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In recent years there have been chapters appearing in qualitative, and even
some health care, research texts to assist the narrative researcher. For
example, Sparkes (2005) wrote “Narrative analysis: exploring the whats and
hows of personal stories”; Rosenthal and Fischer-Rosenthal (2004) instruct
their readers in “The analysis of Narrative-biographical Interviews”; Hurwitz,
Greenhalgh, and Skultans (2004) present us with an edited selection of
works titled “Narrative Research in Health and Illness” and Elliot (2005)
provides an entire book about “Using Narrative in Social Research”. While
these are helpful and do not mix methodologies in the same way as the
studies mentioned above, they retain a common feature. Each book and
chapter seems to be unique in its presentation of narrative as research.
Interest in narrative research is clearly continuing to increase. As narratives
are as diverse as the people who form them, and as variable as the number
of times they are told and the myriad of ways they can be interpreted, it is
highly unlikely that narrative research will ever fit neatly into a rigid
methodological form. This should not, however, deter us from delving into
this bountiful source of knowledge. Stories are strong, rich, valuable
resources that can stand up and speak for themselves. Some of them shout.
Some of them whisper. Sometimes we have to listen more carefully than
others. Whatever the story though, a narrative on its own, simply by virtue of
what it is, actually offers a framework. Research can be based on the
framework inherent in narratives.
With this in mind, I would now like to do four things. Firstly I would like to
build a picture of what a narrative, or story, is. This account will provide a
broad understanding of narrative and offer some insights into the many
different things that stories are and do. Secondly, the specific framework of
narrative that I have chosen to largely base this particular research project on
will be explained. Thirdly, I shall look at narrative within some of the nursing
and midwifery literature. The fourth and final point to be addressed will be the
moralness of stories.
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Narrative
What is a Narrative? It has already been ascertained that narratives have been utilized by human
beings for eons, and that they have played a significant role in our history to
convey matters of importance (Colwell, 1991; Davidhizar and Lonser, 2003;
Yoder-Wise and Kowalski, 2003). We grow up learning through stories, so it
is a natural progression that people actually expect to learn from stories
(Yoder-Wise and Kowalski, 2003). It is also not surprising to discover that,
“while looking for a theoretical answer to the question of how sociality and
society are constituted, one of the factors that researchers encountered was
the social function of linguistic communication in general and of narrative in
particular” (Rosenthal and Fischer-Rosenthal, 2004, p. 259). Ochs and
Capps claim that personal narratives are a “central proclivity of human kind”
(2001, p. 2). People have a strong predisposition to tell stories, and these
stories have a crucial function in our living with others.
It is expedient, therefore, for us to understand more fully what a narrative
actually is. It should be noted at the outset that, whilst it is possible to achieve
a good, broad understanding of narrative, it is not possible to put narrative in
a tidy little box. As constructs of people, narratives are very complex, ever
changing vital tools of life that can, most likely, never truly be defined. An
increased awareness of what narratives are and can do, however, will be of
great benefit. With an enhanced understanding, it is possible to reflect upon
and interpret narratives at a deeper level and gain new insights that may
have been overlooked previously.
A great many authors have explored stories and endeavoured to define
them. Boje has offered a definition which is helpful. It says a story is “an oral
or written performance involving two or more people interpreting past or
anticipated experience” (Boje, cited by Abma, 1999, p. 170). Although this
definition is a little narrow, it draws our attention to three important features of
narrative. They are the temporal, active and interpretive aspects. Boje’s
definition is not dissimilar to what Ochs and Capps (2001) say about personal
26
narratives, claiming that they assist us to order life’s events logically across
time. This demystifies the events and enables us to make sense of them
across past, present and future. For Ochs and Capps, narratives also involve
interlocutors – two or more people. They speak of “ordinary social exchanges
in which interlocutors build accounts of life events” (2001, p.2). Stories
always include these elements of storyteller, audience, time, event, and need
for interpretation. Missing from these definitions, but evident in stories, is the
fact that they are, most commonly, context specific and, of course, can be
expressed in many ways – oral or written, crafted from paint or wood, and a
myriad of other media as varied as the human imagination.
Colwell says there are “three essential elements” for storytelling, and there
must be harmony among the three elements (1991, p. 16). They are the
story, storyteller, and audience. She also informs us that there are three
“essential ingredients of successful storytelling” (1991, p. 17). The storyteller
needs to be interested and involved, give a detailed picture of the events of
the story, and hold a desire that the listener (audience) shares and
understands the storyteller’s feelings. Colwell is actually discussing
storytelling as a skill, an art, a type of entertainment, not as a research
method. However, the points she brings forth are altogether pertinent, and
serve to clarify the versatility and importance of stories in our lives. That they
can be, and are, used for teaching, art, entertainment, and research, and
often all of these things at the same time, is testament to the inestimable
value of stories to persons. I use the points she makes above, however,
because she draws attention to an aspect of narrative that I believe to be
crucial.
Any narrative is so much more than “just a story”, conveying a depth that
cannot be shared meaningfully, on the same level, without the audience
being with the storyteller. In this sense of being with, I mean that the
audience needs to be with the storyteller as a midwife is with her client,
engaging with them – even though, in the case of the storyteller and
audience, they may not necessarily be physically in the same place (e.g. a
story told through art in a gallery, or in a book). Colwell (1991) says that the
27
storyteller has a desire that the audience shares and understands his or her
feelings. Similarly, Yoder-Wise and Kowalski say that there is “a desire to
connect with the listeners in a meaningful and purposeful way” (2003, p. 37).
The narrator of a story wants their audience to engage with them. Stories are
commonly a form of two way communication. Narrative research, however,
becomes a three way (or more) communication, as it involves participant,
researcher and, ultimately, the readers of the research (audience). Stories
are told and retold, interpreted and reinterpreted. This engagement of the
other draws us again to the moralness of narrative, which I will attend to a
little later.
Some authors, such as Schutze (1983, cited by Flick, 2006), regard
narratives as true representations of events, and as a tool we utilize to
convey these events to others. Others, including Bruner (1997), Maher
(2003) and Rosenthal and Fischer-Rosenthal (2004), are more inclined to
believe that we utilize narratives to make sense of and construct events, or
indeed our lives. This latter feature of narratives, that of it being an important
instrument we engage to construct and make sense of events, and the fact
that they are found and utilized in everyday life and knowledge, make stories
very viable as research material (Flick, 2006). The way they are constructed,
and the way they construct, makes them both appealing and enticing to the
researcher.
Stories do not just construct events though. Some authors argue that stories
actually construct us. Drawing on many authors, T. Miller (2005) puts forward
this picture of narrative. Firstly, she suggests that we come to work out who
we are through the stories we tell, and it is also the way that we allow others
to come to know us. Various life events are brought together into episodes
through narratives that we construct and reconstruct, and these enable us to
make our lives comprehensible. We retrospectively bring a sense of
intelligibility and structure to the events that make up our lives. Thus, our
narratives create an order for individual activities or events which, on their
own, make no sense at all. We are at the same time the protagonist and the
playwright. “We use these accounts both to make sense of our own
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experiences and to present ourselves in particular and strategic ways to
others” (T. Miller, 2005, p. 9).
Table 1: Features and Functions of Stories
Features of Narrative – Jerome Bruner Bruner (1987, 1991, 1994, 1997), and an increasing number of other authors
such as Maher (2003) and Rosenthal and Fischer-Rosenthal (2004), assert
that narrative actually constructs reality. Ricoeur’s concept of narrative, as
explained by Frid, Öhlén and Bergbom (2000), where narrative creates the
narrator’s lived world and identity, also fits well with this view of narrative.
Bruner (1991, 1994) has provided a clear, structured outline of the features of
narrative. The ten features of narrative that he identified are very helpful in
the understanding and interpretation of not only the narrative material in this
thesis, but also the narrators (participants) and audience (myself, as
researcher). Inevitably, the audience later became, at times, the narrator,
with a new audience, and it was and remains fascinating to see these
features of narrative living, just as the stories live.
Summary of Features and Functions of Stories
Are temporally ordered Impose meaning Force interpretations Communicate
knowledge Are reconstructions of past
events Convey significance and
meaning Are socially situated Require an audience Foster personal discovery Invite emotional
involvement Arouse attention, and
foster feelings of community Make life
comprehensible Transmit culture,
religion, tradition, morals, values and beliefs
Are context specific Inform choices and facilitate
problem solving Allow and encourage
engagement Contain evaluative/moral
frameworks to help people know how to act and what their role is Allow meaning to be passed on
Connect us to wider stories Involve two way
communication Come together to form
larger stories Reflect life Are a tool we use to make
sense of and construct events and ultimately, our lives
drawn from Abma, 1999; American Health Consultants, 2003; Bruner, 1991; Bruner, 1997; Emden, 1998a; Geanellos, 1996; Maher, 2003; T. Miller, 2005; Roof (cited by Emden, 1998a); Rosenthal and Fischer-Rosenthal, 2004; and Yoder-Wise and Kowalski, 2003.
29
The ten features of narrative as identified by Jerome Bruner (1991, 1994)
are:
(i) Narrative diachronicity Narratives are temporal. They continue throughout and over time. Despite
this, they may not be ordered or structured in terms of time. They are not
static, and as they continue may change as they are interpreted and
reinterpreted, constructed and reconstructed.
Stories, like lives, have a past, present and future, and they refer to these.
They may not represent the past as it actually happened, nor do they
necessarily project the future as it will be, but they are as the story is, a lived
reality for the narrator. In her study investigating expert thinking in nursing,
Penden-McAlpine (2000) found that past and present understandings evident
in the nurses’ stories (which manifested in the form of early recognition) were
very significant. They actually directed both thoughts and actions of the
nurses in the future. Stories occur over time and represent time, but not,
Bruner (1994, p. 19) points out, “clock time”. They are much more closely
aligned, he suggests, with Ricoeur’s concept of “human time”.
(ii) Particularity
A narrative focuses on, or refers to, particular events or occurrences, but falls
into a general type (e.g. boy woos girl, midwife delivers baby). So it comes
about that the “particulars of narratives are tokens of broader types” (Bruner,
1991, p.6). In a sense, the making of a narrative is by completing the
particulars in the appropriate basic story type.
The particulars of a story are highly significant in that they make the story
distinctive – unique amongst its “broader type”. In the midwifery context, an
example of a birthing story could be utilized. If it was claimed that all birth
stories were the same, the matter would be strongly contested by many
mothers, midwives and doctors. Although they do fit into the same “broader
type”, their particularity makes each and every birth story different – and, in
the vast majority of cases, this is of great importance to the infant’s parents.
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(iii) Intentional state entailment Bruner says that “Narratives are about people acting in a setting, and the
happenings that befall them must be relevant to their intentional states while
so engaged – to their beliefs, desires, theories, values, and so on” (1991, p.
7). When persons are going about the business of life, they follow,
consciously or subconsciously, these beliefs, desires and so forth. Thus, their
stories will be consistent with their intentional state and aligned with their
beliefs and values. Arguably, moral beliefs figure prominently in these
situations. Such beliefs can be difficult to discern at times, especially if one is
not looking for them.
(iv) Hermeneutic composability The term hermeneutic means “there is a text or text analogue through which
somebody has been trying to express a meaning and from which somebody
is trying to extract a meaning” (Bruner, 1994, p.21). The implication is that the
text may have a meaning that is different from what has been expressed, and
there is no straight forward way to ascertain this meaning. Narratives,
therefore, call for hermeneutic interpretation, which aims “to provide an
intuitively convincing account of the meaning of the text as a whole in the
light of the constituent parts that make it up” (Bruner, 1991, p.7).
Although all narratives need to be interpreted, Bruner (1991, 1994) informs
us that this sometimes appears not to be the case. These can be situations
of “narrative seduction” or “narrative banalization”. The first type, narrative
seduction, is when a story is told so convincingly and well, that it seems there
could be only one way for it to be understood. There is no (apparent) need
for interpretation, for there is only one possible way to interpret such a story.
Narrative banalization, on the other hand, is where a story (or its type) is so
well known, in keeping with a familiar canon, that a routine interpretation is
automatically (or even subconsciously) applied. Bruner likens these
interpretations to the default settings on a computer, designed to take the
load off our daily interpretive tasks.
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Narrative compels interpretive activity if it is to be understood. This is not only
about its content. We also need to think about why it is told when it is, how it
is, and why it has been interpreted as it is by both narrator and listener.
These interpretations will be affected by the background knowledge of
narrator and audience, and by what each understands the background
knowledge of the other to be. All of these understandings and interpretations
play a part in the formation of the narrative, and to its reconstruction as it is
told and retold. Each person may, influenced by their own background
knowledge and that of their audience, modify the story in different settings,
and at different times.
(v) Canonicity and breach A canon is a general law, rule or principle which is accepted as legitimate. It
is something that is widely acknowledged as the way things should be, or
should be done. Bruner (1991, 1994) asserts that the stories that are worth
telling are those in which a canon has been breached. The very tellability of
the story rests on the fact that it gives testimony to, or illustrates, something
out of the ordinary. A simple midwifery example of a canon being breached
would be a birth story where a baby was born in the car on the way to
hospital. This would be a story told far and wide.
(vi) Referentiality
Narrative has a reference to truth, but not to reality. We can link narrative to
narrative truth. We can not be sure, with narrative, of the actual occurrence,
that this story relates how “it” actually was. Thus, it is not possible to judge
narrative by its verifiability. We can, however, judge it by its verisimilitude,
which is its lifelikeness, or appearance of being true. Bruner (1994) asserts
that narrative has a sense of creating or constituting reality rather than
referring to it. In other words, the reality stories engage with is a constitutive
reality.
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(vii) Genericness
Sometimes narratives fall into a recognizable form. Genres that are familiar
to most include farce, romance, saga, satire and tragedy. In general, genres
such as these help reduce the interpretive task of making sense of our lives
as they “predispose us to use our minds and sensibilities in particular ways”
(Bruner, 1994, p.28). Genres assist us to both construct our plights, and to
make sense of them.
(viii) Normativeness
“Because its “tellability” as a form of discourse rests on a breach of
conventional expectation, narrative is necessarily normative. A breach
supposes a norm” (Bruner, 1991, p.16). A narrative, having been formed by
the breaking or challenging of a canon (something that is generally accepted
as a norm) can do several things. It might restore the norm, reinforcing its
importance. Alternatively, through interpretation of the narrative, it is possible
that a new, more appropriate norm may be formed, due to the challenge that
has presented. A story’s “trouble” may not, however, necessarily be solved
through the normativeness of narrative.
(ix) Context sensitivity and negotiability
In this aspect of narrative, Bruner (1994) acknowledges that all persons bring
something with them to a narrative, whether they are the narrator or the
audience. Narrative is assimilated on our own terms and we interpret
narratives in light of our understanding of the narrator’s intentions, our own
background and our perception of the narrator’s background. Narrative is
necessarily contextual. Also, the meaning of a given narrative can be
negotiated. When two people tell their stories of an event or occurrence they
are rarely, if ever, identical. As each person places their own interpretations
on the events as they occurred, and again as they constructed their story-as-
told, the story is coloured and textured with the nuances of that person’s
understandings and perceptions of the events as they experienced and
interpreted them. Yet, even though each person’s story is different, these
people are able to negotiate the meaning of their narratives and readily
conclude that they refer to the same event.
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(x) Narrative accrual
We join stories together to form larger, wider stories at every level of life (self,
family, society, institutional). In turn, these wider stories lead to the formation
of cultures, histories and traditions. Narrative accrual is a joint endeavour; it
can not be achieved alone. Even our personal narratives are constructed in
conjunction with those others with whom we interact and share a social
history. A relevant example would be the accrual of stories told by midwives
to generate a midwifery tradition.
Narrative and Nursing
A decade ago there would have been little research to report on in this field.
As I commented earlier, narrative has only been utilised in nursing
scholarship comparatively recently in relation to both other methodologies,
and other disciplines. Yet, Maher tells us that the use of narrative in nursing
is a “time-honoured tradition” (2003, p. 11). Nurses have always told and
listened to stories, to share knowledge and information, gain understanding,
and to pass on and continue the culture of their unique practice (Maher,
2003). It is a little incongruous that a profession that relies so heavily on
stories should neglect them for so long in the context of formal learning.
Perhaps it is true that storytelling is a lost art in health care leadership and
nursing, as Smeltzer and Vlasses (2004) claim. Largely disregarded in the
early years of nursing scholarship, the diversity, richness and usefulness of
narrative has now been discovered, and not only for research. People writing
about nursing, and those doing nursing research, have learned that narrative
offers a depth of understanding that other methodologies do not. The result
has been the discovery, exploration, utilisation of narrative in a variety of
ways within nursing and its professional literature. The often rich and diverse
stories that have been gathered and utilized have been shown to facilitate
change, enhance practice, and benefit clients and staff in many ways (Allen,
2006). Some examples follow.
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Nurses and the Law
Chiarella’s (2000) work was not so much a narrative study as a study of
narratives. She wanted to assist nurses with the difficulties and uncertainties
they experienced. By examining legislation and case law of three countries
over a period of almost a hundred years, Chiarella found that “stock stories”
of nurses existed which presented the prevailing views of nurses, yet they
were quite different from the nurses’ own perceptions, which she has called
“outsider stories”. These were as follows:
Stock stories (nurses under control):
• The nurse as a domestic worker
• The nurse as the doctor’s handmaiden
• The nurse as a subordinate professional
Outsider stories (nurses in control):
• The nurse as ministering angel
• The nurse as autonomous professional Chiarella, 2000, p. 194
The prevalence of the stock stories leads to certain expectations of nurses
and their behaviour. For example, if a doctor is acting in a manner that is
dangerous, the “handmaiden, subordinate professional” nurse is not
expected to intervene, nor is she able to insist that the doctor acts upon her
concerns. She is silenced before she is able to speak. It is hardly surprising
that some nurses have found situations such as this intolerable. Indeed,
“when nurses are repeatedly faced with this problem, they often become
deeply disheartened and demoralised, and may leave nursing” (Chiarella,
2000, p. 195-196). Similarly, if a nurse is concerned about the medical care a
patient is receiving, she is, in light of these stock stories, powerless. She can
express her concerns to the doctor, but should the doctor choose not to act
on those concerns, the nurse has no clearly legally defined course of action.
As doctors have been accepted as being qualified to speak for nurses within
the law, nurses’ own stories have been effectively silenced and this has
resulted in a skewed dominant image of nursing that prevents the safe and
35
effective functioning of professional nurses. Chiarella laments, “a nurse may
or may not intervene to stop a doctor from making a mistake which may harm
a patient. It will not depend on the law. It will depend on how brave they are.
They operate inside (or outside) a legal framework which insufficiently
recognises their work and their presence” (2000, p. 198).
Storytelling for teaching
American Health Consultants have said, “it is as old as humankind itself, yet
when we recast through modern technology, storytelling is becoming one of
the newest and most effective techniques for engendering cultural change
and facilitating performance improvement in health care” (2003, p. 13). No
doubt this is one of the reasons why narratives are being warmly embraced
and nurses are being offered opportunities to learn from them. Many people
have realized that stories are a wonderful teaching tool. Across nursing and
midwifery, many examples can be found where stories have been
successfully used in different settings to convey knowledge. American Health
Consultants explain how video storytelling was utilized, in different ways, for
staff training, commenting that “its uses are virtually limitless” (2003, p. 13).
Benefits from video storytelling (in various forms) have included improvement
in clinical processes, teaching of critical thinking, reformulation of a
medication process (to a better one) through reflective storytelling, and
patient safety education. There has also been opportunity for “live stories”,
both good and bad, to be shared with groups of staff, patients and family
members, offering rich learning opportunities.
Some of the reasons why stories work so well in the conveyance of
knowledge include the fact that they are creative and different from the usual
work of nurses; they engage people, creating interest and inviting emotional
involvement. They convey more than dry facts. The facts are there, but they
become tangible, real and meaningful as they are placed in context, with real
people, in real situations. Nurses can make better sense of the facts, which
are more interesting and more worthy of attention, because they are in
36
context (American Health Consultants, 2003; Davidhizar and Lonser, 2003).
“In an environment that alienates nurses from each other and their patients,
storytelling offers a humane approach that responds to emotional need”
(Davidhizar and Lonser, 2003, p. 217).
Nursing leadership/ administration/recruitment Storytelling can be used to benefit both nurses and their administrators. In
recent years there have been both nursing shortages and dissatisfied nurses.
Smeltzer and Vlasses (2004) inform us that stories have many benefits when
shared. They question why leadership does not listen to the stories of the
clinical staff and state that if nurses’ stories were truly heard, the clients
would reap the benefits as the nurses would have been energized and
motivated through being shown respect. Hearing nurses’ stories will help
leaders reflect on their own practice and, these authors contend, assist them
to form (reform) the culture of the workplace.
Pinkerton (2003) tells us about how McKee (a screenwriter) relates a critical
incident within a story. It has, she says, to do with how a person manages to
deal with “difficult opposing forces” (Pinkerton, 2003, p.298). She opines that
some may shy away from storytelling because “it may uncover too much of
what is wrong with an organization or the profession”. She acknowledges
“There are many troubles and tribulations that exist in health care”
(Pinkerton, 2003, p. 298). Her point is that storytelling can be utilized to
address some of them. Drawing our attention to the problems nursing is
facing with recruitment and retention, the possibility of using stories as a
communication method which energises and stirs emotions is put forward.
Used this way, stories could be a viable tool to both attract and retain nurses.
Another use of stories to recruit nurses is really innovative. Rodriguez (2004)
writes about The Nurse Storytelling Project which has been set up in Arizona
(USA) to educate children in their early school years. Through stories they
will learn about healthy behaviour, different types of nurses and nursing.
These stories will include nurses of different ethnicities and both genders,
and demonstrate how nurses work in a variety of different settings. It is
37
hoped that engaging with children in this way will cause lasting memories
and that they will later take up nursing as a career.
Narrative and Midwifery In the past, midwifery research was frequently encompassed within the
broader nursing research, especially in the ethics literature. It is a source of
considerable frustration to some midwives who fiercely protect their “midwife”
status, stating that they are not nurses, but midwives (personal experience).
As a midwife myself, I have always found this a curious thing, as I was a
nurse first, and am equally pleased to be acknowledged as both nurse and
midwife. Whilst digressing slightly here, there is an important fact to be
recognised. A midwife is not the same as a nurse. She has a distinctly
specialised role, requiring specialised skills that a general nurse does not
have. There is absolutely no doubt whatsoever, that whilst we must
acknowledge that the vast majority of midwives are, in fact, nurses, and thus
a part of the nursing profession, they are in and of themselves, a separate
profession. Midwifery is a culture within a culture and has a distinctive
purpose10. There is now an ever increasing body of literature emerging that
is specific to midwifery, a vital sign of a unique profession. This trend for
midwifery to have its own forays into new areas is clearly evident within the
narrative field.
Storytelling for Teaching in Midwifery Just as in other fields of nursing, storytelling has been utilized for teaching in
midwifery too. Yoder-Wise and Kowalski (2003) write much that resonates
with what the American Health Consultants (2003) have said. They tell us
that people are more likely to be receptive to a storied presentation than to
one which is data-based, and that a story, well told, can effectively convey
the values, information and principles of the narrator to the audience. They
boldly state that “a story can illustrate whatever needs to be taught” (2003, p.
37; italics added). Yoder-Wise and Kowalski (2003) provide an example of a
10 Midwifery is a social practice. This aspect of the practice will be further explored in Chapters 3 and 7.
38
story which was used as a teaching / learning experience. As a midwife
audience to this story, I was engrossed, as the story has an unusual slant.
The story related is of nurses in a Maternal and Child Health setting having
made a mistake with serious consequences. Instead of being punished, as
they were expecting, they were given opportunity to discuss the situation,
take responsibility for their actions, and learn from their mistakes. The
authors explain that the story became well known and conveyed a strong
message that all staff members were very much supported by the director.
The implications were that the staff could be open and honest without fear.
Barbara Behrmann (2005), a sociologist, wrote a guest editorial in the
Journal of Perinatal Education. She has spoken and written much about the
stories mothers tell in the area of breastfeeding and birth, but she begins this
editorial with her personal experience, of when she shared her own story.
She first told her audience that, when she was pregnant, she devoured other
women’s birth stories. Then she said, had she heard other women’s breast
feeding stories, she would have felt much less alone in the early days of
motherhood. During that time she had found breastfeeding extremely
challenging. Behrmann comments that the birthing stories other women
shared with her were “every bit as helpful” in preparing her for the birth as the
more standard preparations of learning the technical aspects of birthing
(2005, p 11). She laments the absence of breastfeeding stories and suggests
that these “mothers’ stories” are not very visible and so go unnoticed;
something that Bruner (1991) might call a case of narrative banalization11.
Breastfeeding mothers consequently receive the message that they are
alone, and their stories are unimportant. These stories are, however, of
enormous value. Some of the benefits of sharing breastfeeding stories that
Behrmann (2005) draws our attention to include the reduction of anxiety, 11 Narrative banalization is when a story is (or appears to be) so well known we apply an “automatic” interpretation to it, which may or may not be close to the correct interpretation. In this case, one might think, “All breastfeeding stories are the same. Breastfeeding is natural. Babies latch and suck”. We do not, therefore, go to the effort of interpreting them. This can ultimately lead to the stories being silenced. Any midwife or mother would be able to tell you that the scenario I have painted is far from the truth.
39
loneliness and insecurity; the validation of women’s experiences; and an
enhanced understanding that breastfeeding is not only about nutrition, but
also an intimate relationship between mother and child. The sharing of the
stories themselves enhances our understanding of our culture and where we
stand within it. Behrmann concludes her article by sharing a story with her
readers. She had given a talk in which she had shared a story. As mentioned
earlier, and as happens so often with a story shared, an audience member
identified strongly with the protagonist in the story and had had her own
decision affirmed, even though her family had been trying to sway her. “Such
is the power of storytelling” (Behrmann, 2005, p. 14), having the power to
affirm, to give courage, and to change lives.
Enriching research findings
Some have utilised narrative to enhance understanding of research they
have done previously. Kennedy (2004) had undertaken prior studies into
midwifery practice and wanted to ascertain if narratives would enhance or
expand the findings of her Delphi study12. Interestingly, during her Delphi
study, several of the midwives had used vignettes to illustrate their points,
suggesting they were, in Kennedy’s words, “natural storytellers” (2004, p.
506). A number of papers which she authored alone and jointly were
published in 2004, reporting on the findings of the narrative research.
Kennedy found that, having conducted the narrative study after the Delphi
study, the findings of the former study had been enhanced. The narratives
provided thicker and richer descriptions. The stories were contextual, adding
shape to what the midwives said about their practice, and the interactions
between midwives, the recipients of their care and the system within which
they worked was more fully explicated and brought into focus. The Delphi
study was unable to “fully convey the intricacies of a midwife’s work. The
narratives brought those dimensions to life…” (2004, p 507). The actual
12 A Delphi study is where a panel of experts is approached and asked to contribute their opinions and knowledge, anonymously, regarding a complex problem. They have the opportunity to determine how, or if, their evaluation of the issue aligns with that of other experts in the field, and a chance to change theirs if they wish. The knowledge exchange continues over a number of rounds until either consensus or stability is reached (Kennedy, 2000).
40
results of the narrative study are reported more fully in two co-authored
papers (Kennedy and Shannon, 2004; Kennedy et al. 2004).
Kennedy and Shannon (2004) present a paper whose title begins Keeping
Birth Normal. It opens with the words “Women have served as midwives
since the beginning of time” (2004, p. 554). This is indeed true, however
childbirth has become increasingly the domain of doctors, and intervention
has become commonplace. Downe (2006) suggests one of the difficulties
contributing to the dilemma of striving for normal birth is the uncertainty of
what normal birth actually is. As people have different understandings of
what constitutes normal, when women and midwives are heading for a goal,
they may not be running in the same direction. For different people, normal
could include augmentation, restriction to bed, foetal monitoring or pain
medication, some of these things or none of these things. Given the
enormous number of variables that could present, there are a myriad
different directions midwife and mother (and father) could be heading, each
earnestly following their own concept of normal. Downe (2006) offers a
solution. She says we need to grasp “unique normality”. This, she says,
takes account of each woman’s labour in the context of her pregnancy,
her family clinical, psychosocial, and emotional history and the story of
her life. It sees birth as an ‘ordinary drama’ – not as a crisis, and not as
a routine event, but as a one-off exciting event, full of possibility
Downe, 2006, p. 354
Such an approach encourages people to work in authentic partnerships, with
both colleagues and clients, and presents possibilities rather than limitations.
Accepting that “normal” may not be a constant or uniform concept, we shall
return to Kennedy and Shannon (2004). Knowing that “Narratives provide
insight about the practice of nursing and an exceptional venue to extend our
knowledge of what works well in clinical practice” (Kennedy and Shannon,
2004, p. 555) they collected narratives from midwives to explore the
processes of care that they provided. Interviews were video recorded and
41
later transcribed. A computer software package was utilised to assist data
management in the coding, thematic clustering and interpretation stages.
The findings of Kennedy and Shannon’s (2004) study offered a depth of
understanding regarding the care that midwives provide to their clients. The
midwives worked with the women, striving to help them have faith and trust in
themselves and their bodies’ ability to birth. They believed in normal birth and
they believed in women. Acknowledgement of fear by the midwives meant
that they made conscious efforts to dispel the fears that women brought with
them to the birth experience. Creation of a physically and emotionally safe
space was an important aspect of being with women in labour, as was
patience. The midwives were comfortable waiting for things to happen in their
own time and accepting that there are wide variations in normal, trusting in
the assessments of maternal and foetal wellbeing. One very important theme
that was evident was “Presence : the physical act of being with woman” (Kennedy and Shannon, 2004, p. 557). The midwives expressed that staying
in the room with the women in labour, even when “not needed”, engaging
with them and maintaining trust, was a way of showing the women that they
were in the care of someone who was an expert in normal birth. This helped
the women feel secure and ensured unneeded interventions were not
introduced, while the midwife was all the time monitoring the labour through
astute observation.
Although their study was quite different from the one described above, Maher
and Souter (2002) discovered something quite similar. They set out to
investigate midwives’ perception of the role of lay support people, but the
midwives themselves became a focal point in the study. They discovered that
midwives played a significant role in assisting birthing women to formulate a
birth narrative. For Maher and Souter, a narrative is a discursive construction
which gives sequence, order and meaning to a real-time physiological
experience. Being flexible, developing and holding trust, understanding and
helping women to understand that birth is often an unstable event in many
ways (how we understand it, context, the actual process) were all a part of
42
helping women to formulate stories that helped them to make sense of the
unique experience that was their birth.
Kennedy et al. (2004) present a narrative study of midwifery practice. Three
main themes were discovered within the stories they gathered. These were
The Midwife in Relationship with the Woman, Orchestration of an
Environment of Care and The Life Journeys of the Midwife and the Woman.
The first theme, relationship, centred around mutuality. The midwives were
interested in the women’s desires; they encouraged an equal relationship,
with recognition and acknowledgement of the women’s experiences as
authentic. Many qualities of midwives were visible, such as humility, integrity,
humour, and compassion, having a passion for midwifery and being non-
judgemental. To orchestrate an environment of care the midwives trusted in
women and believed in normal birth. They were accountable and acted as
advocates to assist the women safely achieve the birth they wanted. An
important aspect of this was the midwives’ understanding the context, where
things were happening, and also being aware of the woman’s understanding
of her place within that context – helping her to fit, make sense of and
traverse the people, places and system. The final theme reflected the fact
that both women and midwives learn and grow through their experiences.
The birth experience could be transformative for birthing women, but also for
midwives who reflect on their practice, providing a sense of achievement,
satisfaction and adding to their life stories in sometimes very unexpected
ways.
Narrative to critically reflect and examine practice Perez-Botella and Downe (2006) utilized the personal narrative of the first
author to critically examine current practice. Disturbed by the way a senior
midwife had acted, “Rachel’s story” is related and the clinical issues involved
in the scenario are critically analysed in light of the available evidence. The
narrative enables us to identify with the author. We sense her feeling of loss
as the calm is disrupted and Rachel’s labour is taken over. Her perception
that she is helpless, lacking the power to change the situation, as she stands
by watching the senior midwife “direct” the labour in a manner that is not only
43
different to the direction and manner she would have liked, but also contrary
to what she knew to be best practice according to current evidence, brings us
right into the room. The depth in this short story has us empathising with both
the author and the client. The paper provides a powerful example of how
sharing and reflecting on stories can challenge midwives to be assertive to
advocate for their clients, and their need to express their concerns – two
points that are noted in the paper. It also shows how useful stories can be for
questioning, reflecting upon, teaching and changing practice where
appropriate. We revisit this story later in the thesis.
Client Stories
Some of the most important stories in midwifery are not midwives’ stories, but
the stories that their clients hear. It seems to be the case that every
expectant couple is, as Bainbridge says, “everyone’s business” (2006, p.
265). Whether they want to hear them or not, pregnant women and their
partners are the recipients of endless stories (and undeniably, they will one
day be disseminating their own stories with equal fervour and conviction).
Bainbridge informs us of some important aspects of this type of storytelling.
She notes that it can be frightening and confusing when scary stories are
told, and also indicates that some less than helpful advice can be given.
Whilst this can be seen as a negative side of sharing stories of birth and
parenting, she says that there are some positive aspects that need to be
noted. Midwives have a vital role in clarifying the stories and providing up to
date knowledge. With ongoing research and ever increasing knowledge and
understanding, even recent mothers can sometimes be out of date. Perhaps
the most positive aspect of these shared stories, however, is that, in a society
where people rarely talk to one another unless there is need, communication
is reborn along with the excitement of the new life growing within the
mothers’ wombs. A sense of community develops around pregnancy and its
associated stories and, although some of these stories can be unhelpful,
some of them are gems of wisdom.
Michael’s Story is written by his mother (Barnes, 2006). Published in
Midwifery Matters, a journal primarily aimed at midwives, it conveys a
44
powerful birth story. We are bombarded with classic examples of
misinformation, lack of understanding, insufficient information and quite likely
unnecessary interventions as Barnes takes us into the delivery room, and
then the operating theatre with her for Michael’s birth. We listen to her baby
cry for a feed, while she lies, post-caesarean and unable to move, and
shudder when the nurse tells her, in an unfriendly manner, that she must wait
until handover is finished before any assistance can be given. The story
continues and Barnes concludes that she was the victim of an over busy,
understaffed hospital, and that “you have to be extremely lucky to get a good
hospital birth” (2006, p. 26). They may not be research, but when narratives
such as these appear in midwifery journals, they provide strong stimuli for
midwives to reflect on their practice.
Although men play an active part in preparing for childbirth with their
partners, are frequently present at the birth, and regularly plan to be a
significant hands-on care provider for the child, in the early days at least,
men’s role in these aspects of life has received very little attention in
research compared to that of women. Dellmann (2004) has provided an
extensive review of the literature to build a narrative of fathers’ experiences
of childbirth. It is of interest to note that Dellmann belongs to a minority group
of authors in the midwifery literature – he is male. The general conclusions
that he was able to draw were that fathers mostly felt distressed and at a loss
as to what to do when their partners were in pain during labour, but the actual
birth was (also for most), a truly amazing moment. Men are often not sure of
their role during labour and, at the same time, fail to live up to the
expectations of that role. None-the-less, fathers’ presence at the birth of their
babies was seen to have a positive effect on mother, and baby, as well as
the fathers themselves.
The Moralness of Narrative Although they did not set out to study ethics, when Kennedy et al. (2004)
studied midwifery practice the narratives that midwives shared with them
were considerably laden with ethical notions and considerations. The authors
say “Perhaps the most profound messages were also the subtlest in the
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realistic approaches the midwives used in caring for women. They did not
shy away from the hard questions as they strived to understand someone
whose life and desires might be very different from theirs” (2004, p. 21). They
provide an example of how both our stories and our everyday midwifery
practice are inherently moral. Some of the moral ideas and behaviours that
Kennedy et al. (2004) found during the analysis of their narrative material
include mutuality, validation, participatory care, respect, intimacy, disclosure,
humility, integrity, non-judgemental attitudes, compassion, advocacy,
accountability, listening to women, ethical reasoning, providing information
and options, provision of comfort and care, going out of their way, trusting,
believing, and honouring. This impressive, extensive list comes from the
stories of fourteen midwives and four recipients of care in one study, and
provides an excellent platform to begin our discussion on the moralness of
narrative. Stories are a natural channel for moral expression and learning.
This is also a good point in time for us to reflect again on Sandelowski’s
words, quoted earlier in this chapter, and I quote again here, in part.
“Mourning the devaluation of narratives as sources of knowledge, and
emphasizing the moral force, healing power and emancipatory thrust of
stories” (1991, p. 161, italics added), scholars “discovered” our natural
narrative inclinations. Sandelowski draws our attention to the moral aspects
of stories as being their primary point of being. Ochs and Capps (2001)
concur, claiming that we have to make the moral meanings of events fit
together each time a story is told. Thus, everyday storytelling can be utilized
as a source of moral education. They quote Charles Taylor, who they say
reminds us that the structure of narrative
builds a moral framework for understanding human comportment:
“Making sense of my present action, when we are dealing with … the
issue of my place relative to the good, requires a narrative
understanding of my life, a sense of what I have become, which can
only be given in a story.” Ochs and Capps, 2001, p. 51
In such a way, the events, the meaning of the events, and my place and
actions within that situation all come together, through interpretation, as my
46
story is told. You might liken this to the way a jigsaw is completed piece by
piece, to make a coherent “good”, or, at the very least, acceptable picture.
It is possible to gain further insight into the moralness of narrative by
exploration of some of narrative’s features. Many of these features have
been identified earlier in this chapter and outlined in Table 1. If we view them
through an ethical lens, the moral nature of stories becomes increasingly
clear. Some examples looking at narrative features this way are outlined
below.
Narratives are reconstructions of past events. Interpretation is a natural and necessary part of reconstructing an event or
occurrence so that we are able to formulate our story. It is inevitable that the
beliefs and values we hold will have a significant influence on the way in
which we view the situations of which we have been a part and/ or witnessed,
and therefore the way in which we interpret them both as they are happening
and as we reconstruct them to formulate our stories. Reconstructions are
thus ethical endeavours.
Stories are composed and interpreted hermeneutically.
This attribute of narratives is linked to them being reconstructions, in-as-
much as beliefs and values are applied with each interpretation and thus all
interpretation is ethical. This feature of narrative, however, takes us beyond
simply reconstructing past events. Many authors, including Bruner (1991,
1994); Emden (1998a); Frid, Öhlén and Bergbom (2000); and T. Miller (2005)
agree that stories are told and retold, constructed and reconstructed. Each
time a story is told, it is being interpreted by both narrator and audience, the
values and beliefs of both (or all if the audience is more that one) in action as
new stories are being formed by each person present. This continues again
and again, every time the story is retold, and reconstructed. Beliefs and
values affect how and what we understand, influence what we do and say,
and challenge us to justify our thoughts, words and actions, so when we
apply these to an interpretive task, it becomes very much an ethical
enterprise. Their hermeneutic composability and the fact that stories are
47
composed in combination with an “other”, in itself makes them a moral
activity.
Engagement
Histories are created in conjunction with others, through interaction with
others, and never in isolation. Isaacs (1998) informs us that our regard for
others is an ethical responsibility, and we have already been informed that
we are amidst a moral situation if there is more than one person present (J.
Thompson and H. Thompson,1996). There are obvious implications for
narrative, for all narratives involve two or more people – a narrator and an
audience. So there is automatically a moral situation and an ethical
responsibility present. The way in which we regard others will affect our
stories and our histories.
Transmission of culture, religious practices, traditions, morals, values
and beliefs (Geanellos, 1996).
Most people readily accept morals, values and certain kinds of beliefs as
ethical concepts, aspects of life that encompass guiding principles, including
ideas of right and wrong, good and bad – clearly ethical components. The
remaining three, culture, religious practices and traditions can also easily be
seen to have ethical importance. These carry particular meaning for the
storyteller and his/her audience. All are linked to values and can be changed,
challenged or reinforced in the telling and interpretation of the story. Story
plays a very important role in the continuation of society through the
transmission of these six things, for they enable the conveyance and
teaching of what is considered right and acceptable behaviour.
Communication of knowledge and skills.
We have seen quite clearly through the literature that stories are an
extremely useful resource for teaching. When we consider our stories as
having these capacities, they may actually hold an ethical imperative. That is,
if we wish to strive for good (an ethical end), then we have a responsibility to
convey particular knowledge in a particular way. Therefore, we should pass
on our knowledge and skills appropriately and well. Naturally, it would
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behove any midwife to behave in such a way, for this would be considered
ethical behaviour, and ethical behaviour is inherent in professional behaviour.
If one is going to claim professional status, there comes with that claim a
responsibility to be aware of and utilize ethical principles (Schultz, 1993).
Arguably, there are some things we are all morally obliged to share through
stories. This cannot be stated, however, without also noting that following
through on this moral obligation can, at times, have negative personal or
professional implications. The inherent risk may, therefore, make the cost of
acting in the morally appropriate way (and sharing the story) very high. A
common situation where this occurs is whistle blowing (or a refusal to do so).
Problem solving.
When trying to solve a problem, most people, either consciously or
subconsciously, invoke an ethical framework to assist them. Midwives might
look to the Code of Ethics (Australian College of Midwives Incorporated
[ACMI], 2001), or the Code of Ethics for Nurses in Australia (Australian
Nursing Council [ANC], 1993) to assist them if it was a professional issue
they were facing. Personal ethical frameworks are frequently applied in
problem solving, and conscience often plays a part also (Kinnane, 1996). Our
conscience predisposes us to choose to do that which we believe we ought
to do (Beauchamp and Childress, 1994). Stories can provide guidance and
ethical direction (Abma, 1999). When we hear a story, we place our
interpretation(s) upon it. How we interpret the outcome, as good or bad, for
example, may well determine how we respond to a similar problem in the
future – problem solving in advance. The narrator of the story may reinterpret
the story and make different judgements about how they should have acted,
or how they might respond if a similar situation should arise at another time.
The moralness of story is , of course, quite simply evident in the fact that one
is telling the story to the other – remembering that there is a moral situation
wherever two or more people are present (J. Thompson and H. Thompson,
1996). Fruitful discourse could arise as a result of the engagement between
narrator and audience, which may lead to further problem solving and ethical
discussion.
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Attention arousal, engagement and community.
Stories are a little like recipes. A number of different ingredients are
combined. On their own, each ingredient is rather bland and uninteresting,
but as they are brought together and mixed up, the flavour develops. The
greater the number of ingredients, the richer and more interesting the flavour
becomes. So it is, as the components of the story are combined and the
characters blended with the plot, then placed in context, interest is aroused.
The narrator allows and encourages engagement. In this sense of
engagement, the narrator is involving an “other” in an act of sharing.
Commonly, in the case of storytelling, narrator and listener respect and value
the “other” during such engagements. Emotional and intellectual sharing
frequently ensues, and this leads to feelings of community.
Evaluative and moral frameworks are provided.
Stories can tell us what to do, how to behave and even who to be – then they
can help us to assess how we are doing. The following quote from Abma
(1999) gives a brief but powerful summary of why people tell stories. Within
this description it is possible to see the moral attributes of storytelling that I
have mentioned above. She says, “People tell each other stories to find out
how they should act in certain situations, how they relate to others, and what
their identity and role is. In telling stories, actors are involved in the act of
generating value, judging the worth of their lives and social practices” (Abma,
1999, p.170).
Listening
An interesting aspect of the moralness of stories is listening. “We can be
responsible for listening or failing to, and we make a difference as a result.
Listening is an activity of being attentive; it is a way of being in a moral world”
(Forester, 1980, p. 220).The act of listening shows an interest in the “other”,
and respect for the “other”. Without an audience, a story’s power is not
realised. It needs a listener to reach its fullest capacity. I am not entirely sure
that I agree with Thomas, who asserts that “the most powerful part of
50
storytelling is listening”, but it is unequivocally an extremely important
component (2005, p. 24).
Summary
All of life’s narratives are inherently moral. Ochs and Capps (2001) discuss
how we all adopt a moral stance. We must negotiate our moral stance
continually throughout life. Even within a particular story our moral stance
may be unstable, wavering due to circumstances, or our own uncertainties.
Perhaps we have been challenged by a situation we have not met before,
and we are constantly in the process of interpretation and reinterpretation.
Alternatively, a challenge to our moral stance may be presented by an
interlocutor interrupting our story, and it has to be reinterpreted right there
and then. The issue at hand though, is that there is always a moral stance.
There is an embedded moralness in every story. Ochs and Capps suggest
that we thus all have a kind of inbuilt mode for seeking goodness – through
narrative.13
The moralness of narrative makes it particularly appropriate for my research,
and indeed all research that hopes to discover something of a human
experience, of the ethical embeddedness within that experience, and of the
people themselves. In short, narrative allows for a depth of understanding,
through interpretation, because of its features and its nature.
Procedure Ethical Clearance The Queensland University of Technology’s University Human Research
Ethics Committee deemed this project exempt from requiring ethical
clearance. With this knowledge, the large private hospital and the smaller of
the two public hospitals gave me consent to recruit participants from their
staff, without the need for my project to go before their ethics committees. 13 It should be noted that this concept of “goodness” would be from the individual’s perspective. We know that values and morals are constructed in many ways, including culturally and socially, and thus one’s concept of “goodness” would be impacted upon by these also.
51
The large public hospital, however, asked for a full submission to go before
their ethics committee. I submitted this and after several months it came back
with many comments and questions to be addressed. Many of these related
to a need to further explain the qualitative framework I planned to use.
Before the review of this document was completed, I, unfortunately, suffered
a critical, life-threatening illness and a long period of leave was taken from
my study. In the interim, the hospital in question merged with another
hospital, the ethics committee was disbanded and a new one with different
members, a different structure and different procedures was formed. I was
required to resubmit my application for ethical clearance. Conditional ethics
clearance was given. Conditions included that I would “advertise” for
participants, that participants with concerns would contact the hospital’s
ethics committee, rather than the ethics committee of the university, and that
the hospital’s support for the project be acknowledged in any publications.
Recruitment Initially, it was planned that recruitment would be by inviting midwives
randomly selected from a list of employees from each of three hospitals: a
large private hospital in south-east Queensland, a large public hospital in
south-east Queensland, and a smaller public hospital in south-east
Queensland. It was planned that invitations would be followed up with a
telephone call, and further invitations sent out as required until five midwives
from each hospital had agreed to participate in the study. Only one of the
three hospitals agreed to provide me with a list of staff names to facilitate this
mode of recruitment. For privacy reasons, even this hospital was unable to
provide me with addresses or private contact details, so all contact had to be
made through the workplace.
At that hospital, the large Private Hospital, names were randomly selected
from the staff list using a statistics data table (Arkin and Colton,1963) and
invitations containing an introductory letter, information sheet and participant
response sheet (see appendices A, B and C) were sent to ten midwives.
Those midwives who were willing to participate and those who did not return
52
their response sheet were followed up with either a telephone call or a
personal visit at work to ask about their willingness to participate in the
project. The personal visit approach was undertaken at the suggestion of the
Nurse co-ordinator of the unit after many failed attempts at contacting people
on the telephone. In total, four midwives were recruited from this hospital.
At the smaller public hospital in south-east Queensland, it was requested that
I provide information and an invitation to participate to all midwives. To
facilitate this I made up an information package containing an introductory
letter (see appendix D), an information sheet, a participant response sheet
and a reply paid envelope, asking that the response sheet be returned
regardless of the midwife’s decision. There were three options – a willingness
to participate, a request for further information, or declining to participate.
There were few forms returned from people who did not wish to participate,
one request from someone who wanted further information, who
subsequently participated, and seven willing participants.
The large public hospital was the only hospital that deemed my project in
need of clearance by an ethics committee. The ethics committee asked that I
recruit by means of “advertising” for participants. To this end I made up
brightly coloured A4 sized posters (see appendix E) and distributed them,
with a covering letter (see appendix F), to each of the Nurse Practice Co-
ordinators of the areas where midwives work in the hospital, along with
several information sheets14 and participant response sheets. There were
five respondents from this hospital. Unfortunately, several planned interviews
had to be rescheduled with two of these, and both subsequently had to
withdraw from the project before it was possible to conduct an interview.
14 These were slightly adapted from those provided to the participants at the other hospitals to include a reference to the hospital’s ethics committee, should the participants wish to contact the committee with any concerns.
53
Participants
As they were actively involved in the project, this study has research
participants, rather than research subjects. It is the narrative material that
they provided, not they themselves, which is the subject matter of the
research. This is not, however, to understate the value or importance of the
stories to the participants.
Inclusion Criteria
Participants were required to meet three criteria. These were that they
needed to
• be Endorsed to practise as a midwife in Queensland
• have been practising midwifery for the past twelve months
• be working in a midwifery setting at the time of their participation (full
or part time)
Reasons for Inclusion Criteria
I was seeking to learn about the experiences of midwives, therefore it was
obviously important that all participants were midwives. It was felt that having
at least twelve months midwifery experience, and recency of experience,
would ensure that participants would have a large number of practice
situations to draw on when asked to share some of their experiences as a
midwife. More recently qualified midwives, or those who had not practised
midwifery for some time may, possibly, have found it more challenging to
readily bring to mind and talk about their everyday experiences as a
midwives. I also wanted to learn, primarily, about contemporary midwifery
practice, thus recency of practice was relevant for this reason also.
Interestingly, several participants actually chose to narrate events which had
occurred long ago, and they were not precluded nor deterred from sharing
these stories. This showed that, apparently, not only were these events
readily recalled, but that, in some cases, they were at the forefront of the
midwife’s mind when they reflected on their midwifery work.
54
Exclusion Criteria There were no exclusion criteria for those meeting the inclusion criteria.
Number
The total number of participants was 1515.
Demographics
As this research is not intended to produce generalizable results,
demographics were not considered to be an important aspect of the project.
Some basic information was, however, collected from the participants and is
included here for interest. Fourteen of the fifteen participants provided
demographic information.
It was hoped that midwives with broad experience, currently working in
different areas and with different areas of expertise would participate in the
study. It was thought that different work environments would “naturally”
create unique experiences and this would result in the midwives’ stories
being rich and varied.
Gender
The participants were overwhelmingly female. There was only one male
midwife included in the study. This was to be expected, given the small
proportion of midwives that are men.
Age
Midwives were aged between twenty-eight and fifty-one. Two were in their
late thirties; eight were in their forties and two in their fifties. The main reason
that this is of interest is that it reflects the demographic of the midwifery
workforce in Queensland, which we know is aging. Although it would be
inappropriate to draw inference from such a small, non-random sample, this
does draw attention to the likely need to attract people to the profession if it is
to be sustained.
15 As noted below, only 14 of the 15 midwives provided demographic information.
55
Work Area
At the time of their interviews the participants were working in a number of
different areas of midwifery16. These included Birth Suite, Neonatal Nurseries
(Special or Intensive Care Nursery)17, Post Natal Wards, Antenatal Wards,
Clinical Education and Childbirth Education. All of them had, at some time,
worked in at least two different areas, most (twelve) in three or more. Nine of
the participants were currently working in Birth Suite, four in Neonatal
Nurseries and two in Postnatal Wards. One midwife was involved in Clinical
Education and one in Childbirth Education. Some midwives currently worked
across more than one area. Eight of the midwives regarded themselves as
“specialists in”, or identified as “belonging to” a certain area of midwifery. In
this group were four Birth Suite midwives, two Neonatal Nursery Midwives
and two Postnatal midwives.
Years of Experience
The years that participants had been midwives varied quite significantly.
Years of practice as a midwife were generally less than years qualified. This
was not always the case. One midwife, for example, had been qualified for
nineteen years and had been working as a midwife for nineteen years,
another for fifteen. Five participants had been registered as midwives for
between five and ten years, five for between ten and twenty years, and four
for more than twenty years. By contrast, seven had worked as midwives for
three to ten years, five for ten to twenty years, and just two had worked as
midwives for over twenty years. This represented a wealth of experience.
Consent A consent form was formulated according to the guidelines set down by
Queensland University of Technology (see appendix G). In response to, and
in accordance with, the requests of the Ethics Committee, this form was
slightly adapted for use at the large public hospital to include that hospital’s
Ethics Committee as a reference point should participants have concerns. 16 Areas of midwifery I asked them to nominate, if appropriate, were Antenatal Wards, Antenatal Clinic, Postnatal Wards, Birth Suite, Neonatal Nurseries, and “Other”. 17 Nurseries for the care of premature and ill babies have different names at different hospitals. It is these nurseries I am referring to when I use the term “Neonatal nurseries”.
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Each participant was provided with written information about the project
(Information for Participants sheet – see appendix B) well in advance of the
interview. This information sheet clearly indicated that ethics was the focus of
this midwifery project and offered contact details if further information was
required. When the interview time was being arranged, an opportunity was
given for questions and further explanation as required. On the day of the
interview, each participant was given an opportunity to re-read the
Information for Participants sheet and ask any further questions. They were
then asked (verbally) if they were still willing to participate in the project, and
advised that the interview would be tape recorded. Finally, they were
requested to read and sign the consent form prior to the commencement of
their interview.
Confidentiality and Anonymity Participants were assured of confidentiality and anonymity. A number of
measures were employed to facilitate this.
Non Disclosure of Names
Initially the participants’ names were to be known only to myself, as the
primary researcher. The names have, however, also been known to my
principal supervisor. He was not able to link participants’ names to the
narrative material.18
Storage Audio tapes and transcripts have been kept separate from information
identifying the participants. All have been kept in locked filing cabinets. The
only people who have had access to these documents have been those
needing such access for the purpose of the research. These have included
the researcher, transcribers, and supervisory team members. Transcribers
18 Access to the participants’ names and addresses needed to be provided to my principal
supervisor for contact purposes when I was seriously ill and had to take leave from my
studies.
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did not have any identifying information about the participants. Tapes and
transcripts were coded for identification using a letter and date system.
Female Pronoun
As 99 percent of midwives working in the field are female (AIHW, 2006), all
participants have been referred to as females within the thesis. All have also
been given pseudonyms to protect their anonymity. As previously mentioned,
there was one male participant. Clearly, if I were to refer to him as “he”, or
give him a male pseudonym, he would be easily identified, so he also has a
female pseudonym. I would like to apologize to him for this, for it still seems
wrong, even though it is “right”.
Pseudonyms
All persons in the stories and excerpts of stories used as exemplars within
the thesis have been given pseudonyms. Sometimes a non-gender specific
term has been used instead of he or she, his or her etc., where appropriate,
to further protect identities (e.g. baby, or doctor). The details in some stories
have been altered, without significantly changing the main flow or gist of the
story (as I have understood and interpreted it), also for reasons of
confidentiality and anonymity.
Essential Omission
Some wonderfully rich and heart rending stories have, unfortunately,
necessarily been omitted from the final thesis, because I simply could not
resolve how to retain the true meaning of the story without threatening the
anonymity of those involved. They shared these stories with me in
confidence and I cannot risk sharing them with the wider community because
there may be an inherent risk for my research participants. Some stories are
not quite so everyday as others.
Collecting and Collating Narratives Narrative Material
I prefer to call the “data” collected for this study narrative material. Whilst
“data” is, or can be, any information that we use, or work with, narrative
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material more appropriately describes the information used in narrative
research to grasp an understanding of the participants and their situations
and responses to them.
Setting
When a midwife had indicated his or her willingness to participate in the
research project, an individual interview was arranged with them. This
interview took place at a time and place suitable to the research participant. I
was happy to go wherever they wanted, whenever they wanted. It was crucial
that they felt comfortable to talk freely. Many participants invited me to their
homes, one chose to be interviewed at her workplace, one at my home, and
one on neutral ground, for which a motel room was utilized.
Interviews
Keeping the words of Emden (1998b, p.34) in mind, that “not all interview
data are suitable for narrative analysis, one needs to have approached the
interview with the intent of hearing stories”, and also those of Mishler (1986,
p.53), who says that “The discourse of an interview is jointly constructed by
interviewer and respondent”, it was clearly very important to chose an open-
ended question to initiate the conversation between interviewer and
interviewee. Due to information provided on the Information for Participants
sheets, all of the interviewees were well aware that the project was about
ethics. I wanted them, however, to feel free to share narratives from any
aspect of their midwifery experience, not only stories that they classified as
“ethical” for some reason19 (knowing that ethics would likely be embedded in
all of them). For this reason, a broad open-ended question was required to
invite their stories.
The following question was put forward to the research participants. “Could
you please share with me some of your experiences as a midwife? These
might include situations that you have found rewarding, and others that were
19 Despite acknowledging this, it is quite possible that some of the midwives interviewed, knowing I was interested in ethics, told me stories they thought I would like to hear, at least some of the time.
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challenging or even disturbing. You might like to share why it is that you
remember these encounters, what your part in the situation was, or how you
feel about the outcome”. A copy of the question was printed on paper for the
midwife to see and refer to if they wished. This was given to them at the
same time as the question was being asked. Some of the midwives
requested to keep this printed copy of the question, which I naturally allowed
them to do.
Interviews progressed in an unstructured, conversational manner. I prompted
the participant from time to time to elicit further information on the topic which
they had raised. Participants varied widely in their flow of talk. Some spoke
freely and continuously for long periods, whereas others appeared to feel
constrained, or found it difficult to think of examples from their practice. For
the participants who fell into the latter type, encouragement and frequent
prompting was needed to help them to feel comfortable and facilitate their
sharing of midwifery stories. At times questions were also used to clarify what
many of the participants had said. Below are some actual examples of
prompts and questions used in the interviews.
Prompts and questions included
• How do you feel about that?
• What sort of information is it?
• It must be a common scenario, is it?
• With the really bad birth suite day, the recent one, what made it bad?
• Were you able to rectify?
• Can you think about a good day that you’ve had recently?
• Did you find it valuable talking with your colleagues about it? To the
other midwives?
• With the first situation that you were talking about, that you were
actually involved in, how do you, obviously you’re still not happy about
it, you still have fairly strong feelings about the situation now, perhaps
you might like to expand on that?
• And why do you think that it’s important?
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• Where do you think midwifery is heading?
• Do you think that this experience for you and for other midwives is
going to change your practice long term? Will you ever be the same
again?
• Can you describe how you felt?
Interviews varied between approximately one and two hours in duration,
depending on how long the participant wished to continue the conversation.
Transcription
In order to identify and then analyse the narratives from the interviews, it was
necessary to have an accurate record of what was said. For this reason,
each interview was audio taped. The audio tapes were later transcribed
verbatim and yielded transcripts of between 6,300 and 16,300 words in
length. Professional transcriptionists were employed for expediency. This
was not, however, without its difficulties (see difficulties/ limitations).
Editing
The interviews were transcribed verbatim, as mentioned above. I then edited
each transcript myself. This was of great benefit, giving me opportunity to
listen to each interview several times, and engage with the narrative material
of each participant.
When excerpts of interviews have been included in the body of the thesis,
further editing has been undertaken. These changes have been made for two
reasons. Firstly, to protect the identities of the persons involved, and
secondly to improve the readability. As the participants have been assured of
confidentiality, the first is an obvious necessity. The spoken word is often
quite cumbersome and surprisingly unpleasant to read in the written form, so
I have made the decision, in this thesis, to “tidy” the stories of the
participants. The editing may include none, some, or all of the following in
each excerpt. Care has been taken not to alter the meaning of the story by
making these changes.
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Some examples of the editing include:
• Changing or omitting genders (e.g. of babies or doctors) where
possible
• Altering times and dates to protect anonymity
• Altering or generalising gestations of pregnancy/ birth
• Eliminating repeated words, unless appropriate
• Removing umms, arrs, etc
• Correcting obvious grammatical errors that make reading difficult
• Giving all participants, clients, and other persons pseudonyms
• Omitting names of institutions, or calling them the, this or a hospital
• Using the feminine pronoun for midwives throughout the thesis
• Altering the sequence as told, to the sequence as it occurred
• Placing an explanation given appropriately, where it was offered by
the participant either later or separately to the original comment or
statement
• Adding a word. This appears in square brackets, e.g. The baby was
4000 [grams].
• Adding italics to provide emphasis. It is noted in brackets beneath the
excerpt when this has been done.
Becoming Immersed in the Narratives As mentioned above, I like to think of my “data” as narrative material. It is a
tangible, vibrant and living product of persons interacting with others within
the world, and not an objective list of facts that can easily or reasonably be
reduced to a list of facts that we might label “data”.
Listening
The first opportunity for listening to narrative material is, of course, when it is
coming into being. So it is that my interpretation of each narrative began with
the first listening, as the story was told by the participant, whilst I
endeavoured, at all times, to be interested, attentive and engaged.
Distractions in the real life environment of the interview situation can make
this a little challenging sometimes (see limitations). Despite this, the stories
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usually captivated my interest quickly, providing the participants with an
audience that was truly “with them” as they conveyed their narratives.
A chance for a second listening comes with editing. Here there is wonderful
opportunity for hearing details. There is frequently a necessity to go over
some parts of an interview many times, so a familiarity is developed, and
there is a coming to know some parts of some of the narratives very well.
The time when one becomes really absorbed is from the third listening. Each
of the tape recordings was listened to several times, from beginning to end,
and then in parts also. Some called for more “listenings” than others, to allow
me to become truly immersed in the stories the midwives told. This allowed
me to gain a familiarity with the stories and their contexts, the tone and
tempo of the midwives’ voices when they spoke, and a beginning
understanding of the content.
Reading
Similarly to listening, there were several steps in the reading. The first
reading was of the transcripts sent back to me by the transcriptionists. These
were then edited as outlined above, with careful attention to the tape
recordings. Each of these readings increased my familiarity with the narrative
material. When editing was completed, each interview was read in its entirety
with the view of enhancing my understanding of the midwives’ stories.
At this time I was also starting to identify commonalities in the different
midwives’ stories. I could see some of Bruner’s (1991) features of narrative
within their stories, such as the fact that these commonalities were examples
of particularity – “tokens of broader types”. The ethical components of some
of the stories had also become very obvious. Some stories were read many,
many times. New meaning or a greater depth of understanding was
frequently discovered each time the narrative was visited.
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Computer Software Analysis
I cannot possibly say it any better, or more clearly, than Carter, who quotes
Dey who said, “computers can do many things, but they cannot think – and
we can. Unfortunately, that also means the thinking is up to us” (2004, p.
104), and then goes on to say that, “however sophisticated the qualitative
analysis software package you install on your computer, it won’t analyse your
data. The packages are good at some of the mechanical aspects of data
management but they don’t allow you to feed in your data, go for a cup of tea
and come back fifteen minutes later with the analysis complete” (2004, p.
104). My experience endorses his words completely.
For this research project I used a qualitative analysis computer software
package called N-Vivo (Version 2.0 – QSR International Pty Ltd) to assist
with the analysis of the narrative material. Although the program has a great
many functions, I used it primarily for coding the narrative material.
The interviews were all entered into N-Vivo and then manually coded. As
each area of interest was identified a new node was formed and sections of
an interview could be coded into that node. In all, 44 nodes were formed. The
table below shows the names of the nodes, and the corresponding number of
interview segments allocated to each node. Some sections of some
interviews, or overlapping sections, fitted into more than one node, and were
thus coded into both.
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Table 2 Names of Nodes and Number of Interview Segments in Each
1. achievement 22 23. good luck or good management 08
2. administrative pressure 38 24. good story 17
3. advocate 27 25. impact 32
4. anger 13 26. independence 13
5. blame/ fault 31 27. just/ unjust 11
6. caring 33 28. personal 16
7. challenge 18 29. powerless 28
8. choice or influence 27 30. professional development 38
9. collegiality 68 31. questioning practice 64
10. community 35 32. rapport 27
11. continuity (of care) 23 33. relief 07
12. dilemma 40 34. respect 66
13. disbelief 16 35. rewards 42
14. disheartened 29 36. shame 06
15. disrespect 34 37. stress 29
16. doctors 51 38. stress/ distress 32
17. doubt 36 39. support 70
18. emotional 21 40. trouble/ disturbed 46
19. empathy 09 41. understaffed 23
20. fear 28 42. understanding 46
21. frustration 52 43. unsupported 41
22. future of midwifery 35 44. vindicated 04
I was easily able to search for items electronically, and find the exact portion
of any interview transcript I wished, without laboriously searching through
hundreds of pages. It was also possible to view related stories side by side.
Yet another advantage was being able to look at all texts from a single node
to search for similarities, differences, and the number of midwives who had
mentioned something that had been coded into that node.
Interpretation
The coding, however, needed to be recognized as a fairly superficial type of
analysis. It separated the concept (emotion/ idea) from the “whole” stories. It
was in the interpretation and in putting the stories back together in their
context, piecing them together with the who, the where and the what, that I
began to make real sense of what the midwives’ had shared with me.
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As researcher, I was only able to analyse and interpret the narrative material
that was provided to me. On occasions participants shared stories with me
that included some definite statements, or the interpretation led to
conclusions that might be viewed as biased, controversial, professionally
inappropriate or somewhat risky. For the participants, the narrative method
provided a forum in which they were able to freely express themselves
without fear of reprisal. I have endeavoured, at all times, to be faithful in my
reporting of their stories. I note here, that I am analysing, interpreting and
reporting the stories of the midwives who participated in this research project.
The results necessarily reflect the narrative truth within the stories, and not
necessarily the events as they actually occurred. These two things may be
the same. They may not. Therefore, when I make a categorical statement in
the following chapters (e.g. “there was no indication for such an
intervention”), I am referring to the narrative truth.
Plausibility “Life must be lived forward, but it can only be understood backward” (Soren
Kierkegaard cited by Geanellos, 1996, p. 33). Narrative can help us to
understand our lives, as it helps us to form them. The very point of using
stories to undertake research is to arrive at better or new understandings.
These can influence the way we practise and, therefore, the care our clients
receive (Koch, 1998). We might say then, if we have achieved this end, our
research is good research. Although narrative research clearly can assist in
this process, storytelling and other types of interpretive knowledge have been
viewed, by some, as unscientific, uncritical and thus unacceptable. Even with
the proliferation of qualitative research across many disciplines in recent
decades, debate continues about the value of research that cannot be
judged by the same criteria as its older relative, quantitative research. The
latter claims to be stronger, verifiable, generalizable and reproducible; and
qualitative researchers search for ways to “prove” the quality of their work (H.
Smith, 2004).
It has been well established that validity, reliability and generalizability, the
standards for judging quantitative research, do not fit well when applied to
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narrative or, indeed, most qualitative paradigms (Connelly and Clandinin,
1990; Cutcliffe and McKenna, 1999; Riessman, 1993; H. Smith, 2004). Some
have tried to restructure these concepts to make them fit the qualitative
framework, and others have developed new models for assessing the quality
of qualitative frameworks. The qualitative researcher is seeking rich data, so
that he or she might reach a better understanding of the issue being
researched, or perhaps new knowledge, not generalizability (Koch, 1998;
Lüders, 2004).
Just as there are no absolute, clear cut guidelines as to how to do narrative
research, so that one might “know” how to do it; there are no clear criteria by
which to judge it, so that one can “know” what makes good narrative
research. In 1990, Connelly and Clandinin said, “It is currently the case that
each inquirer must search for, and defend, the criteria that best apply to his
or her work” (1990, p. 7). Eight years later, Koch informed us there was “no
agreed upon method for ensuring rigour” (1998, p. 1187) and fourteen years
later, H. Smith can only confirm the complexity of the matter, saying “it is
unlikely that one universally applicable checklist will ever emerge from the
debate. The best advice for now would be to select a checklist or set of
criteria that best fit your own perspective and are most appropriate for the
task” (2004, p. 149). Lüders comments “that although the list of standards for
qualitative research has now become very long, there is as yet no binding
consensus about what minimal standards must be adhered to”, and says this
is an “irritating state of affairs” (2004, p. 359). So, whilst there are now some
more formal options available to assess and critique qualitative research,
they are not, by any means, well defined. I would like the readers of this
project to judge it on the basis of the explanations and understandings it
reveals. I have sought to undertake a research project that displays the
following qualities.
The first three are apparency, verisimilitude, and transferability, which were
identified by Connelly and Clandinin (1990). The fourth is to question if the
research fosters growth, human flourishing or goodness. If so, it would be
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edifying. Research that has these qualities is, I opine, very valuable. This is
what I seek to achieve.
Apparency is a sense of something both seeming and feeling true, and is
frequently self evident. Stories that seem and feel false obviously do not have
apparency. Many of us are acutely aware when we are being “spun a tale”.
Of course, sadly, something can seem and feel true and yet not be so, which
is, for example, how some of the less ethical amongst us manage to deceive
an alarming number of people. Fortunately, most things that seem and feel
true to most people, are.
Verisimilitude, on the other hand, is when what is being said or presented
appears both true and probable. If something displays verisimilitude, it has a
life-likeness. As I have mentioned in a footnote earlier, there is no certainty
that a narrative conveys what actually happened, or tells things as they
actually were (i.e. that it is the truth), however it conveys “narrative truth”. In
this way narrative constitutes or creates reality rather than referring to it
(Bruner, 1991, 1994).
If research has transferability, it means that it fits with other situations or
stories of a similar nature (Connelly and Clandinin,1990). Koch (1998)
provides an example, telling us that transferability depends on how much
similarity there is between the two contexts. For this to be possible, a
storyteller obviously has to share enough about the context for the audience
to know if the story would be transferable. So, for example, in the stories
shared with me, that I now share with you, there needs to be sufficient
information for other midwives, or clients, doctors, administrators etc. to be
able to identify with the story and “see” that it is possible that such a story
could have originated at the institution where they work, or once worked – or
could occur in the future. Then, it would possess transferability.
Koch (1998) asserts that, if our research leads to the creation of vital stories,
this also addresses the question of rigour. I would like to suggest that this is
in alignment with my concept of stories being edifying. The way in which
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Koch describes a vital story brings it into focus as a complete, embracing
body of work. Vital stories, she says, provide context and information; they
involve emotion and engage their audience(s). Presenting many points of
view, these stories come to life. Such stories take time and creativity. When a
narrator involves others in their stories this way, actively seeking to include
relevant information, being contextually appropriate, true to the way things
were, or felt, or are open to their audience, the likelihood of sharing and
learning is high. Good things usually arise from engagements such as these.
A flow-on effect is quite possible. There is a likelihood that both intellectual
and moral growth would result from the learning and sharing, and that, in
turn, could result in personal and professional developments that would
ultimately benefit individuals (staff and clients) as well as institutions. Clearly,
if research provided vital stories that were contextual, engaging and
informative; that led to opportunities for sharing, learning and intellectual and
moral growth, it would be beneficial to the field researched. Time Frame The Interviews were performed, and thus narrative material collected, over a
prolonged period. This period extended from mid 2001 to mid 2004. No
interviews at all were undertaken between 1st October 2001 and 25th May
2003. Eight interviews were conducted in 2001, and seven in 2003/2004. The
large gap was due to researcher illness.
Difficulties/ Limitations Equipment Failure
The tape recorder did not always work, or did not always work well. In one
interview, the main tape recorder failed completely, and the back-up tape
recorder also failed. The end result was that only half an hour of the one and
a half hour interview was captured on tape. In some other cases the
recording is of such poor quality that, at times, it is impossible to know what
is being said, or even who is saying it.
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Interview Environment
As the interviews were undertaken at a time and place selected by the
interviewee, the researcher was unable to control the environment. This
sometimes meant that the conditions were not ideally suited to conducting an
interview. On other occasions it was virtually impossible to situate the tape
recorder in a place where an adequate recording could be made.
Despite the problems with tape recorders, and the distractions caused by
interruptions and background noise, a large volume of adequate to good
quality recording was obtained. A substantial amount of material was
collected, and it is from this that the transcripts mentioned above were
derived. The narratives for this research project have been drawn from these.
Long Gaps
Due to serious illness, there have been two long periods of extended leave,
and many shorter ones, for the researcher during the course of this project.
This has resulted in a sense of starting over, having to become re-immersed
in the project all over again. Coming to know and embrace the material
pertinent to my topic over and over again has been cumbersome and time
consuming. In other ways it has been very exciting and rewarding, as the
long time frame has given me the opportunity to see the field of midwifery
ethics expand so much. Just a mere speck on the page when my project
commenced, this vital field is now quite visible in the academic literature.
Self Selection
One way or another, most of the midwives in this research project, “self
selected”. It is possible, therefore, that those interviewed were a group of
midwives who were unusually interested in ethics, and not at all
representative of the “average midwife”. The results, therefore, may give the
impression that midwives are much more concerned about ethics than is
actually the case. This is not crucial though, as a representative sample is
only vital if results are intended to be generalizable, and this is not the aim of
narrative research. The findings presented in this project are not able to be
attributed to all midwives, everywhere. Although there is no warrant to
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generalize the results, they are potentially transferable to midwives and
midwifery settings other than those referred to in this study. It is quite
possible to engage in vital, enlightening narrative research when all
participants have self selected.
Transcribing Errors As mentioned previously, professional transcriptionists were employed to
convert audio tape recordings to text on paper. Several difficulties were
encountered with this. The first was that no single person was able to
complete all the transcriptions, so by the end of the project three different
transcriptionists had been employed, all using different styles, despite the
guidelines they had been requested to use, so there were inconsistencies in
the format of the transcripts.
Next, the transcriptionists employed were not familiar with the field of study,
and thus there were many words used that they did not know. A common
word in the interviews is primip (a first-time mother). This was frequently
transcribed as primate. Whilst the image of apes giving birth in maternity
wards all over south east Queensland provided a good laugh, it was not
particularly helpful. This was just one example of many words misheard and
thus incorrectly transcribed.
The problem of inaccuracy with the transcribing was an issue (with two
transcriptionists) to the extent that the editing became as big a task as the
typing would have been. Some of the inaccuracies made significant
differences to the meaning of the narratives, so the arduous task of fastidious
editing was a necessary and vital one.
Researcher Bias
In any research, the researcher brings prior understandings to the project. As
the researcher in this project, I have a particular view of midwifery and I
understand the practice from this stance. I also understand ethics in a
particular way. Some or all of these understandings are likely to be different
to the viewpoints and understandings of at least some of the research
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participants. It is noted that researcher bias can be viewed as a problem. In
qualitative research, however, it is considered acceptable practise to
acknowledge one’s biases and demonstrate, as appropriate, how any such
biases or assumptions might affect or inform the research (Cooper, 2006).
Morgan (2004) informs us that it is inevitable that a researcher’s values will
have some effect on the research that they undertake, and this can be at any
or all stages of the research. “There is growing recognition”, she says, “that it
is not feasible to expect the researcher to hold these feelings in check”
(Morgan, 2004, p. 49). Reflection by the researcher plays an important part in
both minimising and recognizing bias and its effects. Kennedy et al. (2004)
claim that, in qualitative research, where the researcher is the “instrument of
analysis”, it is actually an essential requirement that the researcher/s be
adequately prepared and bring with them to the research, perspectives that
will inform the process. I plan, therefore, to invoke the frameworks that I have
mentioned above to inform, rather than constrain, the research.
It is acknowledged that these pre-understandings could potentially have
influenced the research, particularly during the interpretation of the narrative
material. My interpretation of the narratives may not have revealed the
meaning intended by the participant(s). Clarification was sought during the
interviews to assist in reducing incorrect interpretation of the narratives. It is
important to note, however, that the construction and reconstruction of
narratives is influenced by the background knowledge of both the narrator
and the audience (Bruner, 1991). Also, Chase (1996) informs us that the
interpretations of narrator and audience are both to be valued, even though
they may not be the same.
In as much as it could have been seen as a limitation, my being a midwife
could also be seen as an advantage to the project. It is possible that the
participants felt a shared empathy, as I was “one of them” and this enabled
them to talk freely about their experiences, knowing I would understand.
There is also no certainty that my perceptions and beliefs about midwifery
are the same as those of the participants. This sense of belonging to the
same profession may have led both researcher and participant to make
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incorrect assumptions, compounding biases. This did not, however, appear
to be the case. What the participants shared with me resonated strongly with
my views of the profession.
My declared interest in ethics may also have made them feel more
comfortable, believing that, if I am studying ethics, I am bound to “do the right
thing”. Of course we cannot be any more certain of this positive effect than
we can of the possibility of the reverse. Suffice to say, that either one is
possible. Many of my personal beliefs and values affected the way I viewed
the participants and the narrative material that they provided. This would, I
believe, have been different if had I held a different value system. This is a
positive bias that was integral to the project, for it is these very values that
cause me to have a strong interest in ethics.
An interesting and very pertinent point made by Davidhizar and Lonser
(2003) regarding bias, is that it is important, with any story, that the audience
be aware that the narrator could, and most likely does, have some biases.
They inform us that storytellers “tend to tell events in a way that supports
their position and positive self image” (2003, p. 217), a fact acknowledged
also by Rosenthal and Fischer-Rosenthal (2004). Listeners need, therefore,
to be able to appreciate why people may add or omit some details from their
story-as-told, in the light of the bias. Regardless of whether we are
considering the researcher or the research, it is important that this be
recognised by researcher, participant and audience, for all of life is storied,
and each story is told and retold, interpreted and reinterpreted. Every time, it
is reborn, a new story, from a different storyteller’s perspective and, indeed,
with different intentions.
Conclusion Before moving on to the next chapter, I would like to share two quotes with
you. The first is from Jerome Bruner. He says
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The narrative gift is as distinctively human as our upright posture and
our opposable thumb and forefinger. It seems to be our “natural” way of
using language for characterizing those ever-present deviations from
the expected state of things that characterize living in a human culture.
… it is irresistible as our way of making sense of human interaction.
Bruner, 2003, p. 222
The next quote is from Boykin and Schoenhofer who offer insight into the
benefits of narrative for nurses.
The value of story begins with the insight and deepened understanding
practicing nurses can gain into the meaning of their own practice.
Nurses sharing their stories experience acceptance and a sense of
support, both in the telling and in the listening. Nursing stories are rich
data sources for research that is truly nursing inquiry.
Boykin and Schoenhofer, 1991, p. 248
We cannot exist without narrative. It is an essential part of our being and, as
such, it is a very sensible tool for research. The fact that story-telling helps us
to deal with the changes that occur in our lives, and centres on breaches of
canons, makes narrative a very pertinent mode of enquiry for this research
project. With human interactions being such a significant aspect of midwifery,
if our ability to narrate helps us to make sense of these, then the use of
narrative for research makes a lot of sense.
In this chapter we have explored narrative and what it can offer as a form of
research. Narrative was examined, in particular, in relation to nurses’ and
midwives’ stories, and the benefits that might be gained for midwives and
their practice. An explanation of the procedures utilized in the current project
has been provided, and I, as researcher, have situated myself within the
research.
In the chapters that follow, the focus will turn to the rich stories that the
research participants have provided. The stories in the next four chapters
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have been grouped in terms of the main relationship evident to me, as I
interpreted the story. This was usually the relationship or interaction that
caused or constituted the “trouble” in the story20. So it is that there are four
chapters about midwives. Utilizing their narratives, their interactions,
experiences and relationships with other midwives will be explored in
Chapter Three. Chapter Four will convey the findings regarding midwives and
the institutions they work in and administrations they work under, and in
Chapter Five we will turn to the midwives’ interactions, experiences and
relationships with doctors. The last of the Chapters examining the narratives
in this way will be Chapter Six. In this chapter we look at the people that
midwifery practice is all about – the families who are having babies. The final
two chapters, Seven and Eight, discuss the implications of these stories for
midwives and midwifery.
20 Bruner (1991, 1994) speaks of “trouble” when discussing the features of narrative. Trouble is caused when a familiar canon is breached. Thus, our narratives seek to restore or reform norms by dealing with the “trouble”, though this is not always achieved.
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CHAPTER 3 MIDWIVES AND MIDWIVES
They are playing one off against another which shouldn’t happen. It
should be more of a team, a team approach. But, I mean, nursing’s got
that, it’s always had that stigma where we eat our own. You know, we
do. We are the worst people to criticise our own, instead of working in
harmony. Mary
Introduction Midwives work with all kinds of people. Clients of course, the childbearing
woman and her partner; her wider family; doctors at all levels, from newly
trained to vastly experienced, public and private; cleaners, administrative
staff, ambulance service personnel, patient support persons,
physiotherapists, dieticians, social workers, security officers, food services
personnel, registered nurses, and other midwives. There are other people
with whom midwives do have to interact in their everyday work (eg.
policemen, firemen, radiographers), but this is an attempt at listing the people
a midwife might easily and often come into contact with during one shift. You
might be wondering why this is of significance.
The simple fact that midwives have a vast number of relationships to concern
themselves with regularly, every day, means that there are an exceedingly
large number of opportunities for “good” or “bad” situations to arise. Naturally,
not all of the people mentioned above need, or have, a significant amount of
interaction with all the midwives on a shift. Some midwives will not have any
contact at all with some of them on certain days.
The stories that were shared with me during the course of this research
centred mostly on the participants’ interactions, experiences and
relationships with other people. This is not surprising, for midwifery is a social
practice (Isaacs, 1993). The vast majority of these stories involved either
midwives or doctors. Other “players” involved were less dominant in the
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midwives’ narratives. This is with the exception of “they” and administration,
being one and the same, both of whom were frequent visitors to the
conversation. Clients did, of course, feature in some of the stories, but,
interestingly, not nearly as often as doctors, other midwives and
administration. It is for this reason that the midwives’ stories relating to each
of these groups will be examined over the next four chapters. We begin here
by looking at midwives’ narratives of their experiences interacting with
midwifery colleagues.
Setting the Scene Midwives generally work closely with their clients and, where appropriate,
with other midwives. The “Nurse’s Station” or central desk area is a great
place for bouncing ideas off other midwives. If a midwife is concerned,
uncertain, seeking another opinion, or simply wishes to share what is
happening in her “world” lest someone might have some pearl of wisdom to
share that might help her client and/or herself, she might discreetly tell her
tale at the desk to (an) appropriate colleague/s, and listen to whatever
suggestions might come forth. Many minds can make for better care.
The tea room is a sanctuary, a renowned meeting area for informal debriefing
after (or during) a busy shift or a tragedy. It is also a place of celebration,
where midwives gather when they have seemingly conquered nature and
come out victorious in a situation that seemed hopeless. It seems, in my
experience, that the majority of midwives are aware of their limitations, more
than willing to ask for help and advice, and readily share their trials,
tribulations and times of jubilation.
Unfortunately, however, as will be seen in some of the stories that follow,
midwives do not always support each other; nor do they always support the
best interest of the clients. This can sometimes make it difficult to ask for
help, or cause a midwife to be reluctant to ask for advice. Lucy told me about
one situation where she felt she had let her client down, because she didn’t
stand up against another midwife; and Irena tells of one nurse deliberately
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undermining another21. Conversely, Henrietta shared with me a wonderful
story in which two midwives worked together as one, communicating “in
silence”, knowing instinctively what each should do in the midst of a difficult
situation. Let us now visit these midwives (and others), in their respective
hospital settings and situations, that we might begin to grapple with some of
the intricate issues involving ethics in their everyday practice.
Look After Your Client My Way In this story, the midwife in charge of the Birthing Suite, by her actions,
seemed to imply that the midwife did not know how to provide appropriate
care for her client. She was, in effect, saying “I know better than you”. Lucy
was so eager to share this story of her midwifery experience that she began
almost as soon as I walked in the door. I asked her to slow down so that it
could be captured in the research context. It is now possible for this story of
interaction between Lucy, Susan (the midwife in charge of the shift), a doctor,
and Tara (Lucy’s client) to be shared again. Her eagerness spoke of
something. A need, perhaps, to share a burden she had been carrying. This
seemed to be a story that had been waiting for an audience. She said,
I felt that I had failed that lady, that I perhaps; but then I don’t know.
Sometimes I think I should have perhaps spoken up for her and then I
would have thought, you know, professionally, would it have been right
to do it there and then, in front of the woman, you know? Maybe I
should have spoken to the midwife in charge later on about it or
something like that. I did feel I should have spoken to somebody about
it. But then, who do you go to … Lucy
In just a few short sentences Lucy raises several very big ethical issues.
Feelings of failure, questions of professional responsibility, the issue of what
was right and wrong – both in terms of what was the best outcome for Tara,
and what her own response should, or could, have been. She expresses
21 Sometimes, particularly in Special Care Nursery (SCN)/ Intensive Care Nursery (ICN) situations, midwives have referred to nurses rather than midwives. I cannot be certain of the qualifications of the persons they were referring to, so have used the term that they used (i.e. “nurse”). Many SCNs and ICNs employ Registered Nurses as well as Endorsed Midwives as a matter of necessity to maintain adequate staff numbers.
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feeling that she perhaps should have spoken up for her client, spoken to the
midwife in question, and/or spoken to someone else about it. These raise
questions about her integrity, and of her covenantal commitment to her client,
which Issacs (1993) argues is an integral aspect of being a professional.
Lucy seems to be questioning her integrity because she has not managed to
uphold her own values – feeling, perhaps, that she has been untrue to herself
by not doing these things that she mentions (Beauchamp and Childress,
1994). Professions have a covenantal relationship with the communities they
serve, which means that members of a profession act in the interests of
others. “It represents”, Isaacs says, “a commitment to pursue the good of the
other in a context of gift, fidelity and trust” (1993, p. 5). Lucy feels that she
failed her client. This may be because she did not follow through on her
covenantal commitment. Could she have? We will see that she tried to. This
narrative provides us with an excellent example of the “everydayness” of
ethics in midwifery.
Lucy was caring for a multipara who was labouring well, keeping active and
coping well. In line with hospital protocol, Lucy had performed a “routine”
vaginal examination and reported Tara’s progress to Susan (the midwife in
charge of the shift). Susan asked Lucy if she had ruptured Tara’s membranes
– she hadn’t22. So, she was instructed to do so, to “get her going”. It was at
this point things started to disintegrate. Lucy said
I went back to the lady and I said that I was instructed to rupture her
membranes but, at the same time, did tell her that really there was no
indication, there was no foetal distress, foetal heart had been fine, all
her maternal obs had been fine, there was no indication at all. She was
progressing well. So we both decided between myself and the woman
herself that there was every good reason to leave her membranes
intact. When I went back out to the desk and the doctor was out there
with [Susan], and the doctor said to me, “Rupture her membranes and 22 Augmenting labour in this way (by rupturing membranes) usually causes a surge of hormones. As a result, contractions become stronger and longer much more rapidly than commonly occurs when labour follows its natural course. This also rapidly increases the intensity of the mother’s pain and, because of the suddenness, frequently a need for medicated pain relief arises. Augmentation can also lead to other complications and interventions (Shiers, 1999).
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get her going.” And I said, “Well, what indications are there? Why?”
“Because I’m a Medical Officer and I say.” Simple as that, so I walked
away and I went back into the room, soon to be followed by [Susan],
and she instructed my lady to get on the bed, take off her knickers, that
she was going to rupture her membranes, which she proceeded to do,
and the woman didn’t question it. She just did as she was told. I guess
she felt like I felt, we felt threatened by this woman. Just, this woman,
this midwife, just bursting through the door and speaking to her like
that. (italics added) Lucy
Lucy and Tara were caught unawares. They were both caught so totally off
guard that they just did what they were told by Susan, who had burst into the
room. As to who had really made the decision that Tara must have her
membranes ruptured, Susan or the doctor, is really of little consequence. We
know it was not Lucy, and it certainly wasn’t Tara (who should surely have
been the one to ultimately make the decision, particularly in the absence of
complications).
Lucy expressed feeling that she should have stood up for Tara, and for what
she believed to be both good practice and right for her client. At the very
least, she felt she should have spoken to someone about it. The trouble was,
she had no idea who to turn to. She was drawing, amongst other things, on
the ethical concept of advocacy.
Tara had put her trust in Lucy, and they had developed a relationship. “Even
though many cognitive and technical skills are required for the adequate
functioning of nursing practice, nursing can in no way be reduced to such
skills” (Gastmans, 1999, p. 215). The fact that nursing is relation-based
(Gastmans, 1999) is acutely evident within the specialized field of midwifery,
where people are at the exciting, yet vulnerable, point of life when they are
becoming the parents of a new baby – a rite of passage in every culture. If
we assume “good care” is what midwives are aiming to provide, it seems
obvious that Lucy would want to ensure that Tara received the best care
possible in the situation.
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The term “care” has itself been a widely debated issue amongst nurses and
within nursing literature. Whilst it is likely that there will never be an across-
the-board agreed upon definition of “care” or “caring” in the nursing context,
Gastmans (1999) does provide an excellent proposition. He says that caring
is a “morally virtuous attitude” that can generally “be considered as a specific
way of relating oneself to the other in a relational context, with attention given
to the maintenance and development of the other (patient) and oneself
(nurse)” (1999, p. 214). This way of understanding caring fits very well with
Isaacs’ (1998) concept of ethics as being other-regarding. In this view of
ethics, all persons are valued, worthy of respect, acknowledgement, and
having their interests taken into account – both the “other” and oneself. So, it
is fair to say that a midwife would reasonably have been expected to have
had a caring relationship with Tara, and that care would have encompassed
some morally virtuous attitudes. This, in turn, would lead the midwife to want
to do whatever would result in the “maintenance and development” of both
her client and herself. In short, she would be predisposed to do whatever was
the best course of action in her professional opinion. So, simply because
midwifery is a caring profession, Lucy (and indeed, Susan) might have been
expected to behave in a certain way. Further, any midwife would have
expected this of herself and this would have been the ethically appropriate
course of action. The fact that midwifery is a profession adds yet another
dimension.
Whilst the “fact” of professionalism is also debated by some, I am taking the
stand that both nursing and midwifery are, indeed, professions. Professions
have certain understandings, characteristics and obligations. These have
been outlined in many places (See, for example, Ervin, 2006) and, whilst
varying a little, professions can be identified as such by the following
features: they provide a practical service to members of the wider
community, demonstrate self governance, adhere to a code of ethics, have
members who are altruistic, and have a professional association. It is this
professional relationship that, Isaacs (1993) argues, leads to particular
responsibilities for the midwife. He informs us that the professional (the
midwife in this case) seeks to do good for the other (the client), without
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expectation of anything in return, in the context of a covenantal relationship.
As mentioned earlier, a commitment is made with the client to follow through,
in an attitude of gift, fidelity and trust. It is important to note here, that this
covenantal relationship applies collectively to all members of a profession, so
it would be equally expected of both Susan and Lucy, that they would seek
“good” for Tara in an attitude of gift, fidelity and trust. A client ought to be able
to trust their professional, as they work together toward a common goal.
Unfortunately, however, Lucy felt unable to support Tara when Susan overtly
overrode her decision. Lucy had a strong sense that she would be swimming
against the tide – a very difficult thing to do, especially when there is no sign
of the tide changing. This is what I sensed she was trying to convey when
she said,
they all pretty much think fairly similarly in that unit. It would be my
thoughts that are the different ones. So I decided not to do anything
about it.
I think if it was to happen again I probably would speak up a little bit
more. I think I was taken aback. I was probably a little bit shocked with
that sort of behaviour. So I think I’d be more prepared if it happened
again. But I do think that we do ultimately, yes, we need to be
professional, we need to work together as a team, but ultimately we do
need to be client/patient’s advocates. Lucy
Here Lucy draws us to a common problem for midwives. That of divided
loyalties. There is a need to be professional, as Lucy has stated, but what it
really means to be professional is not always straight forward. It is important
to consider what “professional conduct” requires. In light of the discussion
above, midwives clearly have an obligation to their clients. However, must
they support their colleagues? Is there an obligation to follow instructions
from senior colleagues and doctors or, indeed, is there an obligation to
challenge them, in the interest of clients? What of the relationship entered
into with the client/s? What should a midwife do when commonly practised,
“routine” procedures are simply not going to benefit the client/s in her care?
Perhaps she knows of research that supports her position, but hospital
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policy, or more senior colleagues and/or persons in positions of power do
not. Can she, should she, must she challenge the continuance of the practice
(or absence thereof)? If she decided to do this, how would she go about it,
what would be the correct forum in which to voice such issues, who would be
her intended audience? Maybe she simply wants to support the client’s
decision and there is no harm in doing so, but those “above” her, whether
people or policy, put obstacles in the way. To be ethical, a response is
necessarily being called forth. To survive the system, silence is sometimes
more prudent. Of course, such silence may well not serve the best interest of
the client.
“Divided loyalties” can present very real dilemmas to midwives. L. May talks
of “conflict of interest” and says that “The idea that professionals should
serve “virtually total[ly]” the interests of their clients is at best unrealistic and
at worst deceptive” (1996, p. 131). Apart from anything else, it makes an
assumption that the professional knows what the client’s best interests are,
and this itself could lead to an infringement on the person’s autonomy. It also
means that the professional may have to deceive themselves and/ or the
client regarding their own interests and intentions. L. May uses the examples
of lawyers and real estate agents wanting to earn money, and doctors
working for health maintenance organizations (HMO) having to save money,
to show how professionals may not be serving their clients optimally. For the
lawyers, they serve their client well, but they want a good income in return.
The real estate agent finds a good buy for the house hunter, but gets an
excellent price for the seller, thus ensuring a high commission for themself.
The doctor tells the patient they are getting all the tests and keeps the HMO
happy by ordering the least possible or cheapest approved treatments, but
the patient may not be getting the best or most appropriate care available. In
the case of a midwife working in a hospital setting, this might mean allowing
the client to do as she wishes, so long as no-one has to “break the rules”,
either formal or informal, to facilitate her needs. The midwife does not want to
“rock the boat”. The client possibly gets less than optimal care, but the
midwife survives another day.
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Lucy tried to recall how things unfolded. I think she [Tara] sort of gave me a look of, “Oh, you know, well we’re
doing it sort of thing”, but I think she knew how I felt. I knew how she felt
and it was just like we just really, I don’t even recall. … maybe just a
few words were exchanged, like, “I’m sorry that had to happen,” or
whatever … we didn’t discuss it in depth really. Because I sort of felt
that, you know, maybe the way I was feeling I wouldn’t want to sort of
come across unprofessional. I wouldn’t want to bag the other midwife or
the doctors. It was a hard position to be in. You’ve got to try and act
professionally, at the same time being the patient’s advocate.
Sometimes it can be hard, you know, and you’ve got to weigh up what’s
more important: being a patient’s advocate, or being popular with your
colleagues, a bit of faith in what you believe to be right. Lucy
Whilst silence may have seemed to be the better option at the time, Lucy was
left with feelings of guilt and uncertainty. A study by Fagermoen (1997) is
able to shed some light on why Lucy may have been feeling this way. This
study looked at the professional identity of nurses in terms of the values that
they held. Fagermoen found that nurses had moral (other-oriented) and work
(self-oriented) values that underpinned their professional identities. Altruism
was the overarching moral value, with human dignity as a core value. Nine
other values were linked to human dignity23. She says that “values are
inherent in developing and sustaining professional identity and are expressed
in nurses’ actions in relation to others” (1997, p. 436). It could be that, by
remaining silent and not doing what she thought best for her client, Tara,
Lucy was failing to uphold values that she believed were important, such as
human dignity, trust, privacy, autonomy etc. Thus, her own beliefs and values
were challenged, and her professional identity threatened.
Hunter (2005) also has something to offer that may explain Lucy’s situation,
and her discomfort. Hunter’s study found that the relationships midwives
have with their colleagues were particularly important. Yet, they were not
easy relationships to maintain. Frequently sources of conflict, they required a
significant amount of “emotion work”. Junior midwives rarely challenged the
23 The other nine values are: Trust, being a fellow human, personhood, security, integrity, humanity, privacy, autonomy, and hope (Fagermoen, 1997).
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authority of senior midwives, who asserted that authority by a claim to greater
experience and a need to uphold unwritten rules. It was found that the more
junior midwives who were trying to uphold a “with woman” (client centred)
approach were presenting a destabilising “problem” to the institution and
needed to be brought into line with the hospital culture. As Hunter says,
“Newly qualified midwives were still required to ‘play the game’ and comply
with the wishes of seniors” (2005, p. 263). Although Lucy was not a junior
midwife, she was working in a position answerable to Susan, and Susan
certainly asserted her ability to override Lucy’s decisions regarding her
client’s care provision. The fact that midwives have ideological differences is,
to some extent, inevitable, but in the absence of risk, a client’s wishes should
be a primary consideration. As Hunter (2005) notes, the emotional well-being
of midwives is being affected. The likely impact of this is that client’s care will
be compromised – just as Tara’s was.
From the Literature Mercedes Perez-Botella and Soo Downe (2006) present an excellent storied
example which draws our attention to many of the things I have mentioned
above. Other than the details of the situation that Mercedes found herself in
with the client she was supporting through labour being different from those
Lucy had to contend with, the experiences they relate are remarkably similar.
As audience and interpreter of both Lucy’s and Mercedes’ stories, I sensed
that issues and feelings present in both could virtually have been transposed.
Mercedes had been caring for a woman, in a hospital based unit, throughout
her labour. It was customary to notify the midwife in charge (given the
pseudonym Karen) when a client was ready to start pushing. Mercedes did
so. Karen soon entered the room and proceeded to take over. Lights were
turned up, the “calmed atmosphere” that had been “created in partnership”
was cast asunder and, “Throughout the second stage, the author was
extremely uncomfortable with the situation, she recalls stepping back and
staring at Karen while she shouted at the top of her voice” (Perez-Botella and
Downe, 2006, p. 597).
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The article in which this story is related is titled Stories as evidence: Why do
midwives still use directed pushing? (Perez-Botella and Downe, 2006).
Clearly the focus of the authors is on the fact that the senior midwife did not
practise according to the best available evidence, as was also the case in
Lucy’s story. This is doubtless a significant part of what created the tension
for both midwives. The article also draws our attention to all the ethical issues
that Lucy faced. In both stories, the midwife felt unable to speak up once
confronted in the room, by the midwife in charge, in the company of the
labouring woman. Also, in both cases, the midwife and the labouring woman
felt a sense of disbelief. Both Lucy and Mercedes felt guilt, and both actually
said they had “failed” the woman. Mercedes was left “disillusioned, frustrated
and upset” and feeling that she had not acted appropriately as her client’s
advocate when it was needed (Perez-Botella and Downe, 2006, p. 598).
Similar feelings were expressed by Lucy.
The Challenge Professional etiquette demands a certain amount of agreement, certainly with
one’s superiors, absolutely in front of clients. After all, being a part of a
profession means that we are part of a social practice. This in turn means
that we share a culture, common knowledge, and a covenantal commitment
to care for those our profession exists to serve – in a context of gift, fidelity
and trust (Isaacs, 1993). In light of this, one could reasonably assume, it
would not usually be difficult for colleagues to agree on matters relating to
clients’ care. What should a midwife do though, when another midwife or a
doctor suggests or demands an action that the client they are caring for does
not want or, in their considered professional opinion, need? They are stuck
between a rock and a hard place. Ultimately, a midwife has to turn around
and come back tomorrow. They need to be able to keep working with the
same colleagues day after day. How does a person do that if she ruffles
feathers every day? However, she also has to live with herself every moment
of every day. How does a person do that if she hasn’t been true to herself?
Not speaking out for what they believe to be right, what is best for their
clients in this case, may threaten a midwife’s professional identity
(Fagermoen, 1997), her emotional well-being (Hunter, 2005) and her integrity
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(Beauchamp and Childress, 1994). This can lead to job dissatisfaction and
even fragmentation of the self (Beauchamp and Childress, 1994; Hunter,
2005; Kinnane, 1996; Fagermoen, 1997).
Sadly, it is possible to see some evidence of this in Lucy’s words,
I think I have conformed to some extent, again we’re talking about just
to keep the peace and, you know, to try and keep my place in the team
there and try and be professional, I think I’ve had to conform. Umm, it
makes my job less enjoyable because I feel that I’m refrained from
being myself to some extent, umm, yeah, yeah. I just feel like yeah it’s
not the same, it’s not like, it’s not like where I trained where midwives
were able to discuss things (italics added) Lucy
We can recall that, initially, Lucy did not do as she was asked, when told she
should rupture Tara’s membranes. Rather, she discussed it with Tara, and
they decided it was not necessary. Lucy was concerned about the way things
happened, and she wondered if she should have, at some stage talked to
Susan, saying, as we read earlier,
Maybe I should have spoken to the midwife in charge later on about it
or something like that. I did feel I should have spoken to somebody
about it. Lucy
She did not, however. Instead, she has conformed, refrained from being
herself, and enjoyed her work less. This seems to raise more questions than
answers, and it may be that recognition of the complexity of the situation is
the beginning of the answer. Perez-Botella and Downe tell us that midwives
“need to be more assertive and defend the care that they believe is best”
(2006, p. 598). They, and Hunter (2005), have acknowledged that this can be
incredibly difficult in institutional environments, where power and policy
sometimes work together against the midwife trying to exercise autonomy on
the woman’s behalf. Chiarella (2000) opined that whether a nurse’s voice is
likely to be heard or not is more dependent on the strength of her personality
than the strength of her argument. Although Chiarella was discussing nurse-
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doctor interaction, I suggest that this statement can be easily transposed to
any situation where a power relationship exists. In the two stories above, the
senior midwives and doctor clearly overrode the wishes and desires of both
junior midwives and clients whose voices were well and truly silenced. The
more senior parties would do well to heed the words of C. Thomas, who said
“Respect is a two way street and applies to everyone you work with” (2005,
p.25).
Sharing the Load Henrietta shared an experience that was in stark contrast to those of Lucy
and Mercedes. Henrietta narrated a wonderful story of two midwives working
together with a client, each understanding the situation, “speaking” to each
other without words. A special type of understanding was shared, enabling
the midwives to work together as a team. The result was midwives who
retained a family-centred calmness and composure throughout a very difficult
birthing situation24. Part of the story was related to me this way.
I always remember almost one of my first deliveries as a midwife. That
was an unknown IUFD which was obviously stressful for everyone
involved, but to give you a picture of the whole situation, this woman
had arrived just at handover time in the morning, 6.30 I think it was. And
I was on the morning shift, and it was her fourth child and she’d
ruptured her membranes at home and had, you know, clear liquor and
so she was waiting and waiting and basically she hadn’t been put into a
room, no-one had seen her and no-one had spoken to her. And
immediately at handover she started feeling some pressure, so we took
her straight into a room and you know went through the normal process
of having, talking to her and doing a palp umm, trying to palp real hard,
which we couldn’t do. Then we examined her to put on a foetal scalp
electrode and popped that on and got no response from that and by this
stage she wanted to push. So I think the stressful part [the mother] not
just knowing what we know – at this stage she was pretty much
unaware that the baby was dead, so the question I suppose in the back
of my mind and the other midwife that was with me, was, what do we
do? And without, sort of conferring much at all we both seemed to
24 Henrietta’s story involved an undiagnosed intrauterine foetal death (IUFD).
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agree that we would go through the process of having the baby. … the
other midwife called [the doctor] to come to the delivery. She’d informed
him outside. So we delivered the baby, head came, once the head was
delivered, then we started to give her some information, I suppose, ‘that
the cord was very thin and friable, and pulseless’ and once baby was
out we clamped and cut the cord and baby went straight to the
resuscitaire which was right beside the family and then we started
feeding back more information to her. So I suppose that sort of extreme
sort of hangs around with you for a while.
…you have to read what you think is the sort of the right sort of moral or
ethical position to take, whether you say before this lady’s had… this
baby that you think the baby’s dead, or do we let her have her baby and
find out that it’s dead. I mean she doesn’t really have a grieving time,
like you, like [it’s] not that you can go and sit down and discuss it
beforehand but [you have] to make a decision sort of fairly quickly.
…We debriefed the staff that were involved and I think we’re all fairly
happy with the way the situation went as far as we were concerned.
Obviously I don’t know how, you never know, what could have been or
would have been.
I think the reassuring part of the whole incident is probably that the
other midwife, who was very experienced, without us even conferring,
we both, you know, presumed that that’s what we would do.
(italics added) Henrietta
Let us call this mother Una, for I’d like her to have an identity. Although this
chapter is about the relationships between midwives, I am keen not to lose
Una in the process. Her story has much for us to ponder. Unfortunately, she
arrived at the hospital at handover time. Thus, she was asked to wait. It is my
understanding that it is usual practice for someone arriving in labour, at most
maternity hospitals, to be seen by a midwife pretty much straight away,
unless all the midwives are simultaneously occupied. Shift change, handover
time, is the most likely time that this would occur. Her wait did not change the
outcome, but it may have changed the way her baby’s birth was handled.
The death of her baby would have been discovered a little sooner, giving a
little more time for decisions about whom to tell and how to inform them.
More time may have been helpful, perhaps, to prepare Una and her partner
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for the fact that their baby would not be born alive. Regardless, we are talking
about minutes, not hours. It is impossible to know what might have been.
When Henrietta commenced caring for her, it was soon discovered that
Una’s baby was not alive. Una did not know, her partner did not know – but
Henrietta and Vera (the other midwife) knew. Somehow, in an intuitive, silent
understanding, Henrietta and Vera agreed not to tell the parents, but to let
the sad news unfold as the birth continued. They fell into appropriate roles
and did the right things at the right times, without having to discuss who
would be doing what. Although this birth story is quite obviously a very sad
one, and has what I call a “haunting” quality (that is, it remains with a midwife
for many years – as Henrietta says, it “sort of hangs around with you for a
while”), it has a curious twist.
Henrietta conveyed a story about events, feelings and interactions whilst
working with a colleague, just as Lucy did. There are, however, some
significant differences between these two stories and their outcomes. As
audience, I perceive that Lucy’s relationship with Susan was strained. She
felt unsupported, overpowered, and threatened by Susan. Although the
labour/ birthing situation was, as far as we can tell from the information
available to us, quite normal, this became a negative experience for Lucy,
and possibly for Tara also, because of the nature of Susan’s behaviour and
interactions with them.
Henrietta, on the other hand, recalls good things. Although it was a sad
event, and is remembered, in part, because of that, in many ways it was a
positive experience. Henrietta was in the midst of a heartbreaking, real life
tragedy. The way in which Vera worked with Henrietta, just knowing what to
do, knowing what had been decided, knowing that Henrietta had decided to
go ahead and allow Una to birth her baby without telling her first that it had
already died –made a bad situation good. There was a shared understanding
and empathy. It was still sad and stressful, but the supportive relationship
made it workable. Vera and Henrietta had a completely different kind of
relationship. Whereas a requirement of professionalism disabled Lucy, who
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was, in effect, silenced in front of her client, professionalism enabled
Henrietta and Vera, giving them a shared understanding and protocol to
follow seamlessly in a time of trouble.
Ethics on-the-run This story also brings forward an important point about ethics in midwifery
practice. Quite apart from its “everydayness”, ethics often has to be “done on
the run”. Midwives face many different, often difficult ethical situations
everyday and many decisions have to be made. Some are small and
seemingly inconsequential, whilst others are obviously much more
significant. It can present a dilemma when a decision has to be made quickly,
as in the position in which Henrietta was placed with Una. Henrietta summed
up the problem very concisely in the simple statement, “ [It’s] not that you can
go and sit down and discuss it beforehand”.
After it is all over, of course, there is often the “meeting in the tea room.” It is
not an official meeting by any means, it is just the long awaited meal break,
with all the people involved around the table saying things like, “We did that
well”, “My goodness, what a mess”, or “What went wrong there?”. In a
supportive environment, discussion follows and those who have been
fortunate enough to make it to the meeting leave feeling that they have had
many questions answered, and their decisions have either been affirmed, or
they know how to make better ones next time. Ethics in action is not always
easy, but it is always an opportunity for learning. That is not to say, of course,
that such opportunities are always embraced.
All of this serves to reinforce the importance of all midwives having a
thorough understanding of ethics – of their own values, the place of ethics in
their practice, and some idea what to do when confronted with choices or
decisions – and I’d like to suggest that they should “know” how to choose
“right” or “good” over “wrong” or “bad”. In Western societies, most, if not all,
nurses have now been exposed to ethics in some measure within their
practice. In Australia, as in many countries, nurses and midwives have a
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Code of Ethics25 which they are either expected, or required, to follow. As the
education of nurses and midwives has moved from hospital to university
based settings, formal education about ethics and its application in practice
has been introduced. Both of these innovations are positive steps toward
aiding midwives when having to do “ethics on the run”.
Principlism, a form of ethical reasoning drawn from medical ethics, has been
very commonly taught to nurses. This is evidenced by its presence in many
nursing ethics texts (see, for example: A. Davis, 2006; Fry and Veatch, 2006;
Johnstone, 1989). It is based on the use of the following four principles –
respect for autonomy, beneficence (do good), non-maleficence (do no harm),
and justice (fairness). Beauchamp and Childress (1994) have discussed
these principles in detail and there is no doubt that they can be very helpful in
assisting persons to make ethical decisions. However, the principle-based
approach to ethics has limitations.
One of the more obvious limitations is the fact that, sometimes, one has to do
harm in order to do good. Caesarean section is an example of this, where
surgery is inflicted upon someone in order to birth a baby due to
complications that have arisen during the course of labour. Surgery of this
type results in pain, causes injury to muscles and skin, interferes with normal
bodily processes and has many associated risks. However, caesarean
section is performed, in this case, to maximize the safety of mother and baby.
Thus, the harm is necessary to produce the good - that good being the
ultimate health and well-being of mother and child. Another example where
principles can confound matters is when a person’s autonomous decision, for
reasons of insufficient information or unsound mind, might be harmful to
themselves or others – so it would be unwise to respect their autonomy. An
example of this could be found when a mother in the above situation refuses
to have a caesarean because she is afraid of surgery, perhaps not fully
25 For midwives this is the Code of Ethics (ACMI, 2001). For nurses the corresponding code is the Code of Ethics for Nurses in Australia (Australian Nursing Council [ANC], Royal College of Nursing Australia [RCNA] and Australian Nursing Federation [ANF], 2002). Midwives are expected to follow the guidelines provided in both codes.
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understanding the implications of her decision for herself and/ or her baby.
Thus if her autonomous decision was to be respected, both mother and baby
could be at risk. As with many midwifery situations, these scenarios involve
an unborn child. The position and rights of the unborn child are contested
and continue to be debated (Jones, 2000). It is not the aim of this thesis to
enter and contribute to that debate. The particular examples used, however,
are, in part due to the uncertain rights of the baby, very challenging for both
ethical and legal reasons (Frith, 1996; Jones, 2000). Despite their limitations,
a sound knowledge of autonomy, non-maleficence, beneficence and justice
would certainly benefit a midwife endeavouring to make a “good” or “right”
decision.
Being well and truly au fait with up to date practices would also assist
midwives to practise ethically, as this next story, also shared by Lucy,
demonstrates very clearly. It is another example of a situation where
decisions have to be made on the spot. No time to think, only time to do.
Consider, as you read, the many fleeting relationships that enter into this
picture. Remember, as you do, that at any junction where two or more people
meet, we have an ethical encounter (J. Thompson and H. Thompson, 1996).
Look After My Client Your Way
I can remember one night; there was myself and a midwife who’d been
there for a long, long, long time, and an agency midwife. On night
duty… you have ten women each. The agency midwife had a [20-
something] weeker lady who was in, supposedly, early labour. They
sent her up to the Labour Ward, she was given pethidine and sent
straight back out to the ward. The agency midwife said to me about six
o’clock in the morning, “oh, my lady’s back from Labour Ward, but she’s
saying she wants to push”. I’m saying, “well she probably should be in
Birth Suite, transferred if she wants push”. Anyway, I was going down
towards that way anyway because I had to do something else down in
the treatment room. The lady who was sharing the room with this [20-
something] weeker came back and says “I think you’d better come in.
This lady’s making a noise”. Now I didn’t know anything about this
woman really, except that I wasn’t looking after her, the agency midwife
was, and I get there and this lady says, “I want an epidural”. And I said,
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“Oh, really”. Anyway, I felt her tummy. She was contracting big time,
she said she was [20-something] weeks and she’d just been to Birth
Suite and had pethidine. She was starting to push. I could tell she was
pushing. I said, “Right. Let me just have a look down here”, took off her
undies, vertex, that much. (shows several centimetres with hands).
Anyway, I said to the lady next door, I tried to keep my calm about it,
“Well, darling what was your name?” “Oh [Wendy],” she says. “[Wendy]
darling, see where the sink is, there’s a little red button up there, it says
“Emergency”, can you just press that for me?” She goes and presses it
for me. I said to this other lady, “What’s your name?” She told me. “I’m
[Lucy].” I said, “You’re going to have this baby right here, right now.”
The emergency button’s going off; by the time everyone gets here this
baby’s in my hands. The baby, [20-something] weeker cried,
spontaneously, beautiful. Surprising, with Pethidine. We were just
giving it some facial oxygen … I had sent this girl who was sharing the
room … to get me a hot bundle, you know blankets, I said, “Look,
darling [Wendy], can you just go round the corner, there’s a hot box, it
looks like a fridge, just get me a couple of blankets and towels and
stuff”. She was getting all the stuff, because there was no-one else
around, I was on my own. I was on my own.
… and here’s this [20-something] weeker. … I’m trying to look a bit cool
getting everything ready. I thought, “This baby’s coming anyway, there’s
nothing that anybody can do”. There’s no use panicking, it’s coming.
So, the girl next door is helping me and by the time the baby’s born
everyone’s there, we’re giving it some oxygen. … I said, “Just take the
baby and run, run to the resuscitaire,” – and they took the baby and
they ran; and I sorted this lady out and it [the baby] went to special
care, but it was fine, it was fine. And this lady said to me, “Thank god
you knew what you were doing, because nobody else in this bloody
hospital knew”. Because she’d been mucked around in Labour Ward,
the agency midwife didn’t believe her when she said she wanted to
push. I said to the agency midwife…, you never ignore a [20-
something] weeker… But you know it all worked out fine, everything,
you know. But oddly enough the midwife who had been working there
for twenty odd years, she was the one who panicked, absolutely
panicked. She was standing at the end of the bed going “What will I get,
what do you do need, what do you want?” They’ve got to know for safe
practice. For safe practice, they’ve just got to know what to do. In that
case there’s nothing, there’s no use panicking, this baby’s coming, yes
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it’s a [20-something] weeker, but, you know, you just have to catch it, all
you have to do is catch the baby and you know, resuscitate it. …
Everything worked out well in the end, you know, but, maybe it couldn’t
have. You know what I mean? Lucy
We have an unusual story here. Unusual, that is, in that it conveys an event
that is truly unique. Yet, I am sure, similar events have occurred elsewhere.
This brings to mind the feature of narrative that Bruner (1991) calls
particularity. Although many stories are of a similar type, that is, the same,
their particulars, the details about any given story (or this one story), make it
unique. Even though there have doubtless been many premature babies
surprise midwives by their rapid entry into the world, in unexpected places, at
inopportune times; only this baby came after this dose of pethidine, in this
ward, when Lucy had had a chance meeting with Wendy, when she
wandered down the corridor early in the morning, after speaking to agency
midwife, Angie, who just happened to have briefly mentioned that this
particular client had been feeling like pushing. These features (and others)
make this story unique.
If we recall and think of Bruner’s (1991, 1994) fifth feature of narrative,
canonicity and breach, it is easy to see why this is such a good story. It is not
frequent for a lady to give birth in the ward, the vast majority of births occur in
Birth Suite (Labour Ward). Breach #1. Premature births are also not the norm
– people expect their pregnancies to go to term. Breach #2. Usually,
midwives pay a lot of attention to people who say they want to push – the
agency midwife apparently did not. Breach #3. Clients are not regular birthing
assistants, as Wendy was in this case. Breach #4. The midwife who had
“been there for a long, long, long time” – the person with (presumably) a
wealth of experience and knowledge, panicked and didn’t know what to do.
Breach #5. Norms were being scattered to the winds. There was nothing
normal about this morning.
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Can the Code Help? What are we to make of these encounters? To elucidate the situation, I’d like
to refer, in the next few paragraphs, to the Code of Ethics for Nurses in
Australia (2002), which was developed under the auspices of three prominent
nursing bodies – the Australian Nursing Council [ANC], the Royal College of
Nursing, Australia [RCNA], and the Australian Nursing Federation [ANF]
(hereafter referred to as The Code). It was first developed in 1993, revised in
2002, and is again under revision. Codes of Ethics, Codes of Professional
Conduct, Codes of Practice, Scope of Practice documents, written
Frameworks and Guidelines26 are becoming commonplace in many
professions, and midwifery is no exception to this. They have become so
abundant in fact, that some people find them burdensome. Of course the
intent is that they be useful tools for safe, appropriate practice, not a
hindrance. Much has been written on the potential benefits and the inevitable
limitations of such documents (Beauchamp and Childress, 1994). Though
not definitive, they can be, and are, useful if people are actually aware of,
and understand, their content.
The story which Lucy has shared provides an opportunity to apply The Code
to a real-life situation. First, Lucy meets agency midwife, Angie, in passing. A
brief interaction alerts Lucy to the fact that something is happening with
Angie’s client (whom I shall call Yasmin), who is a 20- something week
pregnant mum-to-be, supposedly in early labour. She has had Pethidine. She
wants to push. This usually means baby is on the way. Soon. Angie doesn’t
seem too concerned though. At this point, what should Lucy’s response be?
Yasmin is not her responsibility. Nor is Angie, she is a fully qualified midwife.
She hasn’t actually asked for help or advice. Lucy simply states the obvious,
that someone who wants to push would be best cared for in Birth Suite, and
this is all the more so if they are about to give birth to a premature baby.
Premature babies have an increased likelihood of requiring emergency care
and resuscitation compared with full term infants, so a controlled environment
26 A few examples for midwives include the following: Code of Ethics (ACMI, 2001); Code of Professional Conduct for Nurses in Australia (Australian Nursing and Midwifery Council [ANMC], 2003) and National Competency Standards for the Midwife (ANMC, 2006).
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with maximal access to necessary medical and nursing care, equipment and
medication is definitely preferable for their arrival into this world.
Value Statement 3 of The Code says “Nurses promote and uphold the
provision of quality nursing care for all people” (p. 8). In the light of this
statement, did Lucy have some sort of responsibility to do more that just state
the obvious? Explanatory Statement 1, under this Value Statement, says
“Quality nursing care includes competent care provided by appropriately
prepared nurses.” My interpretation of this would lead me to believe that
Angie (the agency midwife) was responsible for Yasmin. She had the
training, qualifications and, presumably, the knowledge to provide the care
that Yasmin needed.
Angie informed Lucy that Yasmin had had Pethidine and wanted to push. As
it turns out this was fortuitous; however, why did she tell her? From the story
we have, there doesn’t seem to be any reason. Value Statement 4 of The
Code says “Nurses hold in confidence any information obtained in a
professional capacity, use professional judgement where there is a need to
share information for the therapeutic benefit and safety of a person and
ensure that privacy is safeguarded” (p.9). Did Angie unnecessarily breach
Yasmin’s confidentiality? If she was not seeking advice or assistance, then
she probably should not have told Lucy anything at all. If she was actually
concerned about Yasmin and seeking help or advice, should she have
provided more information and been more direct in her approach? With the
benefit of hindsight, this clearly would have been helpful. Lucy did not “hear”
her call for assistance, if it was there.
Lucy happens to be heading down the ward in the direction of Yasmin’s
room. Wendy appears asking for help because Yasmin is making noises.
Lucy follows Wendy into the room and, at that point, Lucy’s responsibility
toward Yasmin changes. Lucy, Yasmin and Wendy then proceed to assist a
very premature baby into the world with as much cool, calm and decorum as
one can muster in a public ward at six in the morning with emergency bells
ringing. As Yasmin had been given a dose of Pethidine, Lucy was concerned
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that her baby may not breathe at birth. Of course, with a premature baby,
there is always that risk, even in the absence of Pethidine. Six o’clock is a
very busy time in the ward, with all the mums and bubs waking for their
morning feed. Wendy is doing a champion job, gathering warm wraps and
towels from the appropriate warming cabinet as instructed. Then
“experienced midwife” arrives asking what she can do when Lucy is literally
holding the baby.
The Code’s Value Statement 1 says “Nurses respect individuals’ needs,
values, culture and vulnerability in the provision of nursing care” (p.6). When
Lucy met up with Wendy in the hallway, and then entered the room she
shared with Yasmin, she also entered into a relationship with both women.
She was now with not one, but two exceptionally vulnerable persons. The
Code tells us to respect individuals in all sorts of ways; their needs, values,
culture and vulnerability. It also tells us, in Explanatory Statement 4, that
“Respect includes the development of confidence and trust in the relationship
between nurses and the people for whom they care.” Somehow, in the midst
of this emergency situation, Lucy needed to gain the respect and trust of
these two women that she had never even met, so that they could work
together as a team to safely birth Yasmin’s baby. They had only each other
to rely on in that moment, before other help arrived. Some babies come into
the world very quickly when they decide it’s time, and this was definitely
going to be one of those babies.
It is significant that Lucy used names. Names are important. They give us an
identity. A name, when it is used, lets its owner know that he or she has been
seen. It is an acknowledgment of their presence and a connection is made.
We respond so much better to our own name rather than to “you there” or
something of that nature (Goins, 2004). The use of a name is not just a polite
gesture, it fosters trust, is other regarding and it is relationship building. By
engaging the “other”, the use of a name, in this context, is an ethical
consideration. Further more, it frequently elicits the desired response.
Cookson repeatedly urges teachers to learn their students’ names, as they
are “very sensitive about being recognized and knowing their names is the
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surest indication that they are visible” (2003; 2004, p. 77). Surely all people,
especially those in vulnerable positions, deserve this simple sign of respect –
and it can work to the advantage of all involved as we feel valued and
respond better and more quickly to each other’s needs. It is, of course, quite
easy to use a name in a disrespectful manner, deliberately not engaging the
“other”, and, indeed, to instil fear rather than to build trust. Other instruments
of language such as tone and gestures add much to the meaning of our
words. In this situation, it was vital for Lucy to gain both Wendy and Yasmin’s
trust immediately. Names, shared in a calm manner, were a positive, helpful
and logical starting point to begin.
Lucy also remained calm. She explained what she was doing, providing and
requesting information for and of Yasmin as she was doing things, fostering
trust in her capabilities to handle the situation. She kept her fears to herself,
doing whatever had to be done. The Code says that, “Nurses fulfil the
accountability and responsibility inherent in their roles.” (Value Statement 5,
p. 10). Explanatory Statement 1 clarifies this further by telling us that, “As
morally autonomous professionals, nurses are accountable for their clinical
decision making and have moral and legal obligations for the provision of
safe and competent nursing care”. Once she met Wendy, it would seem that
Lucy had an obligation to tend to both Wendy and Yasmin’s needs, until
further assistance arrived. This was necessary to ensure that they received
“safe and competent nursing care”, and such care included “catching”
Yasmin’s baby.
“Experienced midwife” arrived, and seemingly had no idea what to do. That
brings us back to The Code, Value Statement 3, which we have visited
above27. The following is part of Explanatory Statement 2, of Value
Statement 3. “Promotion of quality nursing care includes valuing lifelong
learning and engaging in continuing education as a means of maintaining
and increasing knowledge and skills” (p.8). All midwives, indeed all people in
all walks of life, would do well to heed this statement. If quality nursing care is
27 Value Statement 3 of The Code says “Nurses promote and uphold the provision of quality nursing care for all people” (p. 8).
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what we aim to promote and uphold, as a part of ethical practice, as The
Code suggests, then being up-to-date with the knowledge and skills
appropriate to our area of practice is vital if we are to practise ethically. It is
not possible to provide the best possible, most appropriate, respectful, safe,
competent, client focused care, (which would be the “right” thing to do),
unless one is aware of recent, safe and acceptable practices. Such
awareness is gained through ongoing education, both formal and informal.
By now the cavalry has arrived and help is bountiful. Lucy “sorted out”
Yasmin. Even though Yasmin was not actually “in Lucy’s care” that night shift
(remembering she was being cared for by Angie, the agency midwife), Lucy
had been thrust into a situation where she had to assist Yasmin and they had
now developed a relationship. Even though it is not possible to fully
appreciate all that Lucy, Yasmin and Wendy are going through, as Lucy
shares her story, we are able to glean some further understanding of the type
and importance of the relationship that can develop, often very quickly,
between a client and a midwife (see discussion earlier in chapter on
professionalism and covenantal relationships). It seems, from her comments,
that Yasmin trusted Lucy. Lucy tells us that Yasmin said, “Thank god you
knew what you were doing, because nobody else in this bloody hospital
knew”. This is certainly a sad indictment on the rest of the hospital, but great
that Yasmin had someone to trust at a crucial moment.
Yasmin’s baby was taken to the Special Care Nursery and cared for
appropriately. All ended well. However, as Lucy pointed out, this might have
been more good luck than good management. Did all the midwives in this
story respond in ethically appropriate ways at all times? Not just the ones we
met, but also those we did not meet. What of the Birth Suite midwives who
sent Yasmin back to the ward after giving her Pethidine? Was that a
midwifery decision or a medical one? Could or should the midwives have
challenged it? Perhaps they did? Are there things that could have made this
a more ethically acceptable scenario, even without changing the physical
events of the birth? These are, of course, rhetorical questions. Having heard
only Lucy’s story, we can only muse on these questions. Lucy’s story alerts
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us to the extreme complexities of an event that could occur in any maternity
unit in a modern hospital. Intricately interwoven issues of professionalism,
shared responsibility, knowledge (or lack of it), brief passing comments and
chance meetings in corridors can profoundly alter a midwife’s day. How she
chooses to respond to the situation she finds herself in, can profoundly affect
all of the people involved, including herself, but, like Henrietta, Lucy had no
time to sit down and think about what she was going to do. She simply had to
act. Midwifery-on-the-run. Ethics-on-the-run.
Collegial Relationships and Professional Development Recalling Lucy’s words, “They’ve [midwives] got to know for safe practice.
For safe practice, they’ve just got to know what to do”, and knowing that The
Code (2000) encourages all nurses to engage in continuing education to
promote quality nursing care, it seems that it would be a natural and obvious
progression for all nurses and midwives to seek out and be involved in
ongoing learning. Like Lucy, Mary is concerned that her colleagues do not all
concern themselves with keeping their knowledge up to date. Speaking of a
post graduate course that she had done, Mary said,
I did it, because I just needed a new challenge, you know how when
you have done midwifery and that challenge is there and you master
that challenge and you feel that you are competent in your practice,
then you think oh, I need something else just to stimulate me, so that is
when I went and did neo-natal intensive care, … I think it is important
you know, professional development is, and your own personal
satisfaction to know that you have achieved something. I don’t believe
that you should go into a place and stay there for ten or fifteen years
and just vegetate and not do any form of upgrade. Mary
She continued, speaking of some of her colleagues,
… and yet you see it, I mean I am working in a unit where people have
been there for ten years, I mean, just not up with the current changes,
they are not up with the best practice principles, and when you
challenge them and say that that is not what you should be doing, they
get really defensive, it is like you are challenging them personally. I am
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challenging them personally. Not personally, I am challenging them
professionally, because, you know, they’re doing it this way, and yet
evidence based practice tells you that this is the way that you do it now,
and it has been proved that’s why you do it, to change it, and yet they
are still doing it this way. And it is hard; it is really hard to change
people’s practice. Well, there is a better way and I also back it up by
getting the research, going to CINAHL28 and getting the necessary
documentation and saying look, this is what you should be doing.
Mary
It sounds almost as if it is a lost cause. Their practice is not up to date and
they become defensive when challenged. Mary says it is “hard, really hard
to change people’s practice”. Of course, in reality, no one can change
another’s practice. It is only possible to encourage others to seek
knowledge, accept the information that is shared with them and apply this
new knowledge to practice. Section 4.11 of the Code of Practice for
Midwives (Queensland Nursing Council [QNC] and ACMI, n.d.) informs us
that; “In practising as a midwife and to meet your duty of care you must:
assist midwifery students and colleagues in the care team to develop their
professional competence, and to practise to a standard appropriate to their
roles” (n.d., p. 4). A midwife cannot be held responsible to change the
practice of other midwives, but she has a duty to help them to become
increasingly better midwives, through the continual development of their
professional competence. Mary took this responsibility seriously, and despite
the fact that it was “very, very hard”, there was hope. Her colleagues actually
asked for her assistance, and she was happy to provide it.
And the other thing is that they actually want me to present to them you
know, areas of practice that they want to change and present it sort of
like you know as an in-service sort of module. And I mean I am more
than happy to do that, yeh. Mary
In order to provide “good” care, a “good” midwife needs to have up to date
knowledge. This is in keeping with the codes of practice she purports to
follow, and her professional commitment to look after the best interests of
28 Cumulative Index for Nursing and Allied Health
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the clients in her care. Kelly told me about a positive encounter with some
midwifery colleagues that she met prior to starting work with them. A little
apprehensive, but excited at the prospect of beginning work in a new place,
Kelly had met with some of the midwives to discuss aspects of the work, the
environment and the expectations within that unit. Kelly was aware that there
were some skills that she would need to learn and/ or enhance to work in the
new unit. As she spoke, there was a sense, almost of surprise, that the
midwives treated her differently from the way she had previously
experienced. This gave the impression that collegial relationships, the way
things should be, was often not the reality – and that this time, when she
was treated in an open and welcoming manner, it was an unusually pleasant
event. It was unusual enough to be worthy of being told. Remember, a
story’s ““tellability” as a form of discourse rests on a breach of conventional
expectation” (Bruner, 1991, p.16). This is what she said.
… that’s what I mean when I think about, talk about, you know, just
about open relationship and open relationship between the women and
the midwives. Yeah. I think too, it is more, isn’t it, of just like a collegial
type discussion. Yeah, because well, when I went over there [to the
new work place] the other day for a meeting and they [the midwives]
were asking me what I felt happy with doing, what I didn’t feel so happy
with doing. … it was just more to, so okay we can get you up to date
with your IV skills here. Saying we can put you through that programme
here. I said all about suturing, that I hadn’t had a lot of experience in
that, and they said, “Oh, that’s all right, you know, we can eventually
get that done”. Kelly
Things that Kelly thought might have been problems were not. Her
colleagues simply noted them as areas in which Kelly needed support and
education and moved on. This is an example of midwifery colleagues coming
together, engaging with each other, and responding to each other in a
manner that is both professionally and ethically appropriate. They have
shown respect and understanding, encouraging Kelly to express her needs
and concerns, and have provided her with an assurance that they can be
addressed.
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So far we have heard a story where both client and midwife were
disadvantaged by the relationship between two midwives being less than
ideal. Lucy and Tara did not agree with the treatment Susan “suggested”, but
they were forced to conform. They “felt threatened”. Next, Henrietta and
Vera worked together to give Una the best birthing experience possible in
what can at best be described as an awful situation. They instinctively “knew”
what each should and would do. Then Lucy shared with us a story that
certainly activates our ethical thought and reasoning. It was not a good
relationship, or a bad relationship that mediated the outcome of this story. A
number of fleeting relationships play a part, coming together to complete the
story, but none of these was especially “good” or “bad”. Yet, using The Code,
it has been shown that ethics was very much central to this entire situation.
Next, Mary and Kelly were able to draw our attention to the fact that collegial
relationships and ongoing professional development, whilst important, can be
difficult fields to negotiate.
The stories that will now be shared are of a different type again. No one
expects affirmation every day, least of all at work. Nor do they expect to be
deliberately antagonized either. Sometimes though, midwives, nurses and
their professions, as well as their clients, can suffer harm at the hands of
midwives and nurses themselves. Irena related the following stories, which
were a part of her experience in a Special Care Nursery. In these stories,
from the information we have, it seems as though harm has been deliberately
inflicted. Sometimes, in Special Care and Intensive Care Nurseries, both
midwives and registered nurses are employed. It is not clear, in the stories
that Irena shared with me, if the persons involved were midwives, as she
used the term “nurse” in most instances. This is often easier in Nursery
situations, as you are not sure of the training of your colleagues, until you get
to know them. Irena’s words are therefore presented faithfully here as
“nurse”, as she spoke them to me.
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Listen to Me Sometimes it is difficult to understand just what goes on around you and why.
Irena seemed to struggle with this as she spoke to me about her experiences
as a midwife. It was as if her philosophy for practice did not align with that of
many of those around her, and it didn’t make sense. As I listened to her, at
times, it was as if, for Irena, midwifery had lost its heart – the feeling and
caring had gone, and she had become disheartened at the loss of her
profession. I can present here only a small part of her story.
There is no professional attitude that carries on throughout the hospital.
And that’s why we cannot be a profession in my opinion. Nurses; we
bag other nurses, we can’t do this. I mean do you find another
profession? What, GP’s? They don’t bag each other, but nurses do -
and they do it to patients.
…there was an incident late last year, where we had one nurse say to a
mother, “Oh, Don’t let her look after your baby, she’s no good.” (laughs)
and one of the mothers reported it back. Now, that is so unprofessional
for a start. I mean there are many things wrong with that statement.
Many.
The first reaction is that the mother is afraid of the nurse that’s been
bagged, that she is going to harm her baby. That that baby will be
harmed, because the nurse is not competent, because she’s been told
by another nurse that this nurse isn’t competent. And it will probably
take her quite a while for her to work out that this other, the first person,
is a nut case. Put it that way (laughs) it’s so confusing. She goes out
and forever she will remember that. I really think when people are
under pressure with their children in a special care unit, absolutely
everything you say and do, you’ve got to realise that’s probably going to
be committed to their long term memory. Because it’s been a huge
thing in their life. And it’s not in ours. (italics added) Irena
What are the issues we need to consider, looking at this scenario from an
ethical point of view? Some questions we could very reasonably ask would
include the following. Why don’t nurses and midwives band together and
“stick up” for each other? What might have been the nurse’s intentions in
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making the statement to the mother? If she truly thought that the other
nurse/midwife was “no good”, it would have been a far more professional
approach to seek her out privately and discuss concerns and options to
improve practice. In fact, according to The Code of Ethics for Nurses in
Australia (ANC, RCNA, and ANF, 2002) and the Code of Practice for
Midwives (QNC and ACMI, n.d.), if she had reason to believe the nurse/
midwife’s practise was unsafe, she had a moral and professional obligation to
assist her colleague to improve her practise.
Who has been harmed? Obviously there was an immediate effect on the
mother, who then worried about her baby’s care, and who she could or could
not trust. Who was telling the truth? Were any of the nurses and midwives
any good? The nurse/midwife who has been spoken against, even though
she may not have been aware of it, had had her reputation tarnished, and if
she discovered what was said, who knows what damage that did to self
image, professional confidence, behaviour and ability to practise safely and
competently. Then, there is the wider profession. Unfortunately, when a
person meets or encounters a nurse or midwife, and they are of a particular
kind; be it friendly, helpful, nasty, opinionated, affirming, “good” or “bad”; it is
quite likely that all persons of that group will then be aligned with that type
(being tarred with the one brush). Therefore, in this situation, this mother
might draw the conclusion that all nurses and midwives are (a) “no good” and
not capable of caring for her baby appropriately and well, or (b) gossip
mongers and liars who can’t be trusted. It is evident that neither of these
would be a positive outcome for the professions. We are left to surmise that
the impact of this ethical encounter could only have been both negative and
harmful for all parties except, perhaps, the instigator; whose intentions we do
not know and are left to ponder. It is quite safe to say, however, that they
were surely not professional, appropriate, or ethical.
Irena also told me about another disturbing event.
…people [nurses] won’t help them [other nurses]. They like to see
people fail and fall. Now I find that really, really hard to handle you
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know, this idea of “Oh we’ll see what they’re made of”, I think that’s so
wrong. They won’t help them and they’ll give them wrong advice and
they’ll set them up.
…. An example … “Don’t change baby such and such because he has
been over-handled for feeding by visitors….. blah, blah, blah, blah,
blah”. Okay so she doesn’t, and the baby’s gone over 9 hours without a
nappy change. And he’s got a red sore bottom…. And of course the
mother freaked out. And the kid [nurse] was set up; she did what she
was told.
Everybody knew about the red bottom, and the nurse before should
have recorded it….but the second nurse didn’t know…But the
preceding one knew, and should have recorded it and done something
about it. She should have recorded it and what she had done about it.
You know she should have put the bottom under the heater, or put zinc
cream on it; she should have documented what she did. But no, she
didn’t.
I think all parties were harmed. The mother was harmed because she
thought the baby wasn’t cared for properly. The baby was harmed
because the bottom was very red, and that’s preventable. By taking
steps to do something about it, and document it, and air it under the
heater, or zinc cream. The preceding nurse is ethically very wrong, and
lawfully wrong for not documenting that. And the nurse who took over
is harmed because she wasn’t aware. She did what she was told
thinking that the baby needed the rest. And tube fed the baby and
didn’t change its pants. Irena
In this story we see a flow on effect of the harm. One nurse, with apparent
intention to cause another nurse to be found incompetent, through her words
and the subsequent actions (or in this case, inaction) of the other, causes
physical injury to a baby, psychological harm to its mother, and dissention
amongst the staff in the unit. What we say can have an enormous impact.
When people are involved, the importance of correct interpretation of our
utterances cannot be understated. The question in this particular instance is
whether or not there was any misinterpretation? Did the nurse coming on
duty misunderstand what had been said to her about not changing the baby.
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Did the nurse going off duty convey her message poorly, and actually mean,
for example, “don’t change baby this feed, I have already done it”? As Irena
told the story, it appears that the second nurse did just as she was told –
don’t change baby at all, and that was what was intended to be understood.
Let us call these people Nurse A, Nurse B, baby and mother. Nurse A,
knowing now, that by following her instructions, Nurse B has been labelled a
“bad nurse”, because she did not attend to baby’s hygiene needs, is satisfied
that her plan worked. However, she then discovers that baby has sustained
extensive skin damage to its buttocks (an unintended harm) and that its
mother is extremely distressed that her already ill infant is now suffering
further pain. Nurse A now finds that she has caused two innocent “extras”
significant problems. How might she feel about this? Although she had some
(albeit inappropriate) reason for wanting to cause harm to, or assert power
over, Nurse B, she more than likely had no intention what-so-ever to cause
any pain of any kind to baby or mother. By doing so, Nurse A could well be
experiencing feelings of guilt. Even the instigator of such events may not
escape harm.
Cherry has a similar tale to tell. She feels let down by her professional
colleagues.
No. I have actually been quite surprised, but nurses do it to nurses. Do
you know what I mean? Like a friend of mine works [at another
hospital], like she works in special care … there as well, and I’ve, I’ve
just been really quite disappointed in, they’re only stories, you know …,
some staff midwives there are bagging us [at this hospital] and I just
find that really disappointing because we are all midwives, we have all
been in situations. The situations that happen at [this] hospital could
quite easily happen ... anywhere around Australia, and I don’t think it
has affected any other midwives in other places, it has just affected
those here. But I’ve been disappointed to hear that some midwives
aren’t supporting their fellow midwives. But I think that’s nursing as a
whole. We’ve all been through our registered training and you’ve said,
oh, like I know that when I was in [another hospital] you know, [another
hospital] bagged [that hospital], there will be this hospital that will
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sometimes say, Oh god, [town] they did blah, blah, blah, blah, blah,
blah, you know what I mean? So I think that is just nursing in general. …
It, well, oh, yes. It’s um, like you can understand why we’re not where
we would like to be in nursing, because basically as colleagues we
don’t support each other and that happens in ward situations as well.
You know, you look at the medical group and they look after each other
so well. You know, even with other professions, physios and I have got
a brother who is a radiographer and just with things that he says, you
know there are other professions out there that just support their
professions and I just find that nurses can be horrible to each other
sometimes. Cherry
From Irena’s viewpoint and in her understanding, the two situations she told
me of arose as a direct result of unprofessional behaviour. One nurse was
deliberately trying to undermine another. Anyone can plainly see that
professionally and ethically this behaviour is far from ideal, and the vast
majority of people, if not all, would readily agree that it is completely
unacceptable. Cherry, whilst not telling of a deliberate personal undermining
of individuals, coveys a sense of widespread professional disharmony.
Rather than banding together as a unified profession, staff from various
institutions are telling unfavourable “tales” about the midwives from other
hospitals. Unfortunately, it seems this type of behaviour is commonplace and,
this being so, Irena’s perception is quite likely to be a correct one. The
nursing profession has a long history of its members mistreating each other,
and when this occurs within the one level of employees, it has been given the
name, “horizontal violence” (Hastie, 2006; Hutchinson, Vickers, Jackson,
and Wilkes, 2006; Keeling, Quigley and Roberts, 2006; Vonfrolio, 2005). In
fact, horizontal violence is so prevalent and of such significant concern to the
nursing profession that the topic has been widely researched. There is even
a small amount of literature emerging in this field that is specific to midwifery
settings. Fenwick, Butt, Downie, Monterosso, and Wood performed a Delphi
study to discover what midwives thought should be researched. From a
midwife’s perspective, the highest ranked topic was “examining the
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professional issues that impact on midwives’ clinical practice” (2006, p.78),
horizontal violence being one of these.
Hastie (2006) felt compelled to research issues relating to horizontal violence
after a personal encounter with the parents of Jodie, a young midwife whom
she had met some time earlier. Jodie had committed suicide and, in her
suicide note, she had spoken of not being trusted at her workplace and
feeling unequal to her colleagues – never being able to live up to their
expectations, but at the same time not wanting to be like them. Hastie speaks
of toxicity in the workplace, which is, she notes, referred to as horizontal
violence, and is also known as workplace bullying. The complexity of this
phenomenon is quite possibly the reason why it has been studied so much.
In her study it was discovered that new midwives found themselves in very
challenging situations. They often proved to be insightful, resilient and
courageous; but they also experienced feelings of isolation, despair and
loneliness. It is hardly surprising that such extremes resulted in these early
experiences and feelings leading them to either abandon or embrace this
career path.
Some examples of horizontal violence noted in Hastie’s (2006) study include
midwives feeling that others asserted power and authority over them,
negative non-verbal behaviours (eg. avoiding contact) and having their
management of situations attacked or corrected in front of the client.
Interestingly, the tearoom was observed to be a place where horizontal
violence occurs. Hastie quotes one of her respondents;
‘you hear things in the tearoom, you know, so and so did this and this,
you know, the gist of what they’ve done… just what they’ve done or
haven’t done… mainly judgemental… lots of bitching and you feel for
that person’ Hastie, 2006, p.27
Nurses love to tell stories in the tearoom, whether they be affirming or
noxious.
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Stapleton, Kirkham, G. Thomas, and Curtis (2002) found that midwives were
frequently unsupported, and even harassed when they attempted to be their
client’s advocates, rather than following either unit policies or doctors’
preferences, especially if the former was in conflict with the latter. They
received back-lashings not only from an administrative level and doctors, but
also from their midwifery colleagues. Many midwives were more inclined to
go with the flow, seemingly to make life easier. This was in spite of the fact
unit policies and doctors’ preferences reduced client options and often meant
that clients were unable to make their own informed choices. It also meant,
frequently, that clients were cared for in a clinical setting such as a hospital
outpatient’s clinic, rather than in the community where they would be more
open and responsive. The authors note that “going against the flow” causes
midwives to be vulnerable. This led a number of midwives to practise covertly
when possible, so that their colleagues would not find out.
Sadly, it seems that some midwives and nurses do spend time dragging
others down. Mary also had a story to tell of this type of behaviour.
They are playing one off against another which shouldn’t happen. It
should be more of a team, a team approach. But, I mean, nursing’s got
that, it’s always had that stigma where we eat our own. You know, we
do. We are the worst people to criticise our own, instead of working in
harmony, like you’ve got people who will step over you to get there.
And it is to get brownie points for whatever reason. You know, you’ve
seen it in the system, you know how it works. Um, yes. But, I don’t
know how you can change it. I mean we need to change ... You have
got to go back and go to the basics and find out what we are doing, why
we are doing it and how can we change it. How can we improve it for
everybody else? Mary
It has been posited that these type of behaviours have been, to varying
degrees, “accepted” within nursing (Hockley, 2002 cited by Hutchinson et al.,
2006), and are thus likely to be even more prevalent than is evident. For the
victims, horizontal violence can lead to low self-esteem, anxiety, depression
and post-traumatic stress disorder. Job dissatisfaction and high staff turnover
are also likely (Hutchinson et al., 2006). Hutchinson et al. discuss workplace
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bullying in depth, and draw our attention to the fact that there are wider,
institutional and socio-political factors involved. Power relations and the
actions of people involved in “oppressed group behaviours” are not simple
matters. If we continue to depict power imbalance and harmful behaviours as
an inevitable part of the profession because they are a form of oppressed
group behaviour, we will perpetuate both the belief that bullying is “normal” in
nursing, and the behaviour itself. As Mary says, we “have got to go back and
go to the basics and find out what we are doing, why we are doing it and how
can we change it”. Fortunately the research in this area continues.
You Can Manage on Your Own In this final story of this chapter, Kelly will tell you about her experience of
“midwife and no midwife”. This was to have a lasting impact not only on her
relationship with the other midwife involved, but also on her future as a
midwife. There had been a difficult birth – Kelly had cared for the baby’s
mother during her labour – and now there was a meeting to discuss the
“baby’s case”. Kelly had asked the midwife in charge of her unit to come with
her to the meeting.
… there was a meeting … because of the resuscitation, … and I was
the only midwife in the room – there was the obstetrician, or the
Director of the unit, there was the Director of Neonatology from
[hospital] and there was our neonatal registrar, … there was a lot of
discussion … just looking at reasons why basically. They were trying to
explore what we could have done better and things like that, but I’d
mentioned to my NPC29 there, that this meeting was taking place, and
she didn’t turn up, and so it was just this whole experience of feeling,
not in control, not entirely sure that I’d managed the situation correctly
and just, sort of really overwhelmed with the actual, the whole
experience and, and having to deal with that and having to live with the
fact that this baby may have long-term sequelae from the events of the
birth and things like that and I, I really beat myself up about it and, and
you know felt, about the condition of this baby and what was going to
happen, that really weighed very heavily on my mind.
29 Nurse Practice Coordinator
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…I just, I, I just felt really unsupported and I think it was the start of me
not having a lot of confidence in her. I, I think it was a combination of,
you know, it being my first, significant event where outcomes weren’t
exactly, you know, good.
…I just, I felt incredibly isolated in that meeting and it was not, it was
not blaming or anything like that, I didn’t feel that they were actually
blaming, but just myself and I just felt like I should have had some sort
of midwifery support there. So I think it just took away a little bit of the
respect I had for this woman in particular and so as a result I wouldn’t
actually go to her about issues and things, I just, I actually distanced
myself from her.
…Well I just, you know, that, I mean it was basically sort of talked
about, that you know this baby had recovered well …but there was just
this feeling I had, and I’ve often thought about it when, when I’ve had
situations that are difficult since, this always pops up into my mind, just
this feeling of being, sort of unsupported when things don’t go right and,
and really overwhelmed with the responsibility that I have on a day to
day basis. (italics added) Kelly
It is clear that this event had a significant effect on Kelly. Her story
gives a sense of the heightened emotions surrounding the birth,
during the meeting, and even when the events are recalled – popping
into mind each time a difficult situation arises. This can be even more
clearly seen if key phrases are drawn out of the text and viewed
separately. Below, we again see Kelly’s words, but this time only key
phrases.
I was the only midwife
she didn’t turn up,
feeling, not in control, not entirely sure that I’d managed the situation
correctly
really overwhelmed with the whole experience having to deal with that
having to live with the fact
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I really beat myself up about it
weighed very heavily on my mind
felt really unsupported
start of me not having a lot of confidence in her
incredibly isolated
should have had some sort of midwifery support
took away a little bit of the respect
I wouldn’t actually go to her … I actually distanced myself from her this baby had recovered well
there was just this feeling I had
I’ve often thought about it
when I’ve had situations that are difficult since, this always pops up into
my mind, this feeling of being … unsupported when things don’t go right
really overwhelmed with the responsibility that I have on a day to day
basis. (italics added) Kelly
Kelly felt alone and isolated, surrounded by doctors in a meeting discussing
the well-being of a baby which, rightly or wrongly, she felt, at least in part,
responsible for. She felt that she should have had some sort of midwifery
support at the meeting, and had asked her colleague to come, but, in Kelly’s
words, “she didn’t turn up”. The entire experience appears to have been
somewhat daunting for Kelly, who expressed self-doubt, feeling
overwhelmed, out of control and burdened. Happily we hear that the baby
fared well, which was probably more than can be said for Kelly.
From her story, we are able to determine two impacts that this encounter had
on Kelly. The first is that her confidence and respect for her NPC diminished.
She informs us that she no longer went to this midwife for advice (“issues
and things”). As the most senior midwife on the unit, and in light of the things
we have learned earlier in this chapter from various codes, an NPC ought to
be a primary source of knowledge and support to the staff she works with. All
midwives should “work in a collaborative and cooperative way with
colleagues, health care professionals and those involved in providing care”
(QNC and ACMI, n.d.). The fact that Kelly’s NPC failed to support her
through this event, suggests that she did not meet this requirement of the
Code of Practice for Midwives (QNC and ACMI, n.d.). We cannot be sure, of
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course, for we do not know why Kelly’s NPC did not attend the meeting, but it
does appear that she did not collaborate with Kelly. She did make it difficult
for Kelly to meet the requirement in the future, as we know that Kelly lost
confidence in her. Midwives frequently need to work as members of a team,
and “good teamwork” involves the members respecting and trusting,
communicating, and engendering confidence in others (QNC and ACMI,
n.d.).
The second significant outcome of this encounter for Kelly is, in a sense,
what makes this story a haunting one. It will never go away, it has left an
indelible mark. Triggered by any difficult situation, the mark glows like a neon
light, alerting Kelly to the possibility that she could be totally on her own,
completely unsupported. She feels overwhelmed by this responsibility that
she carries. Every single day she knows that she could find herself in this
situation. Sometimes the absence of a midwife can be more problematic
than the presence of a problematic midwife.
Conclusion In this chapter many stories have been shared. These have explored
different types of interactions between midwives and their colleagues. Lucy
felt threatened when Susan entered the room and intervened in Tara’s care.
This raised issues of client and midwife autonomy; integrity; professionalism,
with its associated concepts of caring and covenantal commitment; and
professional identity. Henrietta’s story was one of mutual understanding,
where two midwives worked together empathetically. They simply knew what
to do. This story brought out how midwives have to do “ethics-on-the-run”,
and the importance of having an understanding of one’s own values and the
place of ethics in practice. Next came Lucy, Angie, Wendy and Yasmin, with
emergency bells ringing and a baby being born in the ward, before its time.
The Code of Ethics (ANC, RCNA, and ANF, 2002) was utilized to explore
some of the possibilities within that story regarding responsibility,
confidentiality, provision of care, respect, confidence, trust and knowledge.
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Mary and Kelly enlightened us about some issues relating to collegial
relationships and professional development. It is clear that these can be
challenging, but also have been positive aspects of some midwives’ practice.
Disturbing stories were shared by Irena. In a Special Care setting she had
experienced the undermining of some staff, and not only was there a lack of
support amongst the staff, but harm was being caused, and not only to the
staff. Another story was told by Cherry, who also asserted that midwives not
only fail to support other midwives, but actually “bag” each other. Mary said
“we eat our own”. These stories elicited the concept of horizontal violence.
The final story that was shared in this chapter was that of a midwife all alone.
It was, in fact, her aloneness that caused her problem. The lack of support
she perceived (and received) from her senior midwife has led to ongoing
feelings that she will not receive support in difficult times, and causes her to
feel overwhelmed with responsibility. Kelly carries this story with her to work
every day, a silent, hidden burden. It is there, in her everyday practice, just
waiting to come forth should she find herself in a difficult situation, to remind
her that she could be all alone, totally unsupported.
Midwives work in a complex environment and these stories are just some of
those that were shared with me involving their interactions with other
midwives. They give a beginning understanding of the challenges that
midwives face when working together, and some of the ethical components
that are integral to these situations. The next chapter will examine those
stories which include midwives’ interactions with, or feelings about, the
administration or the institution for which, or in which, they work.
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CHAPTER 4 INSTITUTIONS/ ADMINISTRATION AND MIDWIVES
I thought they’ve got such a wonderful team of midwives, such
expertise in all areas, and they’re not doing their job, as far as I’m
concerned. They’re not doing what needs to be done to get the best
out of people at all times. And that’s really sad because they could; it’s
such a simple thing to do. Betty
Introduction In this chapter I will introduce you to the disembodied group of “people” that
frequently interacted or failed to interact with the midwives in this study. The
midwives who shared their stories with me referred to this disembodied group
variously as “they”, “them”, “the hospital”, and “administration”, and other
names on occasions. Twelve of the fifteen midwives interviewed shared at
least one story involving either the institution or administration. Many of them
shared several narratives about the administration, which would seem to
indicate these interactions hold significance for a majority of the midwives in
this study. They varied widely; from tales of utter frustration, through
expressions of feeling alone – as though they had been left out on a limb, to
stories of being caught amidst communication difficulties. The following
narratives provided by Betty, Cherry and Kelly, illustrate these story types.
• …our management have made our midwifery team the most
miserable I have seen in 22 years (Betty)
• but I’d mentioned to my [Nurse Manager] that this meeting was
taking place, and she didn’t turn up (Kelly)
• with that incident that happened a few people got their back up
about it, and that was management, because they felt that I
hadn’t approached them appropriately prior to speaking to
special health services, and I thought I had (Cherry)
Unless self-employed, or unemployed, a person has to deal with “them”
regardless of the line of work one is in. In an institutional setting, with a highly
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hierarchical structure, such as a hospital, it can often seem that there are a
lot of “them” in contrast to the one of “you”, so “you” really want “them” to be
on your side. Conversely, from “their” point of view, there are a lot of “you”.
So it would make sense for “them” to want to have “you” on their side.
Logically, it makes perfectly good sense for everybody to work together in a
co-operative and collaborative manner, for mutual benefit. Even if we were
only considering the well-being of the employees, this would be prudent, and
assist them to fulfil the purposes and achieve the goals of the organisation or
institution. Naturally, especially in the health care setting, we have to take
into account the clients as well. It is reasonable to assume that, if all levels of
employees are working together well, in an optimal manner, with mutual
understandings and goals, in a supportive environment, this will have a
beneficial flow-on effect to the clients, who will then receive optimal care.
It will, I am certain, come as no surprise to learn that this was not the
experience of all the midwives interviewed. Whilst some midwives did relate
stories of support and encouragement, many told of frustration and a sense
that they were either misunderstood or not cared about by management/
administration. Administration and management were almost always seen, by
the midwives, as being “above them”, rather than as a part of a collaborative
system where all parties needed to, and could, rely on each other. Once
again, the midwives’ stories will be shared, so that we might obtain a sense
of what life is like for them in their everyday, real-life situations in their work
environments. By sharing these stories it is hoped that the pervasiveness of
ethics within the fabric of everyday midwifery practice might show itself a little
more clearly.
At this point, there is a need to remind readers of this thesis that only clinical
midwives were interviewed for this research. These midwives were working
with clients on a day to day basis. Although it did not preclude them from
participating, no midwives working primarily in administrative or management
positions agreed to be involved in my research. It means that I can present
only the experiences from the perspective of the midwives interviewed, not
from the administrator’s/ management’s viewpoint. Naturally, this does not
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mean that the administrator’s viewpoints are not important or valid, and this is
not intended to diminish them in any way.
Sadly, when it came to administration and management, as a disembodied
and impersonal body, almost all of the midwives interviewed expressed
feelings of discontent and/or unhappiness. This even included those
midwives involved in some administrative tasks themselves. From the
stories conveyed to me, it seemed that management both had, and used, a
type of power that the midwives lacked. “They” were able to “call the shots”,
as Lucy said. Power is an extremely complex notion, able to be used to either
the benefit or the detriment of others. Unfortunately, it appears that the latter
was more common in these encounters. Types of power will be discussed in
greater depth later in this chapter and further elucidated in Chapter Seven.
These brief excerpts from their interviews introduce the type of thoughts and
feelings expressed by the midwives. Italics have been added.
• people just get disillusioned with management. Absolutely
disillusioned. (Betty)
• there wasn’t a lot of interest taken (Cherry)
• we’re all feeling intense pressure (Debbie)
• sometimes it is really disturbing when you feel you can’t give the
sort of care that you would like to give because you are being
pulled in a million and one directions (Emily)
• they expect you to do [things] in your own time (Felicity)
• the mountain of workplace health and safety issues that we have to
crawl over (Henrietta)
• Managers up the top calling the shots for better work practices
then, you know, your staff have to follow. (Lucy)
• it’s a very unhappy place due to the hierarchy … they really are
removed from the clinical area and they do not understand, and
don’t want to understand (Natalie)
• Like there are quite a few upheavals in our unit at the moment, with
the management, there’s a lot of agro (Olga)
Such small snippets of the midwives’ words could be misrepresented, or
misinterpreted, so there is great need to move forward and investigate
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further. You can see, however, from these brief quotes taken from nine of the
midwives’ interviews, that all was not well between “us” and “them”. The
midwives and the administration were not on the same wavelength. There
was disillusionment, lack of understanding, and a general feeling that
expectations from above were unreasonably high.
Team midwifery had been introduced in two of the three hospitals where the
participants in my study worked. It seemed, to me, that many of the concerns
that the midwives at those hospitals voiced were related to issues that
stemmed from the introduction of this model of care. It is prudent, therefore,
to review some of the literature so that we might gain an understanding of
team midwifery. With a basic knowledge of team midwifery, we will then be
able to look at the midwives’ perspectives in context. It becomes quite quickly
and clearly apparent that there was a very poor fit between what team
midwifery purported to offer and the experiences of the midwives.
What is Team Midwifery? The overall aim of Team Midwifery is to provide better care for expectant
women, with a significant focus being continuity of carer/s (Tinkler and
Quinney, 1998; Todd, Farquhar and Camilleri-Ferrante, 1998; Tucker, 2000;
Waldenström, Brown, McLachlan, Forster & Brennecke, 2000). It has been
shown that client satisfaction is increased (M. Biró, Waldenström and
Pannifex, 2000; Passant, Homer and Wills, 2003), and the woman is able to
develop a relationship with her care provider in pregnancy (Stockwell and
Little, 2001). One of its objectives is the provision of more individualized and
client-centred care during pregnancy and childbirth than other forms of
obstetric or midwifery care, which may have been task oriented, or unit based
with staff being allocated to specific areas, and clients being cared for by a
number of different staff (Tinkler and Quinney, 1998; Tucker, 2000). It thus
presents as a positive and desirable form of care from a client aspect.
Team midwifery is likely to be cost efficient for employers (Oliver and
Needham, 1997; Passant et al., 2003). Hodnett (2000) alerts us to the fact
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that administrators would, of course, be concerned about this aspect of
introducing a new model of care. In the Cochrane review that Hodnett wrote,
we are informed of an Australian study by Rowley (1995) that included a cost
analysis. Although the exact reasons for reduced costs were not stated, they
could have included factors such as the fact that care provision wholly by
midwives is cheaper than that shared between obstetricians and midwives,
that clients required less medication and anaesthesia (epidurals) during
labour, and that midwives providing “continuity of care” in Rowley’s study
took far less sick leave than their counterparts.
With midwives being (or becoming) proficient in all areas of care provision,
able to move seamlessly from one area to another, team midwifery is staff
distribution friendly. As all midwives are familiar with all areas, they can
readily float between Birth Suite, different wards and clinics, depending
where “their” client, or the greatest workload, happens to be on any given
day. This is highly beneficial for employers, aiding in the smooth running of
the hospital. Another advantage of the team midwifery approach is that it can
reduce burnout and increase staff satisfaction (Stockwell and Little, 2001).
Fatchett (2001) reported, amongst other positive benefits, that professional
and self confidence levels were high.
Midwives involved in this study, however, did not seem to be reaping these
potential benefits of team midwifery. Listen to what Natalie saw was
happening,
I don’t think we deliver technically bad care because we’re unhappy but
I think the environment in which we’re working, basically maternity,
midwifery is a happy area. It should be. It should be one of the
happiest areas, because people really aren’t sick, because it’s a joyful
phase and it should be a happy phase and that should carry through.
But how can, I mean, this is probably one of the most important times of
their lives so how they, they’ve got a grumpy midwife who is just so
miserable in her work environment, it’s coming across to that mother
and then it’s not really very nice. Natalie
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And later she told me
I think that a lot of midwives at [this hospital] have got their backs up
and they’re so unhappy that they don’t care. Natalie
This certainly does not paint a picture that all is well with team midwifery
here. In fact, the benefits of team midwifery have eluded many. Some
research refutes the benefits outright, whilst other research paints team
midwifery in a very positive light.
On the Up Side For the clients
Being part of a team was found to be significant (for clients) by Tinkler and
Quinney (1998). In their qualitative study looking at maternity care
experiences in England, it was discovered that women identified as being
part of a team, as did their partners, and this fostered sound relationships
with the midwives. These women felt better informed and more involved
when it came to making choices and decisions regarding their care than
those women who were receiving traditional maternity care.
M. Biró et al. (2000) also reported a number of positive outcomes including
reduced intervention in labour for the women in their study who were in the
team midwifery group. These women had fewer episiotomies, experienced
less augmentation of labour and less electronic fetal monitoring than those
women receiving alternative forms of care. There was also less medication
used for pain relief (narcotics and epidurals) in the team midwifery
participants (as in Rowley, 1995) and they had shorter hospital stays. No
adverse outcomes were reported in this study.
Continuity of care can be provided by consistency in care provision, not only
by consistency in care provider. It is the former that must be the aim when
team midwifery is in place, particularly if the team is “large” (more that 4 is
considered large). Continuity of midwifery care, as opposed to continuity of
carer, has also been shown to lead to increased satisfaction with maternity
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care. Waldenström et al. (2000) and A. Biró, Waldenström, Brown and
Pannifex (2003) found that this increased satisfaction was most evident
during antenatal care, but discernable across the entire pregnancy, birth and
postnatal care period. The authors of both studies acknowledge confounding
factors that make it difficult to discern exactly what increased client
satisfaction with team midwifery models of care compared to “standard care”.
For example, clients in team care had shorter waits and received more time
with their care providers than those clients receiving standard care, perhaps
giving team care clients a sense of being more important and valued, and
certainly giving them more opportunity for interaction and questions with their
care provider. They also may have felt privileged, being “chosen” to
participate in the new, innovative care program, with those not “chosen”
feeling disappointed.
Waldenström et al. (2000) and A. Biró et al. (2003) attribute the increased
satisfaction that clients expressed with intrapartum care to continuity of
caregiver, as this was “the most obvious difference between the trial groups”
(Waldenström et al., 2000: 9). During labour, team midwifery clients had
fewer midwives than those receiving standard care. Thus, they assert,
knowing your midwife prior to labour is important to clients. Both the link
between increased satisfaction and continuity of caregiver, and the link
between knowing your midwife and having fewer midwives care for you
during labour, are somewhat tenuous. Accepting these findings without
question would not, perhaps, be wise.
Maternal and Neonatal Outcomes A 1996 Cochrane review of studies undertaken in the UK and Australia was
discussed by Oliver and Needham (1997). This discussion concluded that
there were many benefits to team midwifery. These included positive
neonatal and maternal outcomes such as shorter labours, less likelihood of
perineal and vaginal trauma, reduced need for operative delivery and fewer
admissions to neonatal intensive care. It was also noted that, although
restructuring of services would be required, this form of provision of midwifery
services was likely to lead to cost savings. It is important to note that this
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review investigated care provision by either a single or a small group of
midwives, compared with more conventional care. Waldenström et al. (2000),
however, did not find any differences in maternal and foetal outcomes
between team midwifery and standard care clients.
For the Midwives In contrast to the benefits for clients, the effects of team midwifery on
midwives have been variously reported, but they have not been frequently
studied. Midwives in Pontefract, West Yorkshire set up a team midwifery
service following the Changing Childbirth Report in the UK in 1993. This team
midwifery service was reported in a very positive light by Fatchett (2001),
although some challenges were faced. These included communication
difficulties resulting in fragmentation of care, and the very high degree of
commitment required, which was found to be intrusive both at home and at
work. Similar issues have been found to be problematic by others (e.g. Todd
et al., 1998). Negative emotions arose amongst the midwives. Despite these
difficulties, team midwifery was seen to have significant benefits overall.
There was demonstrated interest in continuing education and sharing of
knowledge, relationships with everyone involved in the health care
community improved, professional and self confidence was high, and there
was full use of midwifery skills. Practice was being continually developed and
improved, and the teams were perceived as providing a service that “was
‘flexible’, ‘giving’ and ‘supportive’ to both clients and midwifery colleagues
alike” (Fatchett, 2001, p.32).
Another report asserts that midwives working in a team midwifery service
have gained both skills and confidence. Stockwell and Little (2001) acquaint
us with the team midwifery program in the UK, in Harlow, Essex. Here,
midwives were nurtured and encouraged and consequently gained the
confidence “to provide a better service with greater job satisfaction” (2001, p.
27). The midwives were able to develop relationships with their clients and
over 75 % of women were delivered by a midwife they had previously met.
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A small study that supports the fact that there can be positive outcomes for
midwives working in a team environment has been undertaken. It showed
that graduate midwives, working in a small team, with good support, gained
skills. The participants felt that the model was providing a good service for
women and support for midwives (Passant et al., 2003). A Queensland study
by Walker, Moore and Eaton (2004) also found that midwives’ skills
improved, along with documentation, feelings of self-worth and an awareness
of reflective practice, but these benefits were not without cost to the
midwives. In this Queensland study, many participants felt an enhanced
sense of collegiality amongst the team members.
In-between In contrast, Hart, Pankhurst and Sommerville (1999) found that the vast
majority of women did not consider the continuity of care offered by team
midwifery nearly as important as was expected. Their care provider’s
knowledge, behaviour and ability and willingness to explain things clearly
were more important than knowing the midwife providing the care. This is in
contrast to Waldenström et al. (2000) and A. Biró et al. (2003) who assert
that their results confirm that being cared for in labour by a midwife you have
previously met does indeed make a difference. Although a small number of
women in uncommon situations definitely benefited from the continuity
provided by team midwifery, Hart et al. found that “the scheme demonstrated
negligible improvements in care or satisfaction for the majority of women”
(1999, p.577).
Although the study by A. Biró et al. (2003) showed increased client
satisfaction, the clients actually saw a greater number of midwives during the
antenatal period than those in the control group. The midwives were not
aiming to provide continuity of carer, but continuity of midwifery care. None-
the-less, one would not normally expect clients in a team midwifery program
to have more carers than those who were not.
Team midwifery was introduced in Ninewells Hospital in Dundee, Scotland, in
1996. All the midwives working at the hospital were allocated to one of five
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teams, with the teams ranging in size from17 to 41 midwives. Forty percent
of each team’s members were “core staff” who remained in birth suite,
antenatal clinic or the ward, and the remainder were deployed to different
areas of the hospital to provide care for the women in their team. Core staff
were retained in each area to ensure adequate skill levels and availability of
mentoring for new staff. It was hoped that the introduction of these changes
would reduce the actual number of midwives women had caring for them,
improve consistency of information provided by midwives to women, and
reduce the anonymity of the midwives to the women (Tucker, 2000).
Tucker (2000) identified some issues that inhibited the smooth
implementation and management of the teams. These included staffing
levels, sick and maternity leave , and the high proportion of part time staff. It
was difficult for team leaders to staff their areas and last minute changes
were often required. Overall, the team midwifery model of care was not found
to be overwhelmingly successful at this hospital. With respect to the aims
they set out to achieve, the number of care providers in the intrapartum time
(in hospital, around the birth) was reduced, but the number of carers in the
antenatal period actually increased, when compared to the previous model of
care. Similarly, in Farquhar, Camilleri-Ferrante and Todd’s (2000) study
clients in the team care group received their antenatal care from significantly
more midwives than the women in the comparison groups. Approximately
twenty-five percent of women reported that they received conflicting advice
both before and after the introduction of team midwifery care. Thus there was
no significant change in this regard (Tucker, 2000).
What Were We Thinking? Walker et al. (2004), whilst finding some positive aspects to team midwifery,
found that it also caused midwives difficulties. For example, team midwifery
was blamed for things that had been problems prior to the team’s inception.
One of their participants said “Things that were previously everyday
occurrences and problems that happened within the unit are very much
highlighted and magnified. I mean they couldn’t be solved before but they are
now being highlighted and blamed on team midwifery” (Sharon, in Walker et
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al., 2004, p. 19). The team members felt they were under scrutiny all the
time, and that “the organization” was being obstructive. Some team members
had not embraced the team midwifery model and the associated changes in
the workplace. This caused some to feel ill at ease and created conflict
amongst staff. Alienation of some staff members and an unevenness of
workload resulted.
Some authors have been very critical of team midwifery. Sandall (1997)
reminds us that teams that originally showed positive outcomes, and upon
which results team midwifery was widely accepted and introduced, were
small, consisting of only 4 members. Yet, when the model was introduced in
other areas, teams were frequently much larger, such as in Dundee where
one of the teams was comprised of 41 midwives (Tucker, 2000). Sandall
(1997) states that the pursuit of professional autonomy by midwifery leaders
was at the cost of higher accountability and greater workloads for midwives,
who received the same, or (sometimes) even less pay. She wrote;
Midwives came into midwifery because of the satisfaction of
accompanying a woman and her family through the journey of
childbirth. It is this personal relationship that is at the heart of midwifery
practice. Team midwifery reduces these opportunities for this immense
sense of satisfaction and tears the heart out of midwives as they strive
to establish relationships with so many women in their caseload, ‘just in
case they see her during her birth’.
Sandall, 1997, p. 286 (italics added)
Clearly Sandall (1997) believes that team midwifery is an
inappropriate model of care for midwives in the long run. Todd et
al.’s (1998) study supports Sandall’s findings. In their study, the
midwives felt unsupported by their profession. That is, they felt
that they were not nurtured and encouraged by other members of
the midwifery profession. Over half of them reported that team
midwifery had had a negative effect on care provision; they
recorded high stress levels and frequently worked overtime. Of
particular interest is the fact that the midwives identified team
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midwifery as having a detrimental effect on continuity of care and
on their relationships with women – two of the very things the
model of care set out to improve. In a later study, Sandall (1999)
found that midwives working in teams were more likely to suffer
from burnout than those who were not. High levels of burnout
were associated with large teams, conflict with management, and
midwives not having control over their own workload.
Stress is a common complaint of midwives working in team midwifery
models. Birch (2001) investigated this and found that the perception of stress
was actually much higher than the reality, with 76 % of respondents
perceiving themselves to be stressed, but only 53 % returning moderate to
high scores on their surveys. It was also difficult to attribute their stress
directly to work issues. Many other factors outside of work contribute to
stress, and one’s perception and personality have a significant impact on
how quickly and how stressed they might become. Nonetheless, it was clear
that in the unit where her study was undertaken, there had been a very sharp
rise in sick leave attributed to stress with the introduction of team midwifery
and, the midwives felt stressed. The midwives thought that they would cope
better with stress if they received support from the organization and their
colleagues, and if they had greater flexibility in their working hours. The kind
of support they thought might be helpful is not stated, but few (14%) reported
that the stress management strategies that had been implemented by the
organization had been beneficial.
Birch’s (2001) study is interesting in that it sought to identify and separate
work related stress from that due to other factors. This study could lead one
to believe that it is a midwife’s personality and coping ability that cause her
stress, not participation in team midwifery. Whilst these certainly can be
factors, a quantitative study such as this can inadvertently undervalue real
life experience. We surely cannot consider self reporting of stress due to
work related factors completely invalid.
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On the whole, Passant et al. (2003) reported positive findings. However,
midwives in their study found the changes in their work environment that they
had to deal with both emotionally and physically exhausting. It was a
challenging transition and some found it intrusive in their life. This has been
noted by others also (e.g. Todd et al., 1998).
The model of team midwifery described by Tucker (2000) seemed similar to
that being described by the midwives in this study. It was somewhat unclear
to me, as the midwives I interviewed were describing their experiences of
working in the model, not the actual model of care. In fact, it wasn’t
completely clear from my meetings with the interviewees, that it was actually
team midwifery that was being practised. I had heard from another source,
before commencing the interviews, that team midwifery had been introduced
at the hospitals in question. These pre-understandings, together with the
information shared by the participants, led me to interpret these stories as
being a part of the midwives’ team midwifery experience. It is important to
note once again that, as only midwives working in clinical areas were
interviewed, it is only possible to present here the words and perceptions of
team members, not those of the persons responsible for the implementation
of the model.
“Forced Rotation” As previously stated, two of the hospitals where participants worked had
introduced the Team Midwifery model of care. This was quite recent at the
time when the interviews were conducted. Team midwifery necessitated the
movement of staff from one area to another. This was one of the big issues
facing midwives – having to rotate and work in all different areas of the
hospital. I am referring to this as “forced rotation”, because the midwives felt
it was being inflicted upon them. For most, it seemed to be an unwilling
participation. They expressed feelings that either themselves, or others, were
being “forced” to rotate to, and work in, areas of the hospital that they were
neither comfortable nor confident working in.
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It seemed that the transition from the previous models of care, where
midwives had primarily been based in one area, often for many decades, to
this new model, which was supposed to provide women with greater
continuity of either care or carer, depending on the model it was based on,
caused a great deal of unrest. Another argument for this rotation, is that
midwives need to be skilled in all areas of midwifery, as midwifery is their
area of speciality. Midwives should not restrict their skill area to just Birth
Suite, Post Natal, Special/ Intensive Care Baby Unit, or Antenatal Clinic and
so on, and become ultra skilled or uniquely specialized in only one area, but
should keep all their midwifery skills finely honed.
Many of the midwives spoke of this “forced rotation”, and it seemed to be
causing them considerable angst either directly, or indirectly, through the
distress, lack of confidence or expertise of midwives who were being forced
to work in areas they were unfamiliar with. This was frequently due to long
periods of time out of an area, most commonly (but not always) Birth Suite.
Some midwives were being expected to work in areas that they had not
practised in for more than twenty years. Lack of knowledge of common, up-
to-date practices, and insufficient orientation and mentoring when working in
these “new” environments for the first time in many years resulted in high
stress levels and unusually high amounts of sick leave. This had the potential
to add further to the workload and dissatisfaction of those who remained at
work. Olga, Betty and Natalie share with us some of their feelings and
experiences regarding “forced rotation”.
Like there are quite a few upheavals in our unit at the moment, with the
management, there’s a lot of agro between management and Level
ones and twos because they’re trying, they’re forcing us to rotate. A lot
of people have a lot of problems with that, like they’re going out of their
area of expertise. They’re midwives who’ve been working in an area for
10 or 15 years and they’re being forced to come to the Birth Suite which
is a high stress area and they’re very stressed about that. There’s quite
a bit of conflict there at the moment, in our unit about that, … we’re
having problems. Olga
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So as you can imagine, the thought of having to come and work in birth
suite when it’s very, very busy and under resourced is a terrifying thing
for that lady... and I’ve never seen her take sick leave until this started
coming up. She came and worked one shift with me because she knew
she would be working with me. And she was terrified. It’s not that she
hasn’t got the skills. And I think every single one of our midwives has
got basic skills up there. It’s not. It’s a matter of the level of skills in
each area. If you work in one place for a long time, you get skilled in it.
.. it’s not that I don’t think that they’re not competent, but what they
don’t have is the expertise. And that’s what’s difficult, like for me to go
and work in the nursery, I don’t have the expertise. I have basic
midwifery standards to work there. I can go and tube feed babies,
change babies, do obs and do those sorts of things but I’m not an
intensivist. I don’t want to work with the babies, that, you know on
CPAP, and on head boxes and all that sort of stuff, it’s just not where
I’m at. But if I had to, I would go over and work there and we all do
that. But to be forced to work in that area against my choice….. I don’t
know……. Sad. I don’t know. (italics added) Betty
There are some people, most people they don’t want to rotate because
they haven’t done it for a long, long time and they’re afraid. … If your
staff are happy, they’re going to work well. They’re going to be happy
in their work. They’re going to deliver better patient care because
everyone is happy, it’s a happy environment. …There’s going to be
less sick leave, there’s going to be less stress, because people are
happy they’re going to support each other more and often in a crisis
people don’t really support each other. They run. I would want the
happiest, I would want my team to be so happy, I would want everyone
to be working, you know, and that would, I think as far as budgeting,
the sick leave is a big thing. Giving people holidays when they want
them… you know, within reason… I would want my staff to all be
really happy. I wouldn’t want friction and fighting, but, it’s just like this
power. They want power. They want total control. And I don’t know
where it’s going to end. … They don’t care because it’s been put to
them and they want people to leave. That’s their choice. We’ll just
find someone else. And there’s no-one to do night duty. I don’t really
think they care. I don’t think they’re looking at it. I don’t know. I don’t
know where it’s going to end. It’s a bit scary. Because where is it
going to end? … And another thing that’s a bit scary is that they don’t
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like people who have a good knowledge base because they might
question what they’re doing. Natalie
The midwives did not seem to perceive that the team midwifery model had
been introduced for client benefit, and expressions of any benefits of the
system were rare. Walker et al. have noted that “information on the benefits
to midwives is scant. In addition there is little information available on how
midwifery teams operate together or what midwives perceive as their role in
the team midwifery model of care” (2004, p.18). The most commonly cited
reason, by the midwives I interviewed, for the introduction of the new model
of care was money.
Natalie informed me,
Due to financial restraints, cost cutting, budgeting, the powers that be
have decided that we will all rotate. So people who have been a
midwife for 20 years but have never ever worked anywhere but a post
natal unit, probably at 56 years of age and about to retire, they’re
suddenly having to go and work in birth suite. It’s just destroying the
whole morale, it’s destroying Natalie
We have already heard that Olga quite simply stated,
There are quite a few upheavals in our unit at the moment, with the
management. There’s a lot of agro between management and Level
ones and twos because they’re forcing us to rotate. A lot of people
have a lot of problems with that. Olga
and Betty said,
I think the almighty dollar is at the back of it and I also think that the
power game is at the back of it. Betty
From the midwives’ point of view, the new model was apparently seen as a
cost saving, stress inducing, morale destroying “monster”. This awful,
uninvited, all encompassing change to their work environment had the ability
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to produce conflict and forge a chasm between the workers and the
management. Furthermore, it seemed to be doing both rather efficiently.
Natalie viewed it as a form of control or oppression that management was
purposely imposing from above. Betty also expressed that she thought it had
something to do with control, mentioning the “power game”, and Olga’s use
of the word “forcing” has similar implications. It is extremely doubtful that the
management intended to cause stress or conflict, destroy morale, or create a
chasm between levels of employees. As the midwives themselves have very
astutely pointed out, such actions would have been clearly counter
productive for both midwives and management. Regardless of intent,
however, and we are not in a position to know what the intent was, these
things were happening.
What Can We Make of This? Olga, Betty, Natalie, and Irena spoke the most about this forced rotation.
Whilst all of them had issues with the system, Irena appeared to take a
positive view of the situation for herself and make the most of the challenge.
The encounters that the midwives experienced in regard to the rotation to
different areas are somewhat nebulous. Unlike most ethical encounters,
which clearly involve distinct players in a defined event, this is a recurring
event that is happening due to the prior decision of an unseen body of
individuals (management). The people affected by the decision (the
midwives) seemingly have no reasonable opportunity to respond. We can
clearly see this as being an ethical encounter, if we view management as one
party and the midwives collectively as the other. The decision/s that
management (as a group) made affected the midwives, profoundly, I would
suggest, as a group, but also as individuals. Their responses to the situation
affected management, individually, but also as a group. The purpose that
was (most likely) the intended and main focus of the introduction of team
midwifery, that of better care provision for the women that came to the
hospital during their pregnancy and birth, seemed to be “missed” by the
midwives altogether. Instead, this “forced rotation” was seen as intrusive,
stressful and unhelpful in a number of ways.
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Natalie told me that it
gives the hierarchy total control. The power game. Because they’re
going to break up any little cliques that might be around. They don’t
want anyone, you know, questioning them or, they want the whole,
they’ll have total control, they’ll have total control over staff as far as
rosters …How many people will get their request? …it’s just going to
be an absolute nightmare …it’s just going to have such a great effect
on us. Natalie
She also thought that it provided a means for management to chastise staff,
and thought that she could be a target for adverse treatment. She said,
I mean I feel that some people are punished. In fact I can’t
understand why I haven’t been rotated more to areas that I
really hate because I’m outspoken. Natalie
Betty was very vocal about many aspects of team midwifery and the impacts
it was having. She speaks of both personal implications and the effects she
sees on the wider midwifery team.
We have to diversify, that we have to work in all areas. I agree with it
and I disagree with it. And I think it’s a cruel system. There are a
number of midwives who are not Birth Suite midwives… And they’re
being forced to work in that, with no choice. And that really, really
upsets me, it upsets me a lot. We’ve had meeting after meeting, we’ve
told them [management] over and over again, from every different
aspect and angle that we could think of. … They’re determined to
keep up and keep on with it. That’s very frustrating, very
disappointing. Betty
and
… our management have made our midwifery team the most
miserable I have seen in 22 years, and it depressed me, I was sad
about that. And I thought they’ve got such a wonderful team of
midwives, such expertise in all areas, and they’re not, they’re not doing
their job, as far as I’m concerned. They’re not doing what needs to be
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done to get the best out of people at all times. And that’s really sad
because they could; it’s such a simple thing to do. Betty
Natalie also had comments to make about management and administration
either not listening, or not hearing the midwives’ concerns. It seemed as
though everyone was unhappy except, perhaps, the management.
…we’ve had feedback from the director of nursing saying there isn’t a
problem. There isn’t a problem with maternity services … the
management. It’s the Level 1 staff unwilling to accept change. So
that’s another slap in the face from the director of nursing services.
Level 1’s are very unhappy. Level 2’s are very unhappy.
We did have inter-unit meetings for a long time with the inter-unit
meetings to discuss the rotation and how it was going. It was all the
same old jargon until no-one would turn up. It was all rehashed and
rehashed every week so that all just fell by the wayside. Natalie
From these examples we can see that:
The midwives
• Had to diversify
• Were being forced to work everywhere
• Had no choice in the matter
• Were upset
• Were frustrated
• Were miserable
Management
• Made midwives miserable
• Weren’t getting the best out of their staff
• Persisted with team midwifery despite the midwives’ concerns
• Forced people to work in all areas
• Gave lip service to feedback from midwives
Thus the two groups can definitely be seen to have been engaged in an
ethical encounter. Many ethical components are present here. Even if we
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think at the most basic level, as to how one might respond to an “other”, how
that “other” might be affected by what we do, say or expect of them, it
becomes very clear that any management decision in any setting is an
ethical encounter with the employees who could be affected by such a
decision. I will return to this concept of the ethical encounter shortly, but let
us first delve into team midwifery a little bit deeper, from the midwives’
perspective.
Natalie wasn’t keen to rotate, but felt, professionally, it was probably a good
idea for herself, and other midwives, to do so, and update and fine tune their
skills in the areas where they hadn’t worked regularly in recent years. Whilst
acknowledging this, she also knew that she would need mentoring and
opportunities for education and learning, both on and off the job, if she were
to move out of her area of expertise.
Um, so now they’re telling me you rotate through every area so it
means that they’re not going to educate me to go update my skills in
birth suite, so that means that I really have to go and re-educate
myself again … because things change all the time … We had an
inter-unit meeting and they said you, as from next Monday everyone
will rotate. … it will be fair and equitable for all staff – which it hasn’t
been. I’ve done I think ten or twelve shifts in birth suite. Two shifts a
month. Who can up skill with two shifts a month in an area you’ve
never been to, haven’t been to for eight years?
I said I didn’t particularly want to rotate, I didn’t want to go out of my
league, my comfort zone and that’s where I, you know, spent a lot of
time and money re-educating myself. However, for my own personal
professional development, I felt I needed to rotate in other areas. I
don’t want to spend all my time there, but I just I was happy to rotate
provided I was given education, I was precepted, had a buddy each
shift. That has never happened. Natalie
Natalie perceived that other people were also unhappy and perhaps felt the
same way that she did. She was not really surprised to discover that she was
correct. She told me
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…the people I’ve spoken to who don’t want to rotate, don’t want to
move, I’ve sat down with them and I’ve said to them, “now if you had to
do it, would you be happy to do it if you were educated, if you were
updated, if you had a buddy, if you had a preceptor for every shift you
were in that area? Would you feel better about it then? Would you be
more happy to rotate?” And they said, “Yes.” Natalie
Midwifery is not only a science; it is also a hands-on practical art. Like most
areas of nursing, midwifery is a very dynamic, ever-changing field of practice.
Many midwifery skills are learned and refined through repetition and practice,
and up-to-date skills are learned through research, collegial interaction,
practice and practising the practice. Mentoring of new and returning staff to a
specific area is an important aspect for both skill and confidence building. If
one is not working in the area where specific skills are used on a regular
basis, such knowledge and skills can be dulled, pushed to the back of one’s
mind behind the vast body of knowledge one has accumulated about the
current practices in one’s present work area. Also, from personal
experience, I find that midwives can be guilty of not keeping their knowledge
up to date in all areas, or even in their own area of practice. The time
pressures of everyday work do not allow for reading or research at work and
the cost of professional conferences and workshops is often prohibitively
high. To compound this, midwives are frequently unable to attend learning
activities in work time30 and funding support from employers is both
competitive and difficult to obtain.
A different attitude toward working in new areas was conveyed by Irena, but I
can’t help but wonder if it was, perhaps, a little tongue-in-cheek. She seemed
to adopt the position of one who was resigned to the fact that staff rotation
was going to happen, and there was nothing she could do about it. So, she
30 With the introduction of professional development entitlements (time – leave of up to 3 days per annum, and money – an allowance of $1,500 to $2,500 per annum) now built in to nurses’ and midwives’ wage structure, and proof of ongoing learning soon to be introduced as a requirement for registration, this is likely to change (Qld Industrial Relations Commission, 2006)
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might as well make the most of the situation. She told me she was one of the
first to be moved. This is some of Irena’s story.
… didn’t mind doing post natal at all, because I’d done six months in
post natal before I’d gone into the nursery, full time. Arr… Birth Suite I
hadn’t been in since 1974. And I thought “hey lucky me, I didn’t think I
would ever have this opportunity again”. So I walked in there and said
“Where’s the pan room? I’m going to work from the floor up, I haven’t
got a clue”. Irena
In the postnatal area, where her experience was relatively recent, she felt
confident and competent. Thus, she apparently had no issues with being
asked to work in that area. Again, however, we can detect a hesitance when
it came to being asked to work in an area where the midwife had no recent
experience. In this case it was almost thirty years since Irena had worked in
Birth Suite. It was almost as if she was debasing herself, relegating herself
to the pan room as a starting point, as if it were the only place she felt
qualified to be in Birth Suite.
There is no doubt that team midwifery presented many challenges to the
midwives and to the administration of the hospitals where it had been
introduced. From the perspective of this interaction between the
management and the midwives being an ethical encounter, there are many
issues that are important to consider. They include the following.
• The midwives were unhappy and stressed - … our
management have made our midwifery team the most miserable I
have seen in twenty-two years (Betty); they’re [the midwives] very
stressed about that (Olga)
• The midwives felt they were not listened to, their voice
was not important - we’ve told them [management] over and
over again, from every different aspect and angle that we could think
of. … They’re determined to keep up and keep on with it. (Betty);
they’re [management] really are removed from the clinical area and
they do not understand, and don’t want to understand (Natalie); We
did have inter-unit meetings for a long time … to discuss the rotation
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and how it was going. It was all the same old jargon until no-one
would turn up. (Natalie)
• Morale was very low - It’s just destroying the whole morale, it’s
destroying (Natalie)
• Conflict arose - There’s quite a bit of conflict there at the moment
(Olga); it’s a very unhappy place due to the hierarchy … (Natalie)
• Some of the midwives felt they were being treated unfairly
- it will be fair and equitable for all staff – which it hasn’t been.
(Natalie); the people who are enforcing it are not doing it themselves.
It’s not something that they are going to do themselves either. But
they are happy to foist it on other people and don’t seem to really
care. (Betty)
Management were insisting that staff work in areas for which they felt
unprepared and ill equipped. This system was seen as being unjust. Not only
was it unjust, some of the midwives also felt it was unsafe, as so many were
unprepared professionally for the work they needed to do in the areas they
were being transferred to. They were being forced out of a comfortable place
into an insecure environment, without the support they required to practise
safe midwifery. Not only did they feel uncomfortable, they were also unhappy
and highly stressed. Working in an area that they had not been in for many
years was stated as a reason for being stressed, as was not having up to
date knowledge, but interestingly, the midwives did not say exactly what it
was that made them stressed. Were they stressed about change, about
making a mistake with the legal implications (i.e. possible professional
implications for themselves), or human implications (i.e. possible harm to
mother or child), or perhaps it was as simple as having to move from area to
area on a regular basis or needing to work with people they did not know? As
the midwives perceived that they were being afforded very little personal or
professional respect throughout the process, it is likely that this was a
significant contributing factor. I suspect, however, that it was a combination
of all of these things, and even, in some cases, that the individuals had not
themselves yet reached a state of working out exactly what it was that
caused them so much angst.
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Another point of interest is that all of the midwives interviewed spoke of other
midwives being stressed and distressed about the changes, more so than
themselves. Although they did not deny that the changes had had a
significant effect on themselves, their stories gave the impression that they
spoke of a greater harm that they were trying to bring to my attention. What
was happening was harming the practice and the practitioners, due to the
immense stress and unhappiness, the management’s apparent disregard of
the staff’s concerns and the lack of practical support. Furthermore, it could be
dangerous and lead to client/s receiving inadequate or inappropriate care, as
staff with knowledge gaps were working in areas where they felt ill prepared
and inadequately supported or supervised.
This made for a rather uncomfortable situation, and could be seen as an
inappropriate use of the hospital’s administrative power. Management is
always in a position of power, simply because they are management. Power
is a remarkably complex issue, and it has a vast array of manifestations.
Benevolent power is where one utilises the power they have to benefit
another. Davidhizar (2005) discusses this in relation to the nurse/ client
relationship, but it could be easily transposed to the midwife/ manager
relationship. Betty, Natalie, Olga and Irena would, I suspect, be unlikely to
say that the managers and administration were using this type of power.
They did not seem to be using the power they had to benefit the midwives. R.
May (1972) outlines five types of power which may be of greater benefit to us
in trying to discern the way in which power was being used in the situations
these midwives have shared.
R. May defines power very simply as “the ability to cause or prevent change”
(1972, p. 99), and he outlines five types of power – exploitative, manipulative,
competitive, nutrient and integrative. The first type, exploitative, equates
power to force, and is the most destructive type of power. This is where the
one with the power uses the other to whatever means they wish – they force
the other to do as they demand, and the other has no choice in the matter. If
a person holds manipulative power, they have power over another person.
The other person has some choice, but little. Competitive power is power
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against the other. It can be both positive and negative. In its positive sense,
competition causes people to challenge each other, helping them to develop
their skills and knowledge. It can have a negative side though, as one person
may cause another to go “down” as he/ she goes “up”. Nutrient power, power
for the other, and integrative power, power with the other, will be discussed
further in the next chapter.
Several of the participants have informed us that midwives were being
“forced” to rotate, and this could incline one to think that administrators were
utilising a form of exploitative power, where the midwives had no choice
whatsoever. This is probably not the case, as the midwives did, in fact, have
some choice and some opportunity to respond, albeit that their responses
seemed to fall on deaf ears. We will see below, that they were able to act
upon the choices that they made. Even though they may not have been
happy about having to make those choices, this means that they were not
trapped in a situation of exploitative power, which amounts to a situation of
slavery or bondage in many cases. From the stories that have been shared, it
sounds as though the midwives felt that manipulative power was used –
power over – and that they had very little choice other than to do as they
were being told.
Betty told me of some midwives who simply could not work in different areas
because of family commitments making shift work impossible, and
management’s response was unyielding.
And yet they’re going to be forced into a situation and are being and
have been forced into a situation. “Well that’s tough if you want your
job you’ll do it.” I just, just find that such a terrible, terrible attitude.
Betty
Management can work with their staff or over their staff. Here we see the use
and abuse of power - “Well that’s tough, if you want your job you’ll do it”. This
is definitely a case of “power over”. You can toe the line or you can choose
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not to. We do not really mind, but if you choose not to, you cannot work here.
Betty very wisely points out
that if you’ve got people that are happy in their work then you’re going
to get the best out of them. You’re going to get loyalty, you’re going to
get somebody who’ll come and give you 110 % rather than 80%.
Betty
Betty offers these sage words, which are not dissimilar to those of Natalie’s
quoted earlier in this chapter, " If your staff are happy, they’re going to work
well. They’re going to be happy in their work. They’re going to deliver better
patient care”. Most people will give their all when they are enjoying what they
are doing. Whilst this seems to be quite obvious to some people, like Natalie
and Betty, it is apparently either not obvious, not important, not a priority or
very difficult to attain from an administrative position. If it were, it would be a
natural inclination for all employers to do everything possible to ensure their
staff was satisfied, and as content as possible in every aspect of their work.
Yet, the unhappiness ran deep within this cohort of midwives. In these
circumstances, what choices did the midwives have? They could work in an
area where they lacked confidence, they could take sick leave, or they could
resign. Potentially, doing the first could lead to the second, simply because
there were inadequate human resources to support them in the transition;
that is, they might actually become sick through stress. Some sought new
positions elsewhere and left31.
The attrition rate’s terrible. I think people just get so disillusioned, that
they find other areas to go to. We’ve actually seen a lot of that in the
last six months, where we’re working. Because people just get
disillusioned with management. And just find themselves positions
elsewhere. We’ve probably lost a half a dozen midwives.
Experienced midwives, you know. Betty
31 I would like to propose here, that it is possible that some of these difficult situations (not enough mentoring, for example) arose due to circumstances that were outside the control of the managers/ administrators that were in direct contact with the midwives. For example, in my personal experience, I am aware that there are times when, despite a manager’s best efforts, it is impossible to obtain sufficient numbers of midwives to come to work to meet the staffing requirements when the hospital is extremely busy.
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…it’s not a very happy place at the moment, it’s a very unhappy place
due to the hierarchy … if I could get a job doing something else that
paid me the same amount of money, I’d get out of it. Natalie
… because of management in the area that I work in I am now doing
my child and maternal health to move on. Cherry
In summary, the practice of team midwifery was clearly having a negative
impact on the midwives in my study. It was causing them to feel pressured,
undervalued, disrespected and unhappy to the point where many of them
actually considered leaving the profession altogether. One of the midwives
said it caused her to be depressed and made her the unhappiest she had
ever been in her twenty-two years of midwifery. There was a loss of
confidence in ability to practise; for example, Irena’s request to be shown the
pan room so that she could work there, and the midwives at one hospital
implied that there was an increase in sick leave. One midwife commented
that the attitude filtered through to the clients, that they must surely know that
their midwives were not happy. A constant tension existed between
management and midwives, a feeling that one did not understand the other,
and did not really endeavour to do so, despite meetings, consultation and
surveys. All in all, this system did not appear to be showing many positive
benefits from the midwives’ point of view.
Naturally there were other issues that midwives had cause or need to interact
with management about. One significant area of concern was support for
education. We have already been introduced to this topic, because it became
an acute problem when midwives were asked to work in unfamiliar areas.
This was not, however, the only time education concerns generated friction
between midwives and their managers.
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Education and Training Felicity shared the following example of how management (“they”)
sometimes put pressure on midwives to gain required skills, without providing
adequate resources in terms of time, money, or skilled mentors, as was
appropriate to the situation. Midwives were expected to undertake training in
their own time.
Everything is self directed where we’re working, so you are required to
do a lot of it on your own and you know the epidural package, great,
you can do that on your own, you’re working with it, you can, you’ve
got the information, you can do it, but the interesting thing is they’re
encouraging us all to do the IV package and become competent in
cannulation but the practical side of it, to get the qualification, they
expect you to do it in your own time and I was very vocal in saying
about that, “Well, if you want me to do this package, then you are
going to give me the time to do it. I am not going to do it in my own
time. I’m sorry, I’m not that dedicated to you.” Felicity
One is left to question if this is reasonable, appropriate or ethical. Is it fair for
an employer to require this of midwives? Were funds being directed
elsewhere? Was the situation such that staff shortages meant that midwives
could not be released from direct care duties in work time, because direct
client care would be compromised? In this latter case it would have been
unethical to allow the midwives time away from the ward areas to attend
training session. Could other arrangements have been made? Later Felicity
told me that she, and other midwives
had a couple of occasions where we’ve been down to do the
mandatory in-service day and we have been pulled off it Felicity
Mandatory in-service is, not surprisingly, mandatory. It is usually annual, for
most staff in most hospitals, and depending on the role of the staff member,
includes a variety of different sessions. For midwives, mandatory in-service
typically includes fire, safety and security awareness and assessment,
neonatal and adult resuscitation assessment, and manual handling (lifting)
assessment. It may also include revision as required, as well as updates on
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changes to hospital/ institutional policies and procedures (personal
experience). Common sense is enough for us to see that this type of
education is essential for the smooth and safe running of a hospital. Some of
these requirements are legal, others institutional and some are professional.
Often knowledge and competencies included in mandatory in-service
sessions fall into more than one of these categories. In each hospital where I
have worked, the managers of each section have to arrange for their staff to
be able to attend a session, in work time, as it is the joint responsibility of
both employer and employee to maintain these competencies. Time must be
allowed for midwives to attend these sessions to ensure competencies are
maintained and knowledge of hospital protocols is up to date.
Many of the midwives interviewed accepted some responsibility for their own
education. On the other hand, they noted that many midwives did not make a
similar effort to keep their knowledge up to date, and that there wasn’t much
help, encouragement, or support offered for their efforts. Adding insult to
injury, some of the midwives felt that their knowledge gained through the
extra educational opportunities they had afforded themselves, usually at their
own expense, was not valued at all by their peers or their superiors (i.e.,
management).
Education is the Midwife’s Responsibility Many midwives acknowledged that they had an individual obligation to
ensure that their knowledge was kept up to date. Some enjoyed this
furthering of their knowledge; some found it a financial burden; and most
noted the need for self motivation. This is what some of them had to say
about accepting taking an active role in their ongoing education.
• There are just so many different ways to handle the individual and a
baby, and so I think yes, you do have to constantly keep yourself up to
date. Cherry
• I think you are accountable and you must make sure that you have
continued professional development… I think you have to be that sort
of person that wants to do it, um, (long pause) but I mean, well I’m in
that category and I just like to keep learning. Mary
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• I’ve put a lot of time and money into education. When I was in special
care, I put a lot of time and money into education regarding special
care babies. Went off to seminars and conferences at my own
expense. That seemed to be all wiped when I was moved to post-
natal. So then I put a lot of time and money into breast feeding and
post-natal nursing to educate myself because we don’t get any funding
for anything as you would know. Natalie
• So if you want education now, the general consensus is that you pay
for your own education. You go out and find your education. Olga
Not all Midwives Seem to Agree These same midwives, however, commented that other midwives did not
seem motivated to spend the time or money to continue their education in
similar ways. They found this frustrating, and thought changing practices for
the better was akin to fighting a losing battle. This was sometimes the case
even if up to date information was presented to these less enthused
midwives in the workplace. Something needed to be done if midwives were
planning to continue to practise “good” midwifery. They said,
• I mean there’re people out there who just don’t want to do
anything. Mary
• There are midwives who become midwives and haven’t moved
since they did their training. … You read journals, but there are
people who simply don’t do that. They’re stuck in the old groove of
conducted second stages, not getting women off the bed, having
all the lights on, like they distinctly won’t change their practice.
Even through peer pressure, they don’t change their practice.
Even now, just to get any change in midwifery is an uphill struggle.
Olga
• … people have been there for ten years, I mean, just not up with
the current changes, they are not up with the best practice
principles, and when you challenge them and say that that is not
what you should be doing, they get really defensive… I am
challenging them professionally, because they’re doing it this way,
and yet evidence based practice tells you that this is the way that
you do it now, and it has been proved that is why you do it, to
change it, and yet they are still doing it this way. And it is hard, it is
really hard to change people’s practice. Mary
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Should Support be Offered by Management? In the examples given earlier by Felicity, it seemed obvious that some
support ought to be offered by management, particularly in the case of
mandatory in-service. The case is not so clear cut when we are considering
professional development and the acquisition of new (or refinement of dulled
or lost) skills. It is incumbent upon any professional person to keep abreast of
the developments within their field of practice, but that professional might
also expect some support from his or her employer and profession as a
whole. In what form, or to what magnitude this support should be, or spread,
is a matter of debate. Let us look at some of the midwives’ thoughts.
• But I think there is also the responsibility of the profession to
assist you with that, and to encourage you, to sort of give you
that encouragement where they might say, just simply, we
would like to send you off to this course or whatever because
you are doing such a good job. I don’t think we get a lot of
that and then it comes down to funding and finance. Like I’m
a registered nurse and midwife and … I did two years study in
working in a special care nursery … I felt that I had a lot to
offer when I finished the course …in regards to some skills
that I had learned or practices that were different to what we
were doing but there wasn’t a lot of interest taken from a
leadership point of view Cherry
• I think you have to give them [midwives] some sort of
motivation to want to go and do it [study] you know. For each
of them the on-going education, while their need is for it, what
you’re going to gain out of it, you know, nothing is monetary at
all, you don’t get paid for anything that you do. Its just self-
satisfaction. Mary
• … study leave has certainly played a great role in that you
can get that time off. I think the employer has some
responsibility as well. I mean they should … help pay
something you know…, that’s the way it works [in another
state] you either take the time off or get study leave for it. Or
they pay for you to go to the seminars, conferences. Mary
• I was happy to rotate provided I was given education, I was
precepted, [if] I had a buddy each shift. That has never
happened. Natalie
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Clearly, all of these midwives felt that management had a role to play in
supporting staff in obtaining and upgrading their skills. Cherry felt the wider
midwifery body had a responsibility to encourage individual midwives,
perhaps with support for conferences or workshops. She notes the eternal
problem of (lack of) funds, and her disillusionment when management failed
to embrace her skills learned during her self motivated studies. The latter has
resulted in her choosing to leave midwifery altogether.
Mary sees that a large part of the problem is that there is simply no reason
for midwives to be bothered to attend courses or gain further qualifications.
They require time and effort, and are usually rather expensive. As there is
little or no recognition in the workplace (e.g. Cherry’s experience) and little or
no monetary gain in most instances, there is, Mary says, little motivation to
participate in on-going education other than self satisfaction. Thus,
management has a responsibility to contribute to the costs of staff education,
and she commented that this was commonplace in another state where she
had worked.
Natalie was adamant that management had a responsibility to support and
educate her as they “forced” her to work not only outside of her comfort zone,
but outside of the boundaries of her knowledge and, therefore, outside of the
domain in which she felt secure to work both independently, safely and, by
implication, ethically. As she knew she was working in an area where she
was not fully competent, it would be unethical for her to practise there unless
she were mentored. If Natalie were to work in this area, for her sake and the
clients’, she felt it was appropriate that she should be buddied for at least a
little while, until she was “up to speed”. She had already spent time and
money honing her skills in several areas, but now she was being asked to
work somewhere where she knew her skills were not up-to-date. Support and
guidance were needed. She felt quite let down, and in fact, discovered things
that she didn’t know by chance.
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It was only through sitting down and talking to a few of the girls that I
realised that, you know, I was really out of touch with a lot of things
and no-one had up-skilled me. You know with physiological third
stages, I didn’t realize you had to have hands off, you don’t touch. I
mean I didn’t know, I mean not that I’d practised physiological. But it
was just things like that and I thought “Oh, you know I’m really behind
with all of this”, but only because I had overheard a couple of girls
having a discussion about it, that I sort of said OK now look tell me
about it. Tell me about this. What am I supposed to do? I mean I
hadn’t been there for a long time and I’m not taking risks. Natalie
In the United Kingdom, nurses and midwives are required, legally, to
maintain post-registration education and practice (PREP) skills and also to
participate in continuing professional development with the NHS Knowledge
and Skills Framework (KSF). This means that each nurse and midwife must
have recency of practice (a minimum of 750 hours in the last five years) and
undertake at least 35 hours of continuing professional development in each
three year period (Harding and Salmon, 2006). Maintaining a portfolio is an
appropriate way to keep records of one’s professional development and
Mullen has advised of the benefits of this, say that “by encouraging and
enhancing continuous professional development, the portfolio helps the
practitioner to integrate learning and practice. By exposing gaps and overlaps
… the … portfolio also encourages reflection on strengths and areas for
improvement” (2007, p. 62). In Australia, there are similar expectations that
midwives will maintain and upgrade their skills and knowledge in line with
current knowledge and practices.
The Australian Nursing and Midwifery Council, and the Nursing Councils in
each State, have produced codes and guidelines to ensure nurses and
midwives maintain their skills and knowledge. These include the Code of
Professional Conduct for Nurses in Australia (ANMC, 2003); the National
Competency Standards for the Midwife (ANMC, 2006); and the Code of
Practice for Midwives (QNC and ACMI, n.d.). All of these documents contain
elements that inform the midwife of his or her responsibility to maintain and
increase their knowledge. The National Competency Standards for the
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Midwife Competency 13 says that a midwife “Acts to enhance the
professional development of self and others.” Further to this, we are told that
a midwife “seeks and engages in opportunities to maintain or update skills,
knowledge, attitudes and experience” (ANMC, 2006, p. 7). These statements seem to indicate that both maintenance and enhancement
of knowledge are midwives’ individual responsibility. It is also the
responsibility of all midwives, though, to enhance each other’s professional
development. Many members of management teams in maternity settings
are themselves midwives. We could logically carry their responsibility to
enhance the professional development of the “other” to all the midwives on
the staff of the institution where they happen to work. I wonder, however, if
this was the spirit in which the Competency Standards were written? Could it
be applied so abstractly?
If we apply the concept to an individual situation, though, perhaps there are
situations where a single nurse manager could be held responsible for
ensuring that a single midwife is provided with an opportunity for professional
development? Think of Natalie, and her need for a “buddy” on a shift in a unit
where she felt her skills were not up to date, or Felicity being pulled off
mandatory in-service. Could the nurse manager have been responsible for
ensuring that Natalie and Felicity received the learning opportunities they
needed on these occasions, in their respective locations, on those particular
days? Maybe it could be taken even further. It could be suggested that, at
times, nurse managers have a moral obligation to ensure that midwives they
are “managing” receive the education they need to make provision for safe,
competent client care in the future. This is thinking about basic, safe,
competent care. What about providing the very best care?
It would certainly be to any employer’s advantage to support and encourage
their staff to be as knowledgeable as possible in the field in which they are
working, in whatever ways they could. It appears also, from the midwives’
comments, that the staff would appreciate practical support in the way of
financial assistance or time off work, or even simply acknowledgement of the
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knowledge they have gained. Having said all of this, the responsibility,
professionally, falls upon the midwife. It is incumbent upon each midwife to
make sure her competencies are up to date.
Staffing Constraints Another significant concern voiced by the midwives was that of having to
work in situations where they were understaffed. The onus for this shortage
of skilled people was laid squarely at the feet of management. The midwives
expressed that they had been “left” in these circumstances, as if they had
been abandoned when in need.
Midwifery is very unpredictable. Babies do not run to a schedule, and they do
not let us know in advance just when they are going to arrive. This makes
staffing a maternity unit, especially Birth Suite, inherently challenging. One
can never know for sure if there will be ten ladies, or none, arriving in the
next hour. Nor can it be anticipated with any certainty if those ladies will be
having straight forward, uncomplicated labours with no need for intervention,
or if they will be requiring a great deal of attention, care and time due to
unforseen circumstances. What we can be sure of is that we cannot be sure
– midwifery is always an unpredictable setting. Thus, there is no way to
know, with any degree of certainty, if the unit will require one midwife or
many midwives to operate safely in the ensuing hours. Although I have used
Birth Suite as an example, similar situations can arise in Post Natal,
Antenatal and Nursery areas. A sudden influx of clients or an emergency can
result in an immediate need for a large number of staff. The best that can be
done is to provide staffing on the basis of previous patterns of admissions, or
averages.
Cherry explains the effect of a staff shortage one night where she was
working. She informed me that this was not a once-off occurrence. Another
midwife, Betty, explains how she was left in this situation with clients
requiring close monitoring and too few hands and heads to do the work
required. She found herself “running around like an idiot”.
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… that particular night that this lady delivered, that I was involved with,
I was supposed to be working special care that night and Birth Suite
was left staffed with one senior midwife, the level 2, and her, she was
left with one other person who was there actually doing some training
and refreshing. And then the level 2 that was on received a phone call
to say there were like, five women coming in. So then they had come
and taken me from Special Care and I think in that particular night
there was something like six or seven deliveries and the staffing was
atrocious and on, on rosters, and things like that, your numbers are
there, but if there is say four staff on and two women labouring, they’ve
been trying to take staff away to put in another area of the hospital and
we have the same problem going on in Special Care Nursery. Once
our numbers sort of got down, all our staff would be shipped all round
the hospital and midwifery is just so unpredictable, you don’t know
who’s going to come in at one time, you know, you can’t, bar your
booked inductions and things like that, you don’t have a little crystal
ball that says well you’re going to have six women come in tonight so
you have this many staff on ... Cherry
… we are supposed to have 4 midwives per shift in Birth Suite. And
that night, they left me with a rural midwife, there were two of us, and I
had a lady with meconium liquor whom we had started on a syntocinon
infusion. And I had a prem. A lady who was 33, 34 weeks in labour,
needing analgesia. And, so there I was, running around like an idiot.
Betty
Midwives often come to work when they are sick. As they are already so
short staffed, they feel they would be letting their colleagues down if they do
not come in. This has become all the more so as people know that they will
not be replaced if they do not come to work.
…So that, you know, I suppose that the thing that I find very stressful,
working as a midwife is, not patient care so much, but the way that
we’re affected so intensely by management and their decisions and at
the moment we’ve got such an acute staff shortage, and, and they’ve
got policies, and decisions that they’ve made that affect us on a daily
basis, like they’ve got to the stage where they didn’t want to replace
sick leave. You would come to work so many times, you’d come to
work and you’d be working one down. … if it is quiet and ten minutes
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after they go home we have six patients there, you know. And that’s
just happening all the time now, and it’s very distressing because we’re
stretched so thin. Betty
If they were off sick and replaced by another midwife, their colleagues may
have to work with people unfamiliar with the workplace or the system, or
perhaps inexperienced midwives, but if they were not replaced at all, their
colleagues would simply have to carry twice the load. This placed extra
pressure on individuals when they were unwell, trying to decide between their
own wellbeing, that of their colleagues and that of their clients. Whichever
decision they made, any, or all of the people could be affected adversely. For
example, if a midwife came to work when ill, the following could occur;
• The illness could be spread (adverse)
• Other staff (not just midwives) could become ill (adverse)
• Other staff could need to take time off work (adverse)
• The ill midwife may not recover and eventually need to have a
longer time off work (adverse)
• The client may catch the illness (adverse)
• The ill midwife may not be able to work to capacity due to
illness (adverse)
• The ill midwife may make an error due to thinking less clearly
because she is ill (adverse)
• The unit would have its full quota of staff (positive)
• There would be less pressure on colleagues as the workload
would be shared (positive)
• There may be no adverse effects what-so-ever (ideal)
Conversely, if the ill midwife stayed at home,
• The unit may be short staffed (adverse)
• The clients may be provided with less than optimal care
(adverse)
• Other midwives may be over worked/ stressed and become
ill (adverse)
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• The ill midwife may feel guilty and impair her chances of
rapid recovery (adverse)
• The ill midwife may recover more quickly and return to work
sooner (positive)
• Colleagues may work with relief staff who do not know the
unit (neutral)
Either way, with the knowledge that they are unlikely to be replaced if they
stay home from work sick, a midwife is then faced with a difficult decision.
Her illness then has potential to affect many people other than herself, and
what might once have been a simple thought to stay in bed and get better
becomes a deeply value laden decision. All because of a decision “they”
have made to not replace “sick leave”.
Sometimes, purely due to the unpredictable nature of the practice, a day in
the life of a midwife can become extremely hectic. Many midwives
experience days like this from time to time. The excerpt below from Irena’s
interview gives us an insight into such a day. On occasions it reaches the
point where it is impossible for midwives to take a break at all throughout the
day. While one hopes this is rare, Amy tells an enlightening story.
We had ladies sitting in the TV room waiting to have babies. We were
full. There was an emergency caesar. The staffing wasn’t adequate
for the amount of patients we had. … the poor team leader …. Just
about… went out and shot herself I think (laughter). Ah, there was a lot
of tension. Irena
…it’s very busy I suppose and quite often you’ll miss meal breaks but,
you know, I’ve gone a whole shift without even having a drink of water
because it’s just been so busy virtually, not all the time but sometimes
it can be so busy. Amy
Emily is also concerned about the impact that management is having. She
said
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… with staffing constraints sometimes it is really disturbing when you
feel you, you can’t give the sort of care that you would like to give
because you are being pulled in a million and one directions by other
staff, other patients and various other administrative type things as
well. Emily
Emily, like many midwives, has a story that she has never forgotten. It just
stays with her, an ever present reminder of the way some things sometimes
are in midwifery. Though these stories that midwives tell are greatly varied, in
terms of the people and circumstances involved, they have in common a
haunting quality, an ability to embed themselves into the deepest part of our
minds and are seemingly impossible to erase. Here is Emily’s story.
… a long shift that always, I always think about and seems quite
disturbing to me is when someone’s newly delivered and you are
expected to take on another labouring patient plus supervise a couple
of new grads who are looking after someone. I had this particular day,
I had two new grads and myself. Somebody else was working there
that had to go off to a meeting so I ended up taking on their
undelivered patient, looking after these two grads and my patient who
delivered, even though she had a catheter in, ended up with a blocked
urethra and her fundus grew, and grew and grew and you know and
she ended up having this great big bleed and I just felt really, really
responsible that I hadn’t been able to keep checking on her as much
as I would have liked to because I ended up inheriting this other
labouring patient plus watching these other two girls and I mean you
know there are days like that where I just think Oh, you know, the
expectations of what you can manage can just grow and grow and
grow if you are capable and you’re willing to take things on, you know,
because there is no other option or whatever. So those sorts of days
are really disturbing and always stick in my mind. That particular
scenario I will always remember because that patient had a lot of
problems with voiding down the track and was doing self
catheterisations and it made me feel really bad that I hadn’t done my
job well enough. Ah, but that was a real staffing constraint problem, so
um, yeah Emily
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The story did not end here though, for Emily. She sought to resolve the
situation. She wanted to be sure that her managers were aware that she
thought it inappropriate that she had been left in a position where adequate
care was simply not possible and that there had been ramifications. Emily
also explained to the client’s doctor what had happened and made sure
documentation was correct for legal reasons. This is what she said,
Well I actually asked for a meeting with the boss that day because she
put me in a compromising situation. I felt by leaving the staffing that
way, she was the one that had gone off to the meeting and I was pretty
annoyed that a meeting was more important than meeting the needs of
the labour ward, you know, patients and staff. So at the end of the
day, and the two grads were feeling pretty strung out as well because
they hadn’t had the support that they needed, so I called a meeting
with the two bosses and they sort of said, well you know, yeah, in
retrospect we shouldn’t have gone to that meeting and yes, we did
leave you short staffed and so that was good to actually get that point
across and I spoke to the obstetrician and said you know basically how
the situation arose and you know I am very sorry that that is how it
ended up. And I made sure I kept all the documentation from it all as
well because they are the sort of things that come back and bite you,
you know a few years down the track if people are still having ongoing
problems. And I kind of saw that as being something that is very much
a staffing problem rather than, you know, a lack of skill or care on my
part you know, and so I think you know, a lot of people are getting
more into that sort of frame of mind as well, you have got to cover
yourself if you feel that you have been put in a compromising situation,
you need to make sure you have got all your “I’s” dotted and your “T’s”
crossed and everything. Emily
These midwives were not just busy because of the actions, policies or
decisions that the management have made or imposed. In some cases they
were hungry, thirsty, and possibly sick. Few people work well, to the best of
their ability and capacity, under those circumstances. They felt annoyed,
strung out, disturbed, stressed and distressed. These encounters between
management and midwives, the decisions that “they” made, were having
some obvious impacts on the midwives.
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Emily’s story is particularly interesting. The “haunting” quality intrigues me. In
the first part of her story she says it is quite disturbing, and really disturbing,
and that she feels really, really responsible, it made her feel really bad, and
that she will always remember. Despite the fact that she says, twice, that she
was put in a compromising situation, and that it was a problem that arose due
to staffing constraints – a fact that she also stated twice, and not related to
her skill or ability as a midwife, Emily still feels responsible for the outcome.
She feels not only responsible, but also disturbed and she is unable to forget
the circumstances of that day. Having been placed in a situation which was
outside of her control, Emily found herself spread very thin. Despite this,
whilst acknowledging in words that the adverse outcome was not her fault
per se, she says “it made me feel really bad that I hadn’t done my job well
enough”. There is incongruence. How can this be settled? How could Emily
have done her job better in this situation?
If she had spent more time with her client, who had already birthed her baby,
it may have prevented the complications occurring. She would, however,
have been able to spend even less time with the new midwives who, as it
was, were stressed out due to insufficient supervision. Furthermore, Emily
would also have had less time with the woman who was still in labour, whose
midwife was at a meeting, and difficulties or complications may have arisen
in her labour and gone undetected had she not been monitored
appropriately. From whichever angle this scenario is viewed, even in
retrospect, there is no easy answer. Emily was faced with a dilemma. Who
should receive her attention as a matter of priority? Each of the people in
question – the new mother, the labouring woman, and the recently graduated
midwives – needed her. As it turns out, the earlier encounter she had had
with managers deciding to send staff to a meeting would create an
impossible task for her. She simply could not meet everyone’s needs without
compromising someone’s care.
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Conclusion In this chapter we have seen how managers’ interactions with midwives
impacted upon them and their practice. This appeared, from the stories
shared, to be a mostly negative influence. It is almost as if the two parties
were working on opposite sides, with their goals being diametrically opposed.
Smeltzer and Vlasses have said “At a time in health care when nurses and
other caregivers are in short supply, are consistently reporting dissatisfaction,
and have limits on their ability to provide independent, professional practice,
and when patient satisfaction is arguably in decline, why doesn’t leadership
listen to the “stories of clinical staff?” Many times staff are looked on and
listened to as a group, not as individuals” (2004, p. 74). Could it be that
managers simply do not hear the individuals? Perhaps the hospital’s
administration has become so attuned to being an intrinsic part of the
institution that it has lost sight of the people?
The midwives certainly felt that their managers did not value them either
professionally or personally. They also implied that their managers did not
seem particularly concerned about the quality of client care they were able to
deliver. Management were responsible, as far as the midwives were
concerned, for making them and their workplaces miserable. They were
apparently more concerned with ensuring that budgets were met and staff
were working within the frameworks that they set, than actually striving to
understand how the midwives felt or what they needed. Even when
measures were put in place by management to provide opportunity for
discussion and consultation, there was suspicion, distrust and a sense that it
was pointless to participate or say anything, because, as far as the midwives
could see, nothing changed anyway. All was definitely not well between “us”
and “them”, and this could not help but to have a flow-on effect to any “other”
that might come to pass by the hospital.
We will now move on in our discussions to encompass relationships and
interactions with people outside of the midwifery profession. The main focus
of the next chapter will be the stories that midwives shared involving their
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medical colleagues. Doctors and midwives do not work together in the same
way as midwives and midwives. As a result, the stories that are shared in the
next chapter are noticeably different from those shared so far. Yet, there is a
remarkable sameness when people are working with people.
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CHAPTER 5 DOCTORS AND MIDWIVES
Everyone who has been a nurse, talked to a nurse, or read about
nursing knows that conflicts with physicians are a significant part of a
nurse’s agenda. D. Smith, 2000, p. 227
Introduction Midwives are trained and skilled to care for women and their families during
normal pregnancy, labour, birth, and the early weeks following. They are also
able to recognise deviations from the normal and know when to seek
assistance. Awareness of their scope of practice and the extent of their
knowledge base is an asset. It is possible for midwives to practise
independently, and many do, but when it is recognised that something
outside of normal parameters is occurring, the help of an obstetrician is
sought. Midwives need doctors, and doctors need midwives. Both are
necessarily part of a team.
El Halta (1998) believes there is a basic difference between obstetricians and
midwives. The former, she asserts, insist that women have to prove they can
have a baby without assistance, whereas the latter would like the labouring
women to prove that they need assistance. A midwife, she says, should be
“an expert in normal birth”, and an “obstetrician must be an expert in
pathology” (1998, p.9).
Many of the stories that the midwives shared with me included doctors. As all
of the midwives interviewed work in hospital settings, this is hardly surprising.
Given that several of the participants in this project worked primarily in Birth
Suite, it is also not surprising that a significant number of the stories I heard
that involved doctors occurred in Birth Suite, and thus were usually linked, in
some manner, to a birth.
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Hospital births include natural vaginal births (often called “normal birth” in
Australia), and vaginal births assisted by the use of forceps or vacuum (also
called Ventouse). These latter two types of vaginal births are referred to as
assisted or instrumental vaginal births. Then, there are caesarean births,
increasing in both popularity and number as the years go by32. Forceps,
vacuum and caesarean births are usually performed by a doctor, with a
midwife assisting. Throughout the labour and during the birth, it is vital that
the team caring for the woman communicate effectively so that appropriate
intervention may be implemented if required. The doctor/ midwife relationship
is not, unfortunately, always a harmonious one. During my interview with
Kelly, she brought up some rather salient points.
…one can’t exist with the other, but there’s just this gap and like
blaming on either side that just continually goes on. This ridiculous
fight. … we can’t function without each other. And there’s no point
fight[ing]. I won’t enter into that argument because you just cannot
work one without the other, and I’m certainly not prepared to take on
the responsibility of an obstetrician’s role when I’m not an obstetrician.
I’m a midwife. Kelly
Henrietta, speaking of obstetricians, says
I think they probably have more respect for a majority of the midwives
in their practice. Henrietta
In this brief statement, Henrietta gives us a positive view of doctors. They
most likely have fairly open communications with midwives. We would expect
this to be rather beneficial in their work, both when things are moving along
smoothly and in more difficult times.
32 In 1994, 19.4% of births in Australia were by Caesarean section. By 2003, this rate had risen to 28.5%. Caesarean births are increasing in most developed countries and this increase has been attributed to a variety of factors. These include medico-legal concerns, maternal obesity, maternal request, and increasing complexity of pregnancy and/or birth (McCarthy, Rigg, Cady and Cullinane, 2007).
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Cherry has mixed feelings, though, affirming that communication and
understanding are vital. She found one particular setting where she had
worked very affirming, telling me that
a lot of that had to do with our medical superintendent. He was a
fabulous man and had the utmost respect for midwives. Respected our
judgement, our experience, our skills and really worked with us, and
there was never this medical-midwife, or medical staff-midwifery stuff,
but, you know, he was right into active birthing and everything
Cherry
This certainly depicts an extremely supportive, beneficial working relationship
with doctors. It seemingly worked for everybody, for the doctors, the
midwives and the clients. Later, Cherry told me the “other side of the story”,
that, sadly, much of her midwifery experience had not been like that
mentioned above. This is what she said,
I think that midwifery practice in a hospital setting can be so influenced
whether it is positive or negative just in regards to who your medical
staff are. Because you can have your medical staff who are, like I’ve
had the experience of, so trusting of the midwives and work with them
and everything, but you can then have your medical staff who have
little faith in staff or are just very pro intervention and things like that.
So I find that in a hospital situation, midwifery practice is just so
influenced by that and it is very difficult to get past those people some
times and to practise as a midwife and keep things normal, so to
speak. Cherry
Debbie made comments along similar lines
One person might listen to what you’re saying and allow you to take
the initiative, another would say, “No, we must act on that because it
doesn’t fit within the guidelines laid down”. Debbie
The listener/ reader here is able to place their own interpretations. As a
midwife I am drawn to ponder how a doctor can make my practice positive or
negative. By his/ her trust or lack there of? By listening to me, or not? By
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insisting on early interventions, or interventions that are seemingly not
justified at all? By insisting on following protocol, even at times when it may
not be the most appropriate pathway for the individual at that moment?
Worse still, a doctor might not be attentive to the child-bearing woman, her
desires, needs, hopes and fears. Any of these, which are certainly within a
doctor’s (and, indeed, any person’s) repertoire of possible behaviours and
attitudes, could have a positive or negative effect on my practice, and, for
that matter, may also impact on me.
El Halta (1997) was rather concerned about midwives retaining their
autonomy to practice. She could see that it would be all too easy for them to
lose the autonomy which they do have, if it were not carefully guarded.
Doctors who were inclined to criticize midwifery, El Halta opined, were
probably lacking correct information about the competency of midwives. That
is, they were unaware of just how skilled midwives actually are. She asserted
that “Natural birth is frightening to them, and they hesitate to believe a baby
can be born without high-tech voodoo and apparatus” (1997, p.19). This may
indeed be true, and there are doubtless many other reasons also why some
doctors are inclined to intervene in a natural process.
Normal birth (unassisted vaginal birth) is usually considered just that, normal.
Normal, one might be inclined to think, would be rather straight forward, run-
of-the-mill, the kind of thing that happens every day, without thought or effort.
Narrative banalization readily comes to mind. Bruner’s (1991) term alerts us
to stories that fit into the so common, so everyday, and so routine, that they
appear not to need interpretation at all. A normal birth story (or a story of
anything “normal”), is able to have a routine interpretation imposed upon it,
without effort. Such stories are at risk of narrative banalization.
Keeping Things Normal Far from being banal, however, the concept of “keeping things normal”
proved to be quite intriguing in the context of this research project. Many of
the midwives who shared their experiences told of their struggles to keep
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things normal. As if “normal” was a precious gift, hidden in a flimsy box to be
protected from the ravages of the over-eager interventionists, who were
strong and plentiful. All the time knowing that sometimes the fragile box could
so easily collapse, or open, all by itself; inviting the good interventionists in,
welcoming them with open arms. This made it all the more important to
protect it on the occasions that it could remain intact.
As we turn now to look more closely at some of the midwives’ stories, it will
become evident how the midwives sought to protect this “precious gift”. In
each of the stories that follow, the midwife is doing her best to do her job
well. She is working together with her client, the labouring woman, but at the
same time, has to work with the doctor who is also responsible for the well-
being of the woman. In these particular stories, this created some tensions,
as the doctors and midwives held different opinions as to how matters should
proceed. They certainly did not seem to be operating on the same wave
length.33
Unwanted Intervention Like Lucy, whose story was shared in Chapter Three, Kelly’s story is also
about rupturing membranes. She had a similar experience, trying to keep
things normal for her client. In her case, with considerable perseverance,
Kelly managed to prevent this unwanted intervention.
Whilst relating some of her positive experiences to me, Kelly told me about
Penny. Penny had her baby some years ago and lives interstate now, but still
communicates, by mail, with Kelly. She had a difficult birth. Her story is a
good example of how doctors can sometimes, in practice, make it quite
difficult for midwives to keep things normal.
33 Doctors and midwives approach a birth from a different stance. Remembering that, as El Halta (1998) claims, midwives are experts in normal birth and obstetricians are experts in pathology (births with problems), it is reasonable to expect that doctors and midwives would be coming to the situation from totally different paradigms. Both have, more likely than not, been socialized into their own profession and adopted its unique culture. These matters will be discussed further in the final chapter.
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… you know it was long and I was fighting off doctors at the door to come
into the room and rupture the membranes. You know, I was, and it
happens. It was just that whole thing of it, you just get used to the whole
hospital environment don’t you? Of everyone having their membranes
ruptured and all this management of labour, and I just felt like it was a little
triumph that we actually kept the doctors away. And there was no reason
to be concerned at all, and, of course, if there was I would have done
something about it.
…she wanted a natural birth and she had it. She …fought… a long time
and she worked very hard for it and she had her own issues with that, but
we went through and we talked. It’s one of those situations where it was a
good outcome, but she worked very hard and it was very long and she
was exhausted, but she did it and she had issues about what her body
went through during that time but we talked about it. It has actually been
something that’s turned into something really, really positive for both of us.
Just being able to write down exactly what we’ve been feeling about
things and just putting it in the mail and sending it and, and just the
response back and forth. It’s, it’s been a lovely experience. Mmm. Kelly
Many a midwife would be able to relate to Kelly in this circumstance.
Pressure to rupture membranes is frequently placed upon both midwives and
labouring women to speed up labour, not just by doctors, but often by
midwives. The question is not if this act will speed up labour, although it may
do so.34 The more relevant issue is, however, that many women and
midwives question if nature needs us to intervene in this way (in the absence
of an indication that something is outside of the normal) – if it is appropriate
to (possibly) speed things up, when there is no need for speed. So, Penny
wanted to labour naturally, and Kelly wanted to assist her. It proved to be
hard work for Kelly to be Penny’s advocate. She felt constrained by the
hospital environment – the expectations that came with the setting. Still, she
persisted, “fighting off doctors at the door”.
34 Ajadi, Kuti, Orji, Ogunniyi and Sule (2006) found that amniotomy (rupturing membranes) when cervical dilatation was between four and six centimetres significantly reduced the duration of the first stage of labour. This is in contrast to the findings of the Cochrane review published in 2007, which found no significant difference in the length of first stage of labour for women who had an aminotomy (Smyth, Alldred and Markham, 2007).
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Kelly’s relationship with Penny was paramount, more important at that time
than any other. She respected Penny’s desire to have a normal labour and
the associated decisions to avoid non-essential interventions that necessarily
came with this. Kelly was respecting Penny’s autonomy, and exercising her
own right to practise autonomously in the absence of complications. This
might have been even more important than she realized. El Halta says that
“When midwives allow their right of self-determination to be taken away, they
seriously diminish the opportunities for women everywhere to determine their
own childbirth destinies” (1997, p. 20). She asserts, therefore, that the
autonomy of midwives and clients is inextricably linked.
Autonomy is a moral principle that supports a person’s right and ability to
decide for themselves. There is a very large body of literature in both medical
ethics and nursing ethics that advocates respect for autonomy. Though the
specific body of midwifery ethics literature is considerably smaller, it also
draws our attention to the principle of autonomy in texts such as that by Lucy
Frith (1996), Ethics and Midwifery, one of the very first ethics texts available
to midwives. Beauchamp and Childress (1994) have written extensively on
autonomy in their book Principles of Biomedical Ethics and, whilst not a
simple matter, it is clear that the patient/client, in many cases, is the best
person to make decisions about their care. One of the earliest Australian
writers in nursing ethics, Megan-Jane Johnstone, provides an excellent
summary when she writes, “In application, the principle of autonomy would
judge as being morally objectionable and condemnable any act which
unjustly prevents rational and autonomous persons from deciding what is to
count as being in their own best interests” (1989, p. 77). Autonomy is so
important within the heath care setting, that it finds its way into many
documents directly pertaining to patient care. Some examples include the
following;
Queensland Health Public Patients’ Charter: “You have the right to take part
in decisions about your health care. The staff looking after you will discuss
your treatment and care plan with you. They will give you time to think about
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everything and to talk it over with your family before you make any decisions.
They want you to make as many decisions as possible” (Queensland
Government - Queensland Health, 2002, p. 5).
Code of Ethics for Nurses in Australia (Value Statement 2): “Nurses accept
the rights of individuals to make informed choices in relation to their care.”
(ANC, RCNA, & ANF, 2002, p.7)
Code of Professional Conduct for Nurses in Australia: “Each nurse will
promote and support the health, well-being and informed decision making of
patients/clients in the provision of nursing care” (ANCI, 1995, p. 4).
UKCC Code of Professional Conduct: “As a registered nurse, midwife or
health visitor, you are personally accountable for your practice and, in the
exercise of your professional accountability, must: … 5. work in an open and
co-operative manner with patients, clients and their families, foster their
independence and recognise and respect their involvement in the planning
and delivery of care” (United Kingdom Central Council [UKCC] for Nursing
Midwifery and Health Visiting, 1992).
In compliance with her Code of Professional Conduct (ANCI, 1995), Kelly
had to promote informed decision making. Thus, part of her role as Penny’s
midwife was to ensure that Penny had adequate, correct information to make
appropriate decisions about her care. As part of her registration process,
Kelly has agreed to follow the Code of Ethics for Nurses in Australia (ANC,
RCNA, and ANF, 2002). So, with reference to both of these codes and
applying the principle of respect for autonomy, she was in a position of
having to acknowledge and respect Penny’s decision not to have her
membranes ruptured.
From the information above, it is clear that Kelly had an obligation to be
Penny’s advocate. Penny wanted an active, natural birth, with minimal
intervention. As it happens, one of her specific desires was to not have her
membranes ruptured. Yet, members of the medical staff were keen to
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intervene in her labour in this way, despite the fact that there was nothing to
indicate that this was necessary.35
From the start of this story there were three sources of tension: Penny’s right
to have her autonomous decisions respected; Kelly’s duty to defend Penny’s
autonomy, to be her advocate; and Kelly’s professional judgement. We have
seen, quite clearly, that it is ethically appropriate to respect Penny’s
autonomous decisions. It seems also, if she were to act professionally, Kelly
had to act as Penny’s advocate. To do this, however, she had a battle on her
hands, “fighting off doctors at the door”. It would appear that some people
were not respecting Penny’s autonomy, Kelly’s advocacy, or Kelly’s
professional judgement (that such intervention was not necessary) – or
perhaps all three – by insisting on trying to enter the room to rupture Penny’s
membranes.
Kelly told us that there was no indication of a problem to warrant this action.
Even if there had been an indication for intervention, she would have, as a
professional, had an obligation to accept and act upon the choices Penny
made in relation to her own care, so long as those choices were well
informed. An intrinsic part of Kelly’s role as a midwife was to ensure that her
client had accurate, complete information and was able to make appropriate
decisions on the basis of this information (ANC, RCNA, and ANF, 2002;
ANMC, 2003).
This does, however, present a rather simplistic view of a rather complex
matter. Respect for autonomy and informed consent are matters that are
complicated further in maternity settings by the presence of the unborn child.
There is potential for the mother to make an autonomous decision that, if it
was respected by the medical and midwifery staff, could have devastating
effects on the baby. A mother might, for example, refuse a caesarean section
35 I would like to reiterate, as has been mentioned in the method chapter, that, as is the case with all the stories shared in this thesis, it is “narrative truth” that is being presented here – the story as told, and my interpretation, as researcher and audience, of that story. The medical staff, and, indeed, Penny herself, may have offered different accounts, which would have allowed, and perhaps resulted in, other interpretations.
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(Draper, 1996; Jones, 2000). Whilst her right to decide about having, or not
having, surgery needs to be respected, in some situations even a delay in
this decision could result in the death of the baby. This presents an extremely
difficult situation for care providers who desire to balance the respect for
autonomy, the need for informed consent and a “good” end, with mother and
baby in as healthy condition as possible36. Kelly and Penny were not facing
these difficult decisions though. For them, there were no apparent problems,
apart from doctors wanting to intervene unnecessarily.
A long and difficult labour ensued for Penny. She had to work hard for the
natural birth she longed to have, but with help and support she achieved her
goal, and, it turned into something “really, really positive for both” midwife
and client. They have continued their relationship by writing down their
thoughts in letters. It is an interesting friendship: a positive sharing of
feelings, but not a friendship in the sense of other friends we make outside of
work. Although it may not always be obvious, a touch of professionalism
remains in these relationships. Somehow, a client can never really be a
friend, but something has been shared and only the midwife and client seem
to truly understand what that something is. The concept of friendship will be
explored further in Chapter Six.
Managed Labour Amy relates another situation where midwives face an uphill battle to “keep
things normal”. She told me that a lot of ladies were giving birth to their
babies in bed. I was quite surprised at this, because research has quite
convincingly shown that upright positions are beneficial during labour,
particularly in second stage (De Jonge, Teunissen and Lagro-Janssen, 2004;
Gupta, Hofmeyr and Smyth, 2004; Simpson, 2006)37. Given free choice,
most women will choose either an upright or all fours (kneeling) stance for
the birth of their infant. De Jonge and Lagro-Janssen (2004) found that
women may choose to birth in the supine position, but having the choice to
36 For a fuller explanation, see Draper, 1996. 37 Benefits may include, for example, less severe pain, less likelihood of episiotomy and/ or instrumental birth.
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move freely during labour and find positions that were comfortable and
beneficial to them was important. So, I asked Amy why so many women were
birthing in bed, and she told me,
mainly because they have epidurals. They push epidurals for pain
relief. … The doctors encourage, actively encourage epidurals. … They
don’t like to see them in pain. They think that, in this day and age,
we’ve got epidurals, why go through all the pain of childbirth? Have an
epidural. That’s their mentality. So, they come in and they see a woman
huffing and puffing away and it’s like, “Well, it would be good, if you
were thinking of having an epidural, to get it in now.” They have actively
asked them if they want an epidural in labour. … it is very much doctor
pushed. Because they, they do it at the time that they’re most
vulnerable, when they’re in labour. Right, they come in and say, “Oh,
you’re only 3cm dilated. You’ve got a long way to go. Why don’t you
have your epidural now?”
then the Synto goes up doesn’t it, and then the baby gets distressed,
then we go off for a caesar. …[laughter] Yes. Oh look, I don’t want to
sound too [laughter] cynical about it all but it’s ridiculous. For some of
the obstetricians we have, that is their scenario. Amy
Emily related similar happenings.
some people are quite prescriptive about how they manage different
scenarios and we have these booked inductions and then it’s like you
have your waters broken, you get your synto drip and you get your
epidural and that’s it. It’s just a formula that gets used and it is sort of
like, well, was that necessarily the way to go, or you know, why are you
being induced and you know, like it is just that bit of an ethical dilemma
that we have no control over as midwives because the patients are
private; they are guaranteed top obstetricians who are our customers
as well and so we kind of have to bow and scrape to obey their wishes
even if we don’t feel it’s the best way for the patient to go. Emily
Green and Baston (2007) warn that women may be unaware of the
disadvantages of having an epidural. Generally speaking, once a woman has
had an epidural for pain relief in labour, she is restricted to bed. Although it is
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possible to have something known as a “walking epidural” (Roelants, 2006;
Fun, Lew and Sia, 2008), these are not common, and in practice, offered at
few hospitals38. Thus, most women who have an epidural have significantly
reduced mobility (Anim-Somuah, Smyth and Howell, 2005), which, in
combination with the effects of the epidural itself, can lead to what is know as
the “cascade of interventions”. This is more common if an epidural is given in
the early phase of labour39. These effects can include decreased uterine
tone, reduction in contractions, prolonged labour (Buckley, 2003; Ros et al.,
2007), and slowed dilatation, leading to a need for augmentation with
medication (Anim-Somuah et al., 2005). This medication can cause very
strong contractions, foetal and/or maternal distress, as indeed can a long
labour, and any of these could well result in the need for an assisted delivery
of some sort, often a caesarean section. Epidurals, when used for pain relief
in labour, are associated with higher rates of caesareans and instrumental
births (Green and Baston, 2007; Ros et al., 2007). The authors do note,
however, that the matter is not entirely straight forward.
Amy isn’t sure where the motivation for encouraging epidurals or caesareans
comes from. She wonders if the doctors feel that part of their role is to
provide a comfortable, pain-free birth. Another possibility is that some women
expect doctors to provide them with a pain free birth nowadays. Maybe the
women have requested them and doctors are respecting the women’s
autonomous requests? Van den Bussche, Crombez, Eccleston and Sullivan
(2007) suggest a number of reasons women may choose to have an epidural
in labour. They are: “because of positive attitudes about having a relaxed,
enjoyable childbirth, because of positive stories and advice about EA
[epidural analgesia] from others, and because of the fear of not being able to
cope with pain” (2007, p. 276).
38 This type of epidural is actually more common nowadays, but in practice, although women do have more sensation and movement than they did with “older” style epidurals, they are rarely able to walk around. This may be due to insufficient mobility or hospital policy. 39 The early phase of labour is sometimes called the latent phase. It is when the cervix is dilating from zero to three centimetres and contractions are usually mild during this time (Cassidy, 1999). There is not complete agreement on the “cut off” for the latent phase - some texts say that the active phase (the next stage of labour) does not begin until four centimetres dilatation has been reached.
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Walsh (2007) suggests that it is about where women birth and the type of
care they receive. Walsh presents the possibility that epidurals are, perhaps,
more prevalent as pain relief in labour because of their ready availability.
Another reason might be that clients are not getting the continuous support
that they need from their midwives, who are drawn away to attend to all
manner of other things including collecting items, attending to administrative
matters and eating meals. He says that it has been clearly demonstrated that
one to one care lowers the rates of both epidurals and caesareans.
Regardless, in these stories, it is evident that the midwives perceive that the
doctors have been encouraging these interventions. Of caesarean births,
Amy says
It doesn’t worry the doctors. ‘Cause they’re in control and they have to
go off for a caesarean. It’s probably less litigation with regards to a
vaginal birth. I think that’s probably driving what they’re doing. Amy
There are situations in which a woman, even prior to labour, asks for an
elective caesarean birth where there are no medical indications present.
Midwives, who understand birth, find this strange. Emily told me
the trouble is they’re driven by litigation now, and so if a patient says
“well I want a caesar because I am worried about my pelvic floor”, or
something like that, well you know they’ll probably just do it…they are
doing it because the patients are asking for it and they are fearful of
litigation. Emily
These scenarios raise a number of ethical issues. There is the question of
midwives trying to keep things normal. Having a baby is, after all, a normal
life event. It is not an illness, not a medical emergency, not even a medical
condition. Though it can, in some cases, lead to medical conditions, this is by
no means expected nor is it usual. Pregnancy can result in certain pre-
existing medical conditions being exacerbated, and in these cases, medical
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supervision is often encouraged as a precaution40. For example, asthma may
be mild and not require treatment, but it is essential that a pregnant woman
have a treatment plan should the disease be, or become, even mildly
problematic. Interventions, such as advanced technologies and medications,
are of great benefit during pregnancy, labour and birth when indicated, and it
is likely that the vast majority of (if not all) midwives are happy to utilize these
when appropriate. When all is progressing normally, however, interventions
are not usually required.
Most midwives encourage women in their care to believe in themselves, and
the wonderful strengths nature has provided, working with them to travel
through labour without medical assistance, all things being normal. With
regards to pain, we have a quite incredible ability to make very powerful,
natural analgesic hormones called endorphins (Buckley, 2003). Our bodies,
knowing that we will be going to labour, start producing extra endorphins
from the twelfth week of pregnancy, and continue to increase production as
pregnancy progresses to help us when we need them (Genazzani,
Facchinetti and Parrini, 1981). We can produce them in large amounts if we
manage to stay calm. Sometimes though, for some people, these natural
painkilling abilities are insufficient, or due to complications, some other
assistance is needed. If so, most midwives work well in a team approach with
anaesthetists and obstetricians to provide whatever help is needed, be it
analgesic medication or intervention of another type. On the other hand, if not
indicated, why meddle with nature? In a normal labour, intervening can
complicate matters rather than make them “better”. We have seen, however,
that “keeping things normal” is not always as straight forward as one might
expect it to be.
40 Statistics tell us that some women having a baby in Queensland in 2003 had a medical condition (not pregnancy related) whilst pregnant. The numbers add up to 12.3% of the expectant mothers, but some of them may have had co-morbidities, which are not able to be accounted for in the numbers. The severity of the illness is also unable to be ascertained. In addition, the statistics for pregnancy related complications appear to represent over 50% of pregnant persons in Queensland in 2003 (Queensland Health, 2004). Moreover, some of the ‘complications’ are, in many cases, normal events, e.g. prolonged pregnancy. Obtaining an accurate view of the comparatively rare event that illness in pregnancy actually is, is clouded by the manner in which these statistics are presented.
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Another issue is that of placing our expectations or ideas and fears upon
mothers-to-be. Here I would like to take you back to the paragraphs above
and ask a value laden question. If I ask “What is better?”, the answer
depends greatly from whose perspective I am asking, and to what end. A
woman in pain, at the time of having an early epidural, prior to 4 cm, might
well believe that it was a great decision, even if she had been talked into it at
the time. The pain is gone. It has to be great. So, from the woman’s
perspective, that intervention, at that time, did make things better. She may
end up stuck in bed, with a drip and urinary catheter, endure a long labour,
only to eventually require a caesarean to deliver her baby. She may never
come to know that her early epidural was, more likely than not, a significant
contributing factor. Even if she does, she may not care – her labour was pain
free and that was what was important to her.
At the time it is suggested, early in the woman’s labour, the epidural will
probably figure differently in the midwife’s mind. No doubt she will be aware
that this early epidural will almost certainly result in further intervention41. She
is quite likely to place importance on what will happen after this event, due to
prior knowledge and experience. The doctor, one imagines, has another way
of interpreting the situation. Different information and knowledge might
change better to worse (or vice versa). A different stance can change better
to worse. Simply being a different person can make you view something as
good, that others view as bad. Life, in this case, birth, is never straight
forward.
Amy and Emily clearly felt the doctors were influencing their patients to have
epidurals, a fact that they were not comfortable with as they did not think it
was in the best interests of their clients. At some hospitals, information about
epidurals is routinely provided to the ladies antenatally. Some of the
midwives interviewed felt that this information was very pro-epidural,
encouraging the women to opt for this form of pain relief in labour. Different
hospitals use different information, and the information brochures would
41 For example, Amy and Emily have both mentioned that epidurals go hand in hand with Syntocinon infusions (to stimulate contractions).
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almost certainly change from time to time. Thus, they may have once have
encouraged epidurals, but no longer do so now, but it is certainly worth
considering this matter a little bit further.
There is potential for both good and harm in the provision of information
about epidurals (or anything else, for that matter) to clients prior to labour. If a
woman and her support person have received appropriate, accurate and full
information giving both the benefits and risks, as well as the alternatives, they
will be better equipped to make an informed decision as to whether or not
they would like to consider utilising this form of medicated pain relief in their
labour, should it become necessary. This can only be viewed in a positive
light. It has to be considered a forward step in assisting women and their
partners to be active participants in the management of their labours.
Unfortunately, there is also room for a less than ideal use of this information
giving. The information might not be complete, or it may have a particular
slant, encouraging women to have, or not to have, an epidural. Women may
take the provision of the information to mean that the pain of labour is going
to be even worse than they expected and that, therefore, everyone needs an
epidural. In this form it could instil fear, reducing the chance of the woman
developing her own natural pain relieving hormones (endorphins) and
increase the need for epidurals – a form of self fulfilling prophecy42.
They might simply take it to mean that the doctor and/or midwives think it is a
good idea. Health professionals have a tremendous amount of influence
afforded to us, just by virtue of who we are. So, in this case, they might
decide to have an epidural, even though they previously hadn’t considered
having one, simply because it was suggested, put forward as a good idea by
those who know best. In their European study, Van den Bussche et al. (2007)
found that, of the women who decide antenatally that they are going to use
an epidural for analgesia in labour, 75.9% do so. Raynes-Greenow, Roberts,
McCaffery and Clarke (2007) investigated Australian women’s knowledge
42 Fear stimulates the production of another hormone, adrenaline which, sadly, reduces the production of endorphins.
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and decision making regarding analgesia in labour, and found that they relied
heavily on anecdotal advice, so provision of accurate information in some
form would seem to be an important step in correcting this potential for
passing on subjective, possibly incorrect knowledge regarding pain relief.
The provision of a pamphlet could have a profound effect, just through the
power of suggestion, but this effect need not, and should not, be negative.
Davidhizar (2005) discusses benevolent power, where the nurse utilises her
power to benefit the client. Acknowledging that we are experts in our field, we
responsibly share appropriate information, in the client’s best interests. That
way the parents to be would be given all the information they required to
make the decisions that they face. In the real world, unfortunately, this is
easier said than done. Many midwives do not have contact with their clients
before they come to the hospital to birth, and for those that do, there are time
constraints.
Amy and Emily both found themselves in ethically difficult situations. They felt
they had to support the doctor/s , despite the fact that they sensed
responsibility to the women in their care, whom they felt were often not fully
informed about the benefits, risks and reasons for the procedures that they
were having, such as epidurals and caesareans. It was as if their
professional obligation to the doctor/s was at direct odds with their
professional obligation to the women. They just didn’t fit. To fully support one
was to somehow undermine the other.
By no means to be forgotten is the possible motivation for the doctor/s action.
If indeed, as Amy suspects, doctors are now acting at times from a fear of
litigation, this is going to result in medical interventions occurring that are not
always in the patient’s best interest. It is important to note that “Physicians
are rarely sued for performing cesareans [sic], but often sued for failure to
perform one” (Bernstein, 2007, p. 89). Cohen says
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“Wouldn’t it just be simpler to do a C/S for any hint of a maternal or fetal
problem? Maybe it will even help us avoid lawsuits. The “consensus”
could change our entire decision-making process. It could increase the
C/S rate from 29%, to 40%, 50%, or even 80%” Cohen, 2006, p. 96
Instinct makes most people jump to a reactionary response to this of “that’s
just wrong”, and Cohen’s article alerts us to the difficult decisions doctors
have to make. Unfortunately, we have entered a consumer age in medicine,
and in obstetric medicine particularly, where many people are blaming their
doctor or midwife for things which were often quite outside of their control.
This was evident in several stories shared with me by participants from the
same hospital, which, although none of them used names, I was easily able
to recognise as the same birth story – the same parents blaming the staff for
the occurrences of the day. The events, the people, and the subsequent
happenings, had an enormous and lasting impact on the staff43. Gillett
(2007), however, has noted that health professionals are aware of the
benefits as well as the pitfalls of medical consumerism. The particular
benefits are that clients are generally better informed and more involved in
their care and that there is now a greater focus on meeting the client’s needs.
Sadly, doctors are being successfully sued and this, quite understandably,
makes them and their colleagues nervous. Thus, they intervene more readily,
to reduce the risk of a possible birth injury, to protect themselves, to avoid
being sued, maybe even being deregistered. A survey of consultant
obstetricians in England and Wales confirmed this. Sixty-nine percent of
respondents indicated that they would “perform an elective caesarean birth
on maternal request due to fear of litigation and pressure from the patients”
(Habiba et al., 2006, p. 647). These authors inform us that the rates of
caesarean section performed in the absence of medical indication, at
maternal request, vary from 2.6% in Flanders, to 26.8% in Western Australia.
They suggest that the doctors’ attitudes may play a part in the choices their
43 Unfortunately these very rich and heartfelt stories have not been able to be shared and
explored in depth for reasons of confidentiality.
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clients make, particularly as many doctors would choose an elective
caesarean for themselves or their partner. Maybe intervention that parents
request, even if they are not medically indicated, or apparently the best
course of action from the midwife’s point of view, are in the best interests of
mothers-to-be in the long run, for if too many doctors and /or midwives are
sued, there may be an acute shortage of people to care for them at all. That
would be really wrong. It seems to me to be an almost bizarre perspective to
have to consider the fact that a birth intervention that is unnecessary, from a
physiological point of view, might come to be “right”. Yet, as Habiba et al.
(2006) have noted, it is a very complex matter, not going to go away, and in
need of ongoing investigation for both clinical and ethical reasons. Yes, it
certainly can be an uphill battle to “keep things normal”.
Assisted Births Green and Baston’s (2007) study has shown that women now approach
labour with a greater willingness to accept interventions than they did two
decades ago. Mary also thinks that doctors sometimes perform assisted
births to avoid being sued, and she also suggests there may be a
convenience factor – another aspect that Habiba et al. (2006) commented on
in their study, along with financial incentives.
“Oh well, I will just section it cause it is easier”, and that really annoys
me. It is something you know, you can’t fight against the doctor, you
have just got to go with it. … I mean in some instances, yes, they don’t
want a malpractice, they don’t want to be sued, but I think a lot of it is
convenience, like you see it, especially Friday afternoons, the big
caesar rush Mary
Jenny is inclined to agree with Mary. She told me a disturbing story in which
The indications for vacuum [delivery] were that the obstetrician needed
to be somewhere else. Jenny
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And later
they don’t want to wait, and we’re talking ten minutes into second
stage. So with babies being sucked out with gay abandon because, “I
don’t think you’re going to be able to do this, I’ll give you a little hand.”
When I’m the midwife caring for the woman it’s very difficult for me to
say, “Oh no. Don’t do that. You want to try a little further,” because [the
doctor] is the person that she has put her trust in and you can just see
that, that, “I haven’t seen you ante-natally.” … I wish I had the umph to
stand up and say, “Can’t we just keep trying for a bit?” but usually the
women don’t want to. … and I have seen midwives there who have
been there for a while who will speak up and take the consequences if
you like. Umm, yeah but in a way I feel like I’ve failed the woman. I
mean she’s made the choice based on, yes, if we get this over with
quickly we can have a baby now not later, but I don’t think she’s making
an informed choice so therefore, yeah, I feel like I’ve failed her in a way.
Jenny
Again we see the “need for speed” hunting down the normal. No time to wait.
Not rupturing membranes here, but delivering the baby, by caesarean,
vacuum or forceps. By a certain time – before a doctor goes on leave, before
the weekend, prior to a meeting, in the evening, so they won’t have to return
at 3 am, one research participant told me. One midwife said to me that some
doctors are really good at vacuum deliveries, because they do so many. Like
the rest of the world, in some instances, birth too has to fit in with a time
schedule. Before they are even born, babies have to conform to the rushed
pace of the twenty-first century. In these situations, the midwives felt that
something wrong was happening, but that it was out of their control. They
didn’t know how they could keep it normal, although they had a yearning to
do so.
Many midwives thought the mothers did not fully understand the situation
when instrumental or surgical intervention for birth was suggested. They
believed it was presented to the women in an unrealistic manner, or perhaps
without full information. Midwives expressed that, had the women been
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given a reasonable chance to push the baby out on their own, they may have
done so. One of the consequences for the midwife was a sense of failure.
Jenny said it in plain English, “I feel like I’ve failed her”. Midwives expressed
feelings that they had not been advocates for their clients, at a time when
they were most vulnerable, and had not ensured they were fully informed.
This was often because the midwife felt unable to be, do or ensure these
things. The power dynamics between mother and midwife, midwife and
doctor, and even between midwife and institution come into play in this
scenario. Mary told us “you can’t fight against the doctor, you just have to go
with it”; and Emily says “we kind of have to bow and scrape to obey their
wishes even if we don’t feel it’s the best way for the patient to go”. It is
noteworthy that, where clients had private obstetricians, midwives felt less
able to make suggestions/ recommendations about their care than for those
women who had public obstetricians. These women had much more contact
with the obstetrician antenatally and, in many cases, had developed a
trusting relationship with them. Often they had met a hospital midwife only
briefly, if at all. Two of Chiarella’s (2000) “stock stories” of nurses: the nurse
as the doctor’s handmaiden and the nurse as a subordinate professional,
could readily be invoked.
Triumph Cherry told me a “keeping things normal” story that was a little different from
many of the others. She was involved in the care of a woman for whom a
doctor had pre-arranged a potentially medicalised birth. A different doctor
assisted significantly in enabling the normal to ensue, not by totally
disregarding the aforementioned doctor’s orders, but by working closely with
Cherry and her client, staying tuned into where they were, in this labour, in
this context, at this time. I will allow Cherry to relate the story to you.
I had a really actually nice experience at [this hospital] as well where
there was a lady who had come in and it was her second baby. Her
first baby had actually been, like quite a big baby, like 4000 and
something [grams], and she had had some shoulder dystocia and the
child ended up with a fractured clavicle … and so with this
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pregnancy she actually had another biggish baby on board but they
didn’t think it was as big as the last one, no gestational diabetes or
anything, just had big babies ... there was this stuff written in the chart
that when she presents she must have this examination done and then
when she is this many centimetres she must have this done, you know,
have her waters broken and then when she is this she must have an
epidural put in, and then she must have a vacuum extract. You know
all this sort of stuff was set down by the medical person and this woman
was just like, I don’t want, I don’t want any intervention unless it is
necessary.
… it was actually the consultant who had made all the notes in the chart
and it was the registrar who was on, so it wasn’t actually the consultant
who was personally contacted, it was the registrar. But the registrar
was good in that you know there was the thing like, OK we’ll go ahead
with letting her just contract and do this on her own, but the minute this,
this, this and this, happens we may have to look at doing you know,
this, this and this, sort of thing. So yes.
So the midwife that I was on with was again, as I found with a lot of the
midwives at [this hospital], really skilled, and we just, I suppose we
were the advocate for this woman, do you know what I mean? And we
kept the doctor up to date with every tiny little thing that was going on,
and she ended up having a normal delivery with no intervention, and
had a really nice birth experience and after the baby was, a few weeks
after the baby was born, this other midwife and myself we got this really
lovely letter, just thanking us and it was just a really nice. … that was a
really, a really nice experience that delivery because we worked so
hard and the outcome was just so good. And she didn’t end up with her
waters ruptured and she had a normal delivery, and it was a big, and it
did end up being a big baby but we did a support squat with her and it
all just went well. Yeah. So yeah, I have had some really nice positive
experiences.
…she had her mother in there and her mother-in-law and she had her
partner and her best friend, you know. … And everyone was just so
happy. And it was just really nice to get this letter. I think the nice thing
about the letter, that she particularly thanked us for, was that we
respected her wishes and that we took the time to work with the doctor.
You know what I mean, we just, we didn’t say well this is what the
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doctor said has to be done, has to be done, but then we didn’t say to
the medical person, no we are not going to. We just worked really well
as a team. Yeah, it was nice. (italics added) Cherry
In this wonderful story we see the blending of midwifery and medical skills
and understandings brought together to assist a mother and her family to
fulfil their birthing wishes. Working and waiting together. It is a powerful
demonstration of the benefit of effective communication between mother,
midwife and doctor. None of them denied the possibility of the need for
intervention at some time, but they were all willing to combine their efforts to
keep things normal as long as labour was progressing appropriately. The end
result was a vaginal delivery of a healthy infant to a happy mother, in the
presence of a loving family. No midwife would ask for anything more.
In an ideal world, every mother – midwife – doctor team would be able to
work together collaboratively in this way. Of course, not every birth would end
up being intervention free, but every mother would be able to say, “we
respected her wishes and that we took the time to work with the doctor”, as
Cherry’s client did on this occasion. Reciprocally, that naturally means the
doctor also took the time to work with us. Both doctor and midwife are being
advocates for the client, seeking her best interests.
Stuck in the Middle Sometimes midwives find it quite difficult to deal with the situations they feel
that they have been placed in by doctors. That is, from the midwife’s point of
view, it is something a doctor did or said that caused the difficult situation in
which they now find themself. Sometimes angry or frustrated, other times just
not supported, these midwives felt disrespected by their colleagues. A whole
range of emotions come forth from within a number of stories told by several
midwives. I’d like to share a few of them with you.
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Instrumental Inaccuracy Jenny shared a story that deserves further attention. I have shared just a tiny
bit of this story with you earlier in this chapter, but shall explore it in more
detail here. She was working in a Special Care Baby Unit, so her primary
responsibility was to care for the baby’s needs. An essential part of her role,
naturally, was interacting with the infant’s parents. For Jenny, this was not
easy, due to the events that had transpired before she had even met them.
Here is Jenny’s story, with details quite extensively altered to protect the
anonymity of the persons involved.
I’ll tell you about something that I found really distressing and I often
keep returning to and think about it. I wasn’t involved in the labour and
delivery of this woman but I came on duty to look after the baby in
Special Care. … what I saw in the humidicrib was a baby who had been
badly injured from an [instrumental delivery]. The baby’s head was
dreadfully swollen … so much broken skin, blood, just, I just went
Ugghhh. … took my breath away. Oh what happened here? … I then
heard the story of this woman’s birth, which was earlier that day, and
the indications for instrumental delivery were that the obstetrician
needed to be somewhere else.
[The doctor] had a meeting. She [the labouring woman] hadn’t been
pushing for long, maybe wasn’t pushing super effectively. … [the
doctor] was very flustered and sort of angry at the woman, “Come on.
You’re up”. Out of the room [the doctor’s] gone, “I wish she’d hurry up.
Argh, I’ve just got to be…rr, rr” and so, the instrumental delivery
proceeded and [the doctor’s] obviously misjudged the position or not
applied it [the instrument] correctly, hurried the procedure, and we’ve
got this baby in this state, and it did need a fairly extensive resuss,
surprise, surprise. So I came on, met the parents, and when I came on I
saw the baby experience its first fit. … I was speaking to the parents
thinking, “What is going to happen with this child?” And apparently the
obstetrician spoke to them at length and then said, “Well you’ll have to
have a Caesar next time because…” So [the doctor] basically was
saying to her that it was a problem with her, that was the feedback that
[the doctor] gave her. Jenny
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Jenny found the state of the baby more than a little troubling. From her
explanation we are rapidly taken to a point of understanding that this baby
was in an unusually poor condition, rarely seen. It was significant that the
baby had required resuscitation. This state had, in Jenny’s understanding,
arisen as a result of birth trauma inflicted by the improper use of
instruments.44 The doctor has informed the parents that the procedure was
necessary due to mother’s anatomy, with the associated implication that he is
not responsible for the baby’s condition. Jenny is incensed. There are value
judgements throughout her story.
She said, “so much broken skin, blood … took my breath away. Oh what
happened here?” From what she heard, instrumental delivery was not even
(medically) indicated. Remembering that Jenny told us “indications for
instrumental delivery were that the obstetrician needed to be somewhere
else”, it is a rather small step to arrive at the conclusion that the injuries to the
baby were inflicted completely unnecessarily. It is awful, and indeed wrong,
that anyone should do such a thing to a baby. There may have been some
justification had that type of birth been essential for maternal or foetal
wellbeing – that is, some injury may have been unavoidable45 in that situation
– but this certainly did not seem to apply to this baby’s birth.
Jenny elaborates on what she heard about the circumstances of birth, none
of which were favourable regarding the doctor’s behaviour. By now Jenny’s
audience is disinclined to have this doctor at their birth. Hurried and
inaccurate, the impending meeting takes precedence over the labouring
client. Mismanagement leads to harm for the baby and the doctor somehow
manages to explain it away as being an unfortunate outcome of a procedure
that was needed due to mother’s anatomy – a fact which troubles Jenny
greatly. This is not only because the baby’s mother has not been told the
truth about this birth, but also because it will lead to possibly unnecessary 44 In this case, it seems that both the injuries sustained and the resuscitation required resulted from the instrumental delivery. It is noted, however, that babies can sustain injury, be in poor condition at or after birth, and/ or require resuscitation for many reasons, which may or may not be associated with incorrect medical or midwifery management. 45 This is debatable, as the vast majority of babies born with the assistance of instruments are not significantly injured by or because of the instruments, apart from bruising (anecdotal).
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intervention (by way of elective Caesarean Section) at future births.
Meanwhile Jenny worries about the future of the child who has a swollen,
bleeding head and has shown signs of neurological irritation and possible
damage as well.
From the value laden statements Jenny has made, I now have a picture of
the following doctor. This doctor is unprofessional46, unskilled, careless,
irresponsible, uncaring, hurried, and a liar. This person is much more
concerned about themselves than their clients, and, most importantly, I do
not want them anywhere near me or anyone I care about. Jenny, on the other
hand, is deeply concerned for the parents and the child. She continues the
story.
I looked after her postnatally as well and, all that I could say to her is,
“Have you spoken to the midwives? Are you happy with the explanation
of what went on?”, because they asked a lot of questions about, “Have
you seen this before Jenny?” and “Do you think, you know?” I also
found out that [the doctor] had written like pages and pages of notes
about this, you know, cover the, cover my arse type notes.
I wondered about this child and how it is. … I did ask somebody the
other day. “How is the little [child]?” “Oh, good, good, good and she’s
planning another baby” … It’s a relief, but it’s, it doesn’t make it right.
And I’m just thinking oh, is she going to go back to [the same doctor]?
… I desperately wanted them to have more information than they had
and I didn’t [give it] because of that professional disclosure thing, and
because I wasn’t there [at the birth] I couldn’t really say, this, you know,
what I knew was second hand so I couldn’t give them the information.
Jenny
Later, the questions posed by the baby’s parents were difficult for her to
answer. This was not because she did not know the answers, but because
she had only second hand knowledge of the events and, perhaps even more,
due to the fact that she was, professionally, stuck between a rock and a hard
place. How could she appropriately answer?
46 Please see Chapter 7 for further information regarding being a professional.
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Having a baby is meant to be a happy time, and despite the fact that most
people know that sometimes things do go wrong, they don’t expect it will
happen to them and their baby. Most expectant couples anticipate a
reasonably straight forward birth and transition to parenthood and when even
a minor deviation from this (often subconscious) ideal occurs, they are often
overwhelmed with not only the emotions of becoming parents, but those that
come with the unexpected events (personal experience). Questions are
frequent, varied, and often unanswerable. Parents are usually upset,
sometimes quite distressed, and can be very persistent in seeking answers
to quell their many anxieties and uncertainties as to why things are the way
they are, and what might ensue.
As a midwife not present at the birth, Jenny is in a particularly challenging
position. She addressed this dilemma as best she could by deferring back to
the midwives who were present at the time, “Have you spoken to the
midwives? Are you happy with the explanation of what went on?”, but it is
evident that she was not entirely happy with this as a resolution to her own
problem as to what to say. Jenny feels bound by her professional limitations.
She wants the parents to be told the whole truth, whatever that might be. She
senses that, not only was it wrong that the baby was injured, but also that this
was being perpetuated and compounded by the absence of open discussion
about what happened and why. This baby’s parents deserved more of an
explanation. Yet she does not feel that she can give them the information that
they seek.
Jenny was in the midst of an ethical dilemma. She could have chosen to tell
the parents what she “knew” from what she had been told, or she might have
decided to convey to them as many of the documented facts as she could.
These facts would have been readily obtained from the woman’s chart. Jenny
may not have felt, however, that the facts as recorded provided an adequate
explanation. It is highly unlikely, for example, that the reason for instrumental
delivery would be recorded as “doctor in a hurry”, or that there would be an
indication that the instrument had been applied hurriedly or incorrectly. It is
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possible, therefore, that Jenny may have opined that this was not a helpful or
worthwhile endeavour. It would be possible to provide statistics to the parents
about how many babies have injuries associated with that type of
instrumental delivery. This would involve a little work on her part. Any of
these pathways of action may have made Jenny feel better. It may have
been the right thing to do, but would, I strongly suspect, make her somewhat
unpopular with the doctor. Her professionalism would also, undoubtedly be
questioned and perhaps her loyalty to the institution where she worked,
particularly if it happened to be a private hospital, where maintaining good
relationships with the doctors is an essential aspect of retaining a continuing
flow of clients. If doctors are alienated for any reason, they could well take
their “business” to another institution. Her job might even be on the line.
The question to be asked is, would any of these actions have made a
difference? Herein lies the problem, and perhaps one of the reasons why
Jenny thinks of this family many years later. There is simply no way to know
the answer to that question, other than to turn back the clock and live it out a
different way. The alternative was to do as Jenny did, asking the parents to
reflect upon what they had been told by the people who were present at the
birth. This is professionally appropriate and acceptable. The greatest difficulty
with this approach would seem to be that it simply has not resolved the
situation. Many years later Jenny still feels that something wrong happened
and she was somehow complicit in it by not doing something, though she
isn’t sure what she could have done.
Just before we leave Jenny I would like to note that she, like so many other
midwives, held a sense of wanting to “follow through”. She happened to know
someone who knew this lady, so was pleased to be able to check up on how
the child was going. She has retained an ongoing concern for the child’s
mother also, and we can see this reflected at the end of her story excerpt
above, when she hears that the woman is planning another baby.
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Need to Know Another poignant story is that told by Felicity. Felicity had tears in her eyes as
she told me about her experience with Rose, a young woman who had come
in to hospital to have her first baby. Her labour was being induced. Felicity
was to do a vaginal examination and insert some Prostaglandin gel. She was
confronted with
“I don’t want this, I don’t want this, I want a section…… I don’t want
this.” Felicity
Most women do not like internal examinations, yet they accept them as a part
of the process when being assessed during labour and birth, certainly when
being induced (personal experience). Prostaglandin induction can be
uncomfortable though, and this young woman, not yet an adult, had had one
dose of the gel applied to her cervix the night before. What was to come was
even more surprising though. Felicity reassured her.
“OK. Well, I’m not going to give you the Prostin if you don’t want me to
give it to you, but would you mind me assessing you to see where
you’re at?” And she said, “No. No. No. No. No. No.” Felicity
Imagine, at this juncture, if Felicity had said something along the lines of “Oh
come on, get real, you have come into hospital to be induced to have your
baby, we have to find out how dilated you are?” Of course, we all hope she
would have been more tactful – “I know you’re really uncomfortable, but it is
most important that I perform an internal so that I can advise the doctor how
far along you are. I’ll be as gentle as I can”. After all, Rose was there to have
a baby. Felicity didn’t respond in that way though – a standard “we have to
get the job done” kind of a way. That repeated “no” spoke to her; it set some
bells ringing in her head. Much later she said to me,
Thank god I didn’t push it, you know, I just think I would have killed
myself. Well, I wouldn’t have killed myself – it would have just made me
feel awful if I’d really pushed the issue with her and maybe got her to
agree to something that she didn’t want to happen. Felicity
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This is what actually happened. Felicity continued,
“OK. I’m not going to do this, I’ll ring the doctor.” So I rang the doctor,
my heart cried, and [the doctor] came in and had a big long chat to this
girl about a caesarean section on a young girl as an elective, you know,
impacts incredibly on the rest of her childbearing, etc. [The doctor] was
very good with her and [the doctor] said, “Would you mind. I really feel
that I have to see what you’re doing before I say yes I’ll do a caesarean
section.” So, ah dear, it makes me cry, so we did this internal on the girl
and gave her the gas because Prostin makes them hyper-sensitive,
and she was screaming while this doctor did this very quick
examination, and the gas came off and she said, “It’s never been fun
when anyone’s doing anything down there.” And it just clicked, this girl
had been abused and, oh gee, it was so sad, and the doctor didn’t say,
hadn’t warned us at all that this was the case, because it would impact
on how you deal with the child. And so [the doctor] said, yes, [they’ll] do
a caesarean section and the doctor went out of the room to organize it,
and the mother was there, and you could see that her eyes were just
watering and I went up to her and I got this young girl into the shower
and got her ready for the caesarean section. And I quietly went to the
mother and said, “Is this baby of an abusive relationship?” And she
said, “Yes.” And I was so annoyed with the doctor for not preparing us
for this. I felt so sad because it’s not something you deal with regularly
at all and so that broke my heart. And this young girl had this baby …
and it turned out to be someone that they knew. So she got her
caesarean section and she just couldn’t stand the thought of being
awake for it either, so, the Anaesthetist was beautiful and she went to
sleep and all that sort of stuff. And I felt so sad I just wanted to pick her
up and protect her. … it wasn’t until the following Monday that I could
organise anyone to see them, and they’d had no counselling or support
at all, and I was so angry with this doctor for not telling us. Felicity
Felicity’s position is quite different from Jenny’s, yet she also feels very much
as if the obstetrician has left her in a delicate situation. In Jenny’s case it was
the doctor’s actions that caused a dilemma for the midwife and family; what
the obstetrician had done at the time of the birth, and subsequently, but prior
to Jenny’s involvement with the family – an act of commission. Felicity’s story
conveys an act of omission. Rose’s doctor failed to advise the midwives at
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the hospital that this young teenager was pregnant as the result of an
abusive relationship. Felicity notes that “it would impact on how you deal with
the child”, which could probably be regarded as putting it mildly.
Does a doctor have a professional responsibility to inform her/his colleagues,
both doctors and others who will be involved in the care of his/her
patient/client, of all relevant information that could affect that person’s care?
The answer seems obvious and straight forward enough. Why was this
seemingly important information about Rose not passed on to the midwives
at this hospital? It could be that the doctor was respecting Rose’s privacy and
maintaining confidentiality. As a professional, Rose’s doctor would be doing
the right thing by not advising any other care givers of this aspect of her
history if, in his or her considered opinion, this information was not relevant to
Rose’s care. Midwifery staff did not need to know this aspect of her history if
it was not going to have an impact on how they worked with Rose. Another
possible explanation is that this one fact slipped this one person’s mind on
this one occasion. Doctors are busy people, but most importantly, people.
Maybe the doctor had been interrupted when about to convey Rose’s history,
and then, due to the demands of the interruption (a birth perhaps), did not
return to pass on this rather important information. There is, of course, a
possibility that the doctor was unaware of the pregnancy being a result of
abuse. Perhaps Rose and her family had chosen to hide this from him/ her.
This discussion is not intended to either excuse the doctor or to minimise the
fact that it placed Felicity in a significant and difficult position. However, I
choose to use this as an example that each of us has the power,
intentionally, or inadvertently, to create an ethical conundrum, simply by not
saying something. It may have been why this happened the way it did.
Whether deliberate or not, in the situation mentioned above Felicity was
placed in a position that would have been much less difficult had she been
provided with just a little more information about Rose’s circumstances. This
made her angry. What could or should Felicity do in this situation? Being
angry was not really going to help either Felicity or Rose right at that moment
in time. Clearly her priority was to care for Rose, so she did. She went about
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the business of preparing her for the birth of her baby, which was now to be
by caesarean section. Felicity needed to clarify her suspicions of abuse, and
tactfully achieved this by approaching Rose’s mother whilst Rose was
showering. This knowledge elicited very strong feelings of sadness and a
desire to envelop Rose in loving arms. This wasn’t because Rose lacked
support. In fact, Felicity told me
the love around that young girl was phenomenal and I think that they
were very protective of her. … Her mother, her step father, her father,
his partner and aunt, they were all there and very protective and loving
of her. … Mmm. But, oh geeze, I just wanted to pick her up and protect
her. You know. And so many girls that are in this situation don’t get any
of that and it’s so sad. Felicity
Felicity arranged counselling and appropriate follow-up for Rose and her
family, but I sensed that she found it difficult to let go. Like Jenny and so
many other midwives, her sense of responsibility extended beyond her actual
responsibility. In this case, it also extended beyond her ability and realm.
That is, had she been able to, Felicity would like to have followed through on
Rose, but it was outside of her domain.
I feel comfortable with what I did and it’s just that I would like to know,
sometimes you just like to see how they are a month down the track.
Her mother was younger than me, so you sort of think, it could have
been my sister. You know, this could have been my niece and I think
that some patients make your heart, you take to your heart more and
it’s just like any person. Some people you react to in a different way
and make you feel very maternal – and she made me feel very
maternal, and I think that, in some ways, that’s part of your role as a
midwife is you do take on a mothering role to a degree. Felicity
Although Felicity was very angry at the doctor for not informing the midwives
at the hospital of Rose’s circumstances, the dominant emotion she displayed
whilst telling this story was sadness. She did not allow her anger toward the
doctor to interfere with the care she provided to Rose. Nor did she comment
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if she had ever had an opportunity to address the issue of information sharing
with the doctor in question. Felicity and I, as audience, became so involved in
Rose’s plight that the doctor’s apparent misgivings became of less
importance.
For Felicity there were several very important parts to this story. When
communicating with the midwives, the doctor had omitted information about
Rose which Felicity considered crucial. This made her job more difficult than
it needed to be, and compromised the provision of optimal care to Rose. The
doctor, however, is portrayed as very caring, kind and understanding toward
Rose when she was assessed and prepared for a caesarean birth. It is as if
Felicity is trying to reconcile the two conflicting images of this doctor – one
which is of a doctor who has made a significant error of omission, but the
other is of a compassionate doctor who would not purposely do such a thing.
In the “working out” of the day, it apparently ceases to be an issue as the
caring for Rose takes precedence over any thoughts Felicity may have been
having about what the doctor failed to do. It is certainly relegated to a low
priority status. Central to this story, though, is Rose. From beginning to end,
Felicity is keen for us to be aware of Rose. Why she was there, the emotions
and discomfort she felt, the trauma she had suffered, the support that
surrounded her, the procedures she faced and the people she had to deal
with are all conveyed to us. We can almost hear her saying “No. No. No. No.
No. No.”, and it is not difficult to comprehend Felicity’s desire to reach out
and give her a warm hug.
Working Together Sometimes a doctor and a midwife can find themselves simply unable to
agree and then individuals have to decide on their own course of action.
Such was the case for Betty when she and a junior doctor were caring for a
lady having twins. Betty wanted the consultant to be notified, but the doctor
insisted on doing a vaginal examination. Betty just went ahead and rang the
consultant doctor herself. There is a twist to this story though, and Betty ends
up working hand in hand (almost literally) with a consultant doctor, who
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provides her with one of the most amazing experiences of her entire
midwifery career.
she was a multi, it was her second pregnancy and she had twins. …
She must have been about 36 or 37 weeks … she said to me … I think
I’m going to do it. … So, I rang the doctor, the resident that we had on.
And he said I’ll do a vaginal examination, I said “No I want you to ring
the consultant please. He said “Well he’ll want to know what she is” I
said “No he won’t, just ring him”. He said “No, I’m going to do a vaginal
examination first”, so I said “Okay, I’ll go and ring the consultant then,”
Because we had to have a consultant present for, you know, on
multiple deliveries. … so he went and did a vaginal. And he said she’s
9 centimeters. I said “cephalic?” and he said “Yes” and ah so I turned
to go out of the room, I thought I’ll just ring the consultant again and
make sure he’s on his way, and I looked and here’s a bottom. And I
said to the resident, “Well it doesn’t look cephalic to me”.
I said “would you go out and ring the consultant and tell him to get here
fast.” So I had the first baby delivered up to the abdomen by the time
the consultant got there. … The consultant arrived, and he put his
hand in and we had locked twins. It was the fastest experience of my
whole life in midwifery. Fortunately the Anaesthetist had actually come
up to see her because they were going to put an epidural in. … I had
actually taken her from birth suite down to theatre and I had my hand
in, and I was holding the leading baby up, … And it was the quickest
Caesar I’ve ever experienced in my life, I don’t know how he did it, but I
can remember thinking I said “ Goodness me are you in the uterus?” He
said “Yes”. To feel the difference on my hand. “Watch my fingers”. …
he delivered the second baby first. It was in excellent condition, and
then we did the breech delivery of the first one. And it wasn’t too bad
either. It was about APGAR 6 or 7. And so we had two live babies that
were in good, good condition, out of a situation that both babies could
have been dead.
… And it was the most, umm…it was the most amazing experience.
And these little kids both of them were good. Betty
It is possible for doctors and midwives to work well together. After a not-so-
smooth beginning, this birthing story had a wonderful outcome when Betty
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and the consultant teamed up brilliantly in an emergency situation. As Betty
clearly stated, the outcome could very easily have been quite different.
Chiarella has said “Today or tomorrow or the next day, a nurse may or may
not intervene to stop a doctor from making a mistake which might harm a
patient. It will not depend on the law. It will depend on how brave they are.”
(2000, p. 198). It could be that Betty’s choosing to ignore the junior doctor
and go ahead and ring the consultant saved the lives of these babies.
Whether or not one regards that as brave, is an individual judgement, but it is
not following protocol, and a new or inexperienced midwife might not be so
bold as to take such a step. A strong personality might be more helpful than a
policy when it comes to positively influencing patient care (Chiarella, 2000).
Conclusion So, we have seen that normal is not as simple and common place as one
might think. Sometimes is has to be fought for or reclaimed. On occasions it
can be grasped with the help of midwives and doctors working together
closely with a client. A brief look at an act of commission and an act of
omission helped us to see how a doctor’s actions could put midwives in
challenging situations. Lastly we viewed a birthing story where a
disagreement about a course of action between doctor and midwife could
have resulted in major problems, but each did what they believed was the
right thing to do. This was fortunate as it happened, and the end result was a
happy one.
After reading this chapter, it might cause you to think that doctors and
midwives very rarely work harmoniously together. Personal experience leads
me to believe that this is far from the truth. Doctors and midwives, although
approaching birthing from a different philosophical stance, know that they are
part of a team and, more often than not, they work well together, respecting
the skills and knowledge that the other brings. The reason that numerous
stories of harmonious working relationships were not shared by the
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participants and thus do not appear here is, I postulate, that they do not
evidence something unusual. As a story’s very “tellability” relies on that
(Bruner, 1991), such interactions were not considered worthy to tell. They
were, quite simply, too ordinary.
In the next chapter we will be moving on to stories that involve clients and
their significant others. The interactions that midwives have with this group of
people are of particular significance, for it is primarily mothers-to-be and their
families that are the focus of midwives and midwifery. They are at the core of
the profession.
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CHAPTER 6 FAMILIES AND MIDWIVES
So I’m just very conscious of that fact all the time in a birthing
environment that this is going to be something that a woman takes with
her throughout the journey of the rest of her life. … you do hear of
stories of women that are very upset and very angry about what
happened to them, … and I’m just awfully mindful of that and I want it to
be different. I want it to be different. Kelly
Introduction In previous chapters many stories have been shared that highlighted the
interactions midwives have with other midwives, the institution (or
management) and doctors. Whilst all of these things are important, the
contents of this chapter are, in many ways, far more important. Here the
focus will be on midwives working with childbearing women and their
significant others. They will tell us their stories and, hopefully, as these
stories are read and interpreted, it will be possible to learn a little more and
understand a little better what it means to be a midwife. Women, babies, and
families are (or at least, in my opinion, should be) at the centre of midwifery.
Without them, it would be nonsensical to discuss midwifery at all.
Curiously, these stories, ones which focused on midwives’ interactions with
their clients and their families, were much less common in the midwives’
interviews than those featuring interactions with other staff members or the
more nebulous, almost ethereal “them”. With Bruner (1991, 1994) in mind, I
am inclined to interpret this to mean that clients are less trouble, and thus
create less (in volume) meaningful stories to tell. Another possibility is that
the institutional settings where much midwifery is now practised, and in which
all of the midwives interviewed for this project worked, have come to be so
influential in the practice of midwifery that they, and the people working in
them, overshadow the very people that they are there for. I do hope it is the
former and not the latter.
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It is reasonable to assume that the vast majority of midwives want to assist
the clients that they care for to achieve the best possible birth experience,
and a smooth transition to parenthood and family formation. Certainly the
midwives in this study were very aware of their clients’ interests and saw
them as being central to their practice. This is clearly evident in Kelly’s words
below,
I just want so badly for women to have good birth experiences … when
I’m like there with a woman, I’m just, I’m giving myself wholly to her and
she’s, for me she’s the most important person in the world at that
moment Kelly
With this is mind, it is fair to say that it is likely that most, if not all, midwives
strive to practice within the guidelines set down for practice; following the
Code of Professional Conduct for Nurses in Australia (ANMC, 2003), the
Code of Practice for Midwives (QNC and ACMI, n.d.) and the Code of Ethics
for Nurses in Australia (ANC, RCNA, and ANF, 2002). Each of these
documents provides midwives with useful parameters for appropriate
practice, but they do not tell her what to do in every situation every day. Real
life situations are complicated by people. As each situation is unique, a
midwife has to respond to the individual/s involved sensitively, in a manner
appropriate for them, which is entirely fitting for that particular situation, at
that precise time. This, naturally, could include other midwives with whom
they are working, with each midwife needing to be aware of the needs of
those she is working with (colleagues) as well as those she is working for
(clients). As will be demonstrated as this chapter unfolds, this is not always
straight forward.
Midwives as “Friends” Sometimes boundaries between our professional life and our “real” or
personal life are difficult to draw. Many a worker is familiar with the adage,
“leave your personal life at home”. Whether that life is good or bad, full of
excitement or sorrow, we are expected to flick a switch as we walk through
the door of our work place and become a person completely unaffected by
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whatever else may be happening in our world beyond that door. Lives are
complex though, and it is inevitable that occasions arise when personal and
professional lives come together. It does not, however, have to be a clash of
interest.
It could actually be that some sharing on the midwife’s part is beneficial.
Kennedy et al. (2004) found that the development of a mutual trusting
relationship between midwife and woman necessitated openness, and
sometimes personal disclosure was a part of this. Jones (2000) and F.
Thompson (2004) agree that friendship between a midwife and the woman in
her care can be beneficial, as it fosters trust, intimacy and disclosure.
Jones (2000) writes about “friend” as an ethical dimension of the midwife’s
role. She reminds us that, in the past, nurses and midwives were actually
taught not to engage with clients beyond the professional necessities. This
was supposed to foster faith in the midwife as a capable, trustworthy
professional who was in control of the situation. Whilst they did seem to be in
control, midwives, not surprisingly, also frequently appeared to be somewhat
detached, uncaring and unapproachable. Jones tells us that the idea of
“professional friend” appeals to people who encourage autonomy. She alerts
us to some possibilities regarding this kind of relationship. It could create
some difficulties when we are to provide objective advice, counselling, or
have to give bad news. On the other hand, having created a friendship may
make these very same tasks easier. Jones warns us of the potential danger
of creating a situation of dependence and replacing controlling paternalism
(from the old detached style) with protective paternalism (from the new
friendship style). Either way, the professional would be deciding what is best
for the client. Overall though, Jones views professional friendship positively,
saying that, when appropriately used, it enables midwives to be supportive
and provide advocacy for their clients.
F. Thompson (2004) has also written about the relationship between
midwives and women in terms of friendship. She says that “friendship is a
close relationship in which trust, intimacy, and disclosure open us up to
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another’s way of seeing” (2004, p. 165). She sees the friendships that
develop between midwives and their clients in terms of human engagement,
of midwives being encouraging and supportive, fostering trust and respect.
This is a significant aspect of the ethical practice of midwifery as some of the
stories in this thesis testify.
Sometimes, some midwives find it helpful to continue the relationship with
their client beyond where their legal and professional responsibilities end.
This would seem to be an extension beyond the type of professional
friendship that Jones (2000) was referring to, but may fit with the concept of
engagement that is offered by F. Thompson (2004). Many midwives give of
themselves in this way and several examples can be found within this thesis.
Different midwives, different situations, giving of themselves in different ways,
but each of them continuing their relationship with the client (or family) in
some way, after their official responsibility had been handed over to others.
It seems to be quite common, at least amongst the midwives that I
interviewed, to continue caring beyond the bounds of immediate legal or
professional responsibility. Some examples include Gemma’s story when
caring for Jane later in this Chapter, and Felicity’s experience with Rose in
Chapter Five.
The fact that professional boundaries are often unclear has not escaped the
notice of the wider profession, and its leaders. A booklet titled Guidelines for
Registered Nurses and Enrolled Nurses regarding the Boundaries of
Professional Practice was produced in 1999 by the University of Newcastle
and the New South Wales Nurses Registration Board, and approved for use
in Queensland by the Queensland Nursing Council. This twenty-four page
booklet grapples with the difficult issues of explaining boundaries,
professional boundaries, safe practice and therapeutic practice. The
explanations make it relatively easy to understand that there is a continuum
where there is, as the authors have demonstrated, a “zone of helpfulness”.
Either side of this, a nurse can be under involved; seeming aloof or uncaring,
or over involved; which may be equally inappropriate for a number of
reasons. These include potential exploitation of the client by the nurse/
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midwife, disadvantaging other clients due to the nurse/ midwife favouring the
client, and the nurse/ midwife being exploited by the client. Sixteen principles
of safe practice are offered (see below). Principles one, two, nine, ten and
eleven seem relevant for the current discussion. None of them, however,
really cover the issue of ongoing relationships. They suggest that any sharing
would begin and end within the confines of the therapeutic relationship. That
relationship would generally be understood, I think, to have ended when the
midwife completed her shift; at which time she ceased to be professionally
and legally responsible for that client. It could be argued, however, that a
therapeutic relationship might continue beyond the legal and professional.
It is interesting to question why midwives continue to care in this way.
Although the answers are not clear within the midwives’ stories, and this
Principles of Safe Practice
1. The priority of nurses is to plan care around meeting the therapeutic needs of the client. 2. Nurses need to be aware of their own needs, values and attitudes in a professional
relationship. 3. Nurses must have an awareness of and an ability to describe the therapeutic purpose of
nursing actions that are interpreted against client responses. 4. Nurses are responsible for ensuring that nursing care is never withheld from a client as a
punishment. Any intent to cause pain/ suffering as punishment based on punitive judgement is unacceptable.
5. Coercing client compliance may be an abuse of the power imbalance. 6. Nurses need to be aware of the comfort zones for both client and nurse regarding
therapeutic touch. 7. Care is optimised when nurses and clients do not engage in dual relationships. 8. Where dual relationships are unavoidable there is a potential for prejudicial practice to
occur. 9. Self-disclosure should be limited to revealing information that had therapeutic value to the
client. 10. Self-disclosure should only occur within an established therapeutic relationship. 11. Nurses need to carefully consider their motives for disclosing personal information. 12. Nurses should apply Statement Seven of the ANCI Code of Professional Conduct for
Nurses in Australia (1995) as the standard for confidentiality: ‘Treat as confidential personal information obtained in a professional capacity’.
13. Nurses should not use confidential information or their position of power to advantage themselves in any way.
14. Nurses have a professional responsibility to inform clients about the nursing care which clients are receiving. Nurses should assess and negotiate individual clients’ needs for information relating to their care.
15. Nurses should recognise that the giving and receiving of gifts and involvement in financial transactions within the nurse-client relationship has the potential to compromise the professional relationship.
16. The giving of a gift to a nurse by a client may have an impact on the client’s significant others.
Guidelines for Registered Nurses and Enrolled Nurses regarding the Boundaries of Professional Practice 1999; Page 22. Developed by: The University of Newcastle (Australia) and The NSW Nurses Registration Board. Approved for use in Queensland by the Queensland Nursing Council.
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behaviour does not seem to fit, strictly speaking, within the arbitrary
guidelines that have been set down, it is possible to conjecture. Midwives are
privileged persons, sharing with people at one of the most vulnerable
moments of their lives and, because of this, tend to draw into close
relationships with their clients, especially (but not only) during labour, and, it
seems, particularly when the road is not a smooth one. It has happened to
me, I have seen it happen to colleagues, and many of the research
participants in this project told me of occasions when it has happened to
them. Obviously, it is a common phenomenon. This “drawing close”, the
woman’s vulnerability, the trust that she places in the midwife and the
midwife’s focus on being truly “with” her client in whatever way she needs,
facilitates the development of a relationship that would not normally reach
such a depth in so short a time. This relationship is, however, a professional
one for the midwife, yet, in some cases, it causes them to develop a deep
concern for their clients. This concern results in a need to follow through, until
they know that the client, the family, or both, depending on the situation, is/
are alright.
Is it fulfilling a need of the midwife as well as a need of the client? It could be
that the midwife needs to see the client again to reassure herself and/ or the
client that she did everything she could at the time. When unexpected,
unpleasant, or downright awful things happen, as they unfortunately do on
occasions, people involved in those events are sometimes disposed to blame
themselves, or someone else, for any or every little occurrence. What might
have been able to be handled differently? Could it have made a difference? If
only? Watching over the client postnatally may be reassuring to both client
and midwife. It will certainly show that the midwife in question cares.
Several of the participants told me that women needed or liked an
opportunity to share their birth experience with the midwife who was there,
regardless of whether the birth had been straight forward or complicated.
Some people believe that it shows greater caring if a midwife “follows
through” with his/her clients, making sure to see them again after delivery
(personal experience). Providing an opportunity for women to share their
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birth story can be very beneficial. It allows them to discuss any fears,
concerns, feelings of inadequacy or disappointment they might have. Couple
relationships can be positively influenced, and discussion may help them to
make sense of their birth experience and resolve unanswered questions
(Baxter, McCrae and Dorey-Irani, 2003; Callister, 2004).
This type of visit, or chance to share birthing experiences, is a little different,
though, from the sense the midwives interviewed often conveyed. The follow
through visit after delivery tends to be a one off visit, a chance for a client to
speak with a midwife (usually one who was present when they birthed),
whereas many research participants in this study were speaking of repeated
contacts, or thinking often of the client in question. This has been reported in
other studies (Maher and Souter, 2002). In all of the cases mentioned by
research participants, the birth was a little unusual, special, or traumatic47.
Something held them in the moment. These midwives seem to really care
about the clients that they continue to have contact with or think about. It is
also important to note that some of these situations appear to fit within the
category that I call “haunting stories” – those that stay with midwives across
the years and shape their midwifery identities.
Working together, working with Gemma remembers a client with whom she formed a special bond. She
attributes this, at least in part, to the fact that the client discovered that it was
her birthday, thus sharing in a special part of each other’s lives.
… probably the one I most remember was a young primip, and she was
only 17 and I remember it too because that was my birthday, and the
baby was born on my birthday… when I came on the shift the handover
was a little bit negative in the fact that comments were made that she
wasn’t coping and, you know, to that type of extreme. So I went in and
took over at 3 o’clock, I was working a late shift … they were a really
young couple … the partner was 17 but quite immature, but still very
47 We should not be surprised at this since Bruner (1991, 1994) has informed us the tellability of a story rests on its evidencing, or giving testimony to, something out of the ordinary.
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caring towards her, and they definitely had a connection together. [I]
went in and just got her to change some positions, you know offer her
some different solutions and we just clicked and it was an amazing, the
baby was 10 pound, she ended up having no drugs and the perineum
intact…she was coping really, really well … she tried so hard and she
was so young and worked so hard with me, and it was just a really
lovely birth and that girl’s, every year has contacted me on my birthday
and sent me a card and told me about her little boy – and they’re
actually still together now and the baby is now 7 and, so that one sticks
in my mind probably because of the affiliation that I had with her and
just the fact that I felt like my presence and the way that we worked
together, helped her through that situation, and it was nice to see a
young couple of that age, you know, and that was a nice outcome and
still be together today.
She is the only one that’s every really kept contact with me, so
obviously you know that experience had an impact on both of us and,
as I said, I think a lot of it was because it was my birthday…I’ve had lots
of nice experiences, probably you know a bit similar to that. Gemma
We can draw a number of things from this story, especially if we look at it
with an ethical gaze. Firstly, Gemma was at work on her birthday, probably
not where she most wanted to be on that day. Next, at handover, she was
allocated to care for a young couple who were, apparently, not coping with
their labour. This was, Gemma says, conveyed in a negative way, which left
open an opportunity for all the midwives arriving on duty to take on some
preconceived ideas about the young labouring woman and her partner before
they even met them. However, Gemma entered the room and tried some
different approaches to those that had been suggested up to that point, and
found that she and the young couple “just clicked”. Gemma informs us that
her client worked with her, that they formed an affiliation, and that they
worked together. Gemma was not conducting the labour and birth, she was
supporting and encouraging, “being with” her client. She certainly remembers
the positive outcome, but the whole experience was “nice”.
This is a good example of Integrative Power, as described by Rollo May
(1972). Gemma has come alongside of this young couple, assisting and
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enabling them to better cope with their labour. However, it is not through or
by what she did, rather by the combined effort of the affiliated team. R. May
succinctly says, “My power then abets my neighbor’s power” (1972, p. 109).
The definition of the word “abet” is “to encourage, support, or countenance by
aid or approval” (http://dictionary.reference.com/browse/abet). Although the most
common usage of this word is in the context of aiding a criminal, how
delightful it is to think of abetting someone in labour. It brings to mind the
thought that perhaps integrative power, the concept of coming alongside, is
not only a little bit different, but perhaps even outside of what is normally
accepted by society. Is it usual, or even safe, for a health care provider to be
so rash as to share her power so generously? Just look at the words, we
provide health care; surely we must hold the power so as to determine what
that care will be? Integrative power then, is to have “power with” the other (R.
May, 1972, p. 109).
This is not to say, by any means, that there are not times when it is both
good and correct for health care providers to hold and use the power they
have to assist, guide and sometimes make decisions for clients. There are
times when clients are unable or unwilling to make decisions for themselves.
Examples may include the unconscious, the very sick and the highly
stressed. There are even times when clients make decisions which are not in
their own best interests. Examples of this might include a person refusing life-
saving surgery due to being overwhelmed by the diagnosis, or a depressed
person refusing treatment because they see no future in life. It is in these
situations where nutrient power can be of great assistance. Nutrient Power is
“power for” the other (R. May, 1972, p. 109). Here we use our abilities to care
for and look after the concerns of another, much as a parent cares for their
child. R. May asserts that we derive some satisfaction by caring for others in
this way.
These two forms of power, integrative and nutrient, are the two that it would
be, in my opinion, most preferable to see most commonly used not only in
the health care setting, but in all human relationships. Gemma was definitely
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an advocate of integrative power, whether she realized it or not. She told me
another story, one she remembers very well.
Caring for versus caring about As is evident from the previous story, Gemma has (like many midwives)
embraced the concept of allowing women to choose what they do during their
labour, and how various aspects of their labour are managed. One decision
she encourages them to make is whether they would like the third stage of
their labour to be managed physiologically or actively. Some midwives are
less keen on physiological management of third stage than others.
Frequently this stems from historical reasons, lack of knowledge, a desire for
a rapid third stage, or habit. Gemma used to strongly advocate physiological
management of third stage. She said to me
Don’t get me wrong, I’m still happy for women to choose not to have it
[Syntocinon], but I know that my heart rate goes up and I, and I watch, I
watch a lot more closely than I probably ever did, you know, I never
thought I was neglectful or anything, but I’m more anxious now than I
ever used to be until that placenta’s out. Gemma
What changed her, from a cool, calm, happy-to-wait midwife who encouraged
women to let nature take its course, into one who still respects women’s
choices, but distrusts nature, waiting upon her anxiously in anticipation of
what just might go wrong was, ”of course”, an ethical encounter. Gemma had
met Jane, and this was an ethical encounter with muscle. Why does Gemma
remember Jane so well? It is not simply because she had a haemorrhage
after the birth of her baby. Jane’s birth led to complex and ongoing family
interactions. The impact of this particular birth would stay with Gemma for
years.
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And it happened so quickly you know, like it can, I had one lady go into
D.I.C.48 and that wasn’t the nicest thing in the world to have to go
through, and first baby and end up having to have a hysterectomy, so it
was pretty, pretty bad. …a very sick girl…A young girl…renal
failure…ongoing problems…can’t have any more children…she was in
intensive care for a month… Gemma
One day, an ordinary day, in Birth Suite, Gemma went to work and cared for
Jane. The complications after the birth resulted in Jane being transferred to
intensive care and thus out of Gemma’s care. Legally and professionally, she
was no longer responsible for Jane, her partner, or her baby. Jane’s
husband, however, came repeatedly to Gemma as his wife’s life hung in the
balance. He knew and trusted her as they had developed a rapport.
It was such a black time in their life and he had a little bit of trouble with
bonding with the baby…He definitely … steered clear of the baby a bit
and had some feelings that he didn’t like very much, and he was able to
talk to me about that … he felt that the baby had caused you know, this
huge drama in their life and it was supposed to be a nice, nice thing …
his life was turned upside down Gemma
Gemma, though not responsible for the care of mother or baby, kept tabs on
Jane’s progress. Baby was taken for short visits. Jane was improving.
Eventually, Jane retuned to the maternity ward. Amazingly, she was able to
breastfeed. It is most unusual, in the presence of severe illness, massive
blood loss and/ or the absence of early suckling, for a mother to produce
adequate milk for her infant, and Jane had endured all three. The baby was
mostly very settled, as if it knew its mother needed it to be well behaved – it
seemed to be able to already express its love for its mother in a practical
way. The wider family were incredibly supportive. They were present day and
night. Gemma engaged with this family on a much deeper level, and for
much longer, than was professionally expected or required and she says,
48 Disseminated Intravascular Coagulation – Crafter explains this as “a situation of inappropriate coagulation within the blood vessels which leads to the consumption of clotting factors. As a result clotting fails to occur at the bleeding site.” (1999, p. 266). It is a complex secondary disorder – always occurring as a response to another disease process, and can itself be fatal (Crafter, 1999).
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It was nice, a nice outcome, you know, right at the end, but it was pretty
draining for a long time. Gemma
When she had a follow up visit at twelve months, Jane sought Gemma out to
share with her how she was going. It had been a struggle, but she was
getting on with life. As Gemma’s audience, I sensed she felt honoured that
Jane had made this effort to share with her again. It was important to Gemma
to know that Jane was okay. Jane was alright. Not great, Gemma noting that
it certainly had not been “a walk in the park for her”, but she was on the path
to recovery. What effect though, had this encounter had on Gemma, on her
practice, on midwifery? In simple terms, I could explain this using Gemma’s
own words.
It’s hard when you’re talking about third stage to women, like not to
have a bit of a picture of that. Even though that’s the extreme, you
know like, I suppose my mentality’s gone a bit well, “What’s an injection
if it stops that type of?”. But really, putting it into perspective, it wasn’t
not having an oxytocic that caused it anyway … Gemma
And we remember her words quoted earlier
I know my heart rate goes up and I, and I watch, I watch a lot more
closely Gemma
Clearly, Gemma’s experience with Jane has had a significant impact on how
she thinks about the management of the third stage of labour. Her knowledge
informs her thinking, and she knows that the administration of an oxytocic
medication, that is, managing third stage actively rather than physiologically,
does not assure her that there will be no post partum haemorrhage or further
complications. She knows that it was not the absence of this medication that
caused Jane’s complications. Despite this, remembering Jane, she would
probably feel more comfortable if women chose to have the medication so as
to minimise the possibility of bleeding and further complication. She is edgy.
Always. As if Jane is present in every third stage.
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Although the impact Gemma first told me about was her anxiety relating to
management of the third stage of labour, the real story she had to tell was
Jane’s. On a deeper level there is more to Gemma’s story of Jane than a
changed attitude to the management of the third stage of labour. Her sense
of commitment toward Jane didn’t end when her legal and professional
responsibility ended. Though she found it draining, she didn’t begrudge this.
It was her ethical responsibility that extended beyond the eight hour shift
during which she was caring for Jane. The ongoing care and concern that
Gemma showed for Jane after she left the Birth Suite tells us more about the
ethical encounter that occurred that day. Perhaps it also informs our
understanding of the profession, at least as practised by Gemma.
It seems that it was a natural progression for Gemma to continue to care
about Jane, even though she was no longer caring for Jane. She also felt
ongoing responsibility toward Jane’s husband and baby, even though she
was not responsible for them. A unique relationship was forged here, in a
similar way to that special bond that had developed with the young couple
whose baby was born on her birthday.
The personal/ professional boundary is a challenge for midwives, can
complicate their work, and has an impact on midwives’ ability to maximize the
care they provide their clients (Maher and Souter, 2002). This is due, at least
in part, to models of care being unaccommodating. As in my study,
expressions of caring beyond the midwife’s professional and legal
responsibility were also heard in their study. Maher and Souter noted that
post-birth support and “extended follow-up is not facilitated by the Australian
health system” (2002, p. 38). The stories shared by Kelly and Felicity49
earlier in this thesis have demonstrated how difficult it can be to provide the
kind of care that a midwife feels is the most appropriate on that particular
occasion. This ongoing caring is very much in keeping with midwifery being a
profession which is a social practice, in which the members have a moral
49 Kelly with Penny, communicating for years after the birth experience through letters; and Felicity with Rose, who yearned to reach out to her and follow through personally, but was not in a position to do so.
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obligation or desire to practise ethically. As was discussed in Chapter Three,
the covenantal relationship that exists within such a practice leads its
members to provide for those it serves in a context of gift, fidelity and trust
(Isaacs, 1993).
When the past impacts on the present At the beginning of this chapter Kelly introduced us to how she felt about
being a midwife and the type of care she likes to provide. Her words are
worth repeating, for I am sure many midwives will identify with them in their
own practice. She said,
when I’m there with a woman, I’m just, I’m giving myself wholly to her
and she’s, for me she’s the most important person in the world at that
moment. Kelly (italics added)
Kelly wants to make the woman she is with the centre of her attention, the
whole point of her being. Whilst they are together, nothing else matters to
Kelly. Early in her career as a midwife, Kelly had an experience with a family
which resulted in a difficult birth, with significant complications for the baby. It
certainly was not the last difficult birth she would be present at, but it would
have a significant impact. Kelly’s experience was related more fully in
Chapter Three. It involves other players, just as each and every story in this
thesis does, such as mother, baby, father, doctor/s, and other personnel, but
the most significant relationship in that particular story, as I (as Kelly’s
audience) interpreted it, was that between herself and her NPC50. It is
because of Kelly’s words below, spoken many years later, that I drew this
conclusion.
there was just this feeling I had, and I’ve often thought about it when,
when I’ve had situations that are difficult since, this always pops up into
my mind, just this feeling of being, umm, sort of unsupported when
things don’t go right and, and really overwhelmed with the responsibility
that I have on a day to day basis. Kelly
50 Nurse Practice Co-ordinator – her unit manager.
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The midwife/midwife aspect of Kelly’s story has been discussed in a previous
chapter. Here I am interested in how this previous experience is having a
continuing effect on both Kelly and her practice. It impacts on her as she
works with mothers, their partners, and their support people even today. Try
to envisage how the following situation may have felt from Kelly’s
perspective.
… just the other week I had a moderate shoulder dystocia and… I
accidentally broke the baby’s clavicle, which… if you’re rational and
you’re thinking about it professionally, you think, well, got the baby out,
it was in a good condition, mother’s OK but the baby’s got a broken
clavicle, but that thought still, of that happening, … it bothers me still… I
think about it a lot and I have trouble sort of reconciling the fact that that
happened. I guess ‘cause I always want a good outcome for mother
and baby and so when it’s not so perfect I really question myself and I
think what did I miss, how could I have managed it differently, so, I
mean these situations are great for self reflective practice …
I certainly, with that situation I feel like, retrospectively I probably did the
right thing - but actually at the time when she was pushing up that head
… I’m not a hundred percent convinced that I actually, the thought
“shoulder dystocia” went through my head at that point... One good
thing is that she’d been upright the whole time. She’d been leaning over
the side of the bed with her leg up on a chair, … although I was
probably not thinking that, would have been, you know that was just
more to get gravity behind us to get us pushing up well, umm, I think
that actually probably contributed to the baby coming out in a relatively
good condition … But there’s just this part of me that I think I actually
didn’t recognise it …
… they certainly weigh on my mind quite a bit and it’s something that I,
when I think about my day at work I tend to, the things that are very,
sort of fresh in my memory are the things that perhaps I know I could
have done differently, or why this happened or things like that.
Kelly (italics added)
The language Kelly uses in the telling of this story suggests that she is
claiming the “problems” of this birth as her own. She had a shoulder dystocia,
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she broke the baby’s clavicle, she may have missed something, although the
woman was using an excellent position for the birth, given the circumstances,
Kelly takes no credit, suggesting it was more likely for another reason, not
because she had thought it a good idea in the circumstances. That is, Kelly
conveys the message that this positive outcome was far more good luck than
good management.
Shoulder dystocia is unrelated to the skill of the accoucheur and occurs when
the baby’s shoulders become “stuck” in the mother’s pelvis after the birth of
its head. It is an emergency, as the baby’s head is now born, and baby has to
be fully born within minutes to survive. Sometimes manipulation of the
shoulders to assist delivery results in the person assisting the birth breaking
the baby’s clavicle. Whilst birthing the shoulders is a priority, I doubt that
fracturing the baby’s clavicle is, in fact, deliberate. This can be a life saving
event, as it then allows the baby’s shoulders to pass through the pelvis and
the baby to be born. Morbidity for the infants who have shoulder dystocia
may be as high as 42 %, and mothers also have a higher risk of
complications such as post partum haemorrhage (Shiers and Coates, 1999).
This story is a fine example to affirm Kelly’s feelings of being unsupported
and overwhelmed in difficult situations which occur on a day to day basis – all
of which stem from an experience of feeling that she had been left bereft
early in her career.
Kelly went on to tell me of a conversation with a colleague that had helped
her to put things into perspective, knowing that all births are not perfect.
When she had reflected on the birth in question, she said she knew that she
and her client had managed it well. Of interest, and the reason why I have
shared this particular lady’s story, is the fact that, like Gemma, in the two
previous stories, Kelly developed a relationship that extended beyond the
birthing room. Certainly we know that whilst she was with her client she
wanted to be completed focused on her needs, she told us that very clearly.
We should reasonably expect this of a (good) midwife. After all, this is what
midwives do (for further information see “What is a midwife?” in Chapter
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One). Kelly, however, just like Gemma, saw her responsibility as extending
beyond where her legal and professional responsibility and obligation ended.
I went and saw her three days in a row, just every day just to make sure
that she, that I’d answered any questions that she had. Just to show
that I was, you know, that she was important to me, and that I was
worried about her. I wanted to make sure that she was okay. And I do it
because I feel like that, if this was to occur more, if people were
explained what happened to them at their birth maybe there wouldn’t be
so much horror.
And I think women are living their lifetimes and it’s one thing I’ve said to
a lot of my friends, like for us it’s one moment in a day and it might be a
bad outcome and we think about it a little bit, but eventually it goes
away, but I actually think that women live with this for the rest of their
lives, this horror, and I talk about it as being a horror, the things that
were done to their body, the things that were taken away from them,
and the things that their body actually went through, that horrified them
because of that feeling of being out of control. So I’m just very
conscious of that fact all the time in a birthing environment that this is
going to be something that a woman takes with her throughout the
journey of the rest of her life. Yeah, and you know you do hear of
stories of women that are very upset and very angry about what
happened to them, the way they were treated, the way their bodies
were treated during their birthing experience, and I’m just awfully
mindful of that and I want it to be different. I want it to be different. I
want women, you know, to be in command of what happened to them,
after the event I want for them to be able to ask questions and be able
to reconcile it a little bit for themselves, because I, I think that’s a large
part of obstetrics and maternity care that just hasn’t been recognised.
It’s like you’re a person but and it’s just, well this is what happens to you
but there’s no recognition of the long-term consequences of that.
Kelly
Kelly seems, to me, to be fairly well tuned in to women. In my personal
experience, teaching antenatal classes, I find that many parents-to-be have
heard many of the “horrors” of which Kelly speaks. Those families who have
positive birth experiences seem to share them far less frequently, and with
less enthusiasm, than those who have laid down memories of their birth
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experience as “a horror story”, or a saga at the very least. So, the dominant
birth story in Australian culture has become one of pain, fear, problems, and
intervention. We can readily tie this fact into the feature of narrative Bruner
(1991) calls Canonicity and Breach.
By now we are all well aware that Bruner (1991) asserts that, for a story to be
regarded as worth telling, it needs to have broken a commonly held canon or
norm. In this case we might regard the norm as an unaided vaginal birth. I
would call that a normal birth, a natural birth, or a spontaneous vaginal
birth.51 Within Bruner’s framework of understanding, if your birth falls inside
of this norm, it is generally to be regarded as usual, therefore generally
uninteresting, and not really worth telling.
“I had a baby and everything went according to the book” is a bit like saying,
“I ate lunch today. I had a sandwich”52. It really does not hold the same
interest as telling you about my ten course gourmet meal at a five star
establishment. If, however, I was to tell you a long, drawn out saga of my
three day labour, followed by my failed forceps delivery, with my huge tear,
emergency caesarean, blood transfusion and baby who had to spend a week
in special care nursery whilst I struggled to establish breastfeeding because
the poor little mite was six weeks premature and jaundiced, well, then all
sorts of norms would have been breached and my story would have you well
and truly captivated.
Some things in life really are horrible. There is absolutely no denying that
fact. On the other hand, many things seem very much worse than they
actually are, were, might or could be. This is often simply because we do not
understand what is happening, why procedures are necessary, or because
something is happening to, or around, us in a disrespectful, painful,
embarrassing way. A procedure that is overwhelmingly commonplace to
51 It is difficult to know what we might call “normal” in the future, with caesarean births becoming increasingly common, but for now, a birth via the vagina, unaided by medical instrumentation, is still considered the norm. 52 For the particular mother though, having such a birth is “uniquely normal” and thus warrants telling (Downe, 2006).
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midwives, can be terrifying to a woman or her partner. Midwives and doctors
have come to accept this frequent occurrence as part of the everyday, but it
is quite foreign to our clients. Some examples might include preparing to
insert an intravenous drip, or “losing contact” with the baby’s heartbeat on the
electronic tracing when mum or baby moves.
The wrong words or the wrong tone of voice can adversely impact on
hormones in labour. Even an uninviting environment can inhibit labour.
Simple things can make a big difference. Quite apart from the obvious
emotional and psychological impact, words and environment can have a
significant physiological impact on a woman’s labour. A woman could have a
horrible labour and birth experience because someone spoke to her “the
wrong way” (from her perspective). Women need a positive and calm
environment to labour optimally (Buckley, 2003).
These are just some of the “horrors” that Kelly might have been speaking of.
Regardless of the type of birth a person has had, and the procedures she
may or may not have been subjected to, when someone has a baby, for the
vast majority of people, life is turned upside down – temporarily at least. Their
birth story might fit entirely into the norm, but their life story no longer fits. Not
into their norm at least. All new parents have a story that is worth telling and
worthy of an audience. Kelly seems to have tuned into the fact that this
event, though it may be just another day in the health professional’s life, is
something much more for the family who are having a baby. As such, she
sees them as needing and deserving a particular regard that acknowledges
the tremendous impact this impact may – indeed will – have on them.
You will recall that, early in her career, Kelly experienced a lack of personal
support from her NPC, which resulted in her having ongoing feelings of being
unsupported and bearing a sense of overwhelming responsibility at work. I
see some parallels between what Kelly believed happens to some women,
and what had once happened to her. There was a common experience of
feeling that they were not in control of the situation, and being angry about
how they were treated. Kelly said “I’m just awfully mindful of that and I want it
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to be different. I want it to be different”. She is empathetic. Kelly does not
want her clients to be haunted by their birthing experience as she has been
haunted.
Sometimes a woman will experience a truly complex labour where nature
does not seem to be on anyone’s side. Perhaps mother is not well. So,
naturally enough, father is stressed. Often, somewhere along the line, even
though the labour would be closely monitored, baby becomes distressed and
this usually results in intervention of some type. Maybe there is not a good
outcome for mother, or baby, or both. In some cases, there are many
interventions, surgery, intensive care, and weeks or months of ongoing
medical care requirements. True horror stories do exist. I am sure you have
heard some. Michelle Barnes (2006) told her horror story, sharing the
experience of her son Michael’s birth. A difficult and disappointing birth,
Michelle informs us that she was “deceived, neglected, insulted, abused and
ignored” (Barnes, 2006, p.25).
Wrong place, wrong time Olga became a part of a horror story, when she participated in the care of a
couple I am going to call Yasmin and Quentin. This is what she told me.
… ones I remember have been the ones where things haven’t worked
out. They’ll always stick in your mind for negative reasons. I had a
couple that she’d been in labour for I think 2 shifts, like 16 hours … he
was very angry when I got there. It was something like my 8th or 9th
shift and I was really tired, and I didn’t handle him the way I should
have. Apparently she’d asked for an epidural during the night shift, and
for some reason she hadn’t been given an epidural. When I was there
she wasn’t labouring well, her contractions had gone off and everything
was really negative in the room, and I called doctors in to see her and
they’d said continue, and they’d gone off to clinic. … he said, I want
something done right now. And so I’d get the doctor in to see him and
they’d have a few words to say to him – we’re happy to continue, the
baby’s well and that sort of thing. But his anger had just built up over
the time. And she ended up having an attempted forceps delivery, I
think it was a vacuum and that didn’t work, and they called in [the
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consultant obstetrician] and he said, we’ll go take her to theatre and do
a forceps delivery in theatre and go on with a Caesar, and eventually
she had a Caesar and bled profusely and like all of it built up. Because
he [her partner] was angry all the way through, I don’t know whether he
came in with issues in the beginning but that became very traumatic
after the Caesar, when she ended up, and then with the post-partum
haemorrhage had blood transfusions, it was just a follow-on effect of all
the bad things that could happen to her. And she had a very negative
view of the, even though the baby was fine, … the whole process was
bad for them. So, and a lot of their anger was directed towards me.
The only one it was directed towards. Olga
Olga was just one of several midwives, and each of those was just one part
of a large team of people who had cared for Yasmin and Quentin. Yet, Olga
says, “I think I copped their anger and disappointment from the whole
process even though they had very little contact with me really”. She had
cared for them for only a few hours throughout the entire process of their
labour and birth and, during that time, had done everything within her power
to address their needs.
During that time it had been evident to Olga that Quentin was very angry, and
she was aware that he had needs that were not being fully addressed.
However, she saw her first responsibility as being toward Yasmin, so
concentrated on attending to her, as she was aware that taking time out to
deal with Quentin would essentially prevent her from being with Yasmin.
What Olga did not realize, was the magnitude of Quentin’s anger which was,
unfortunately, immense. She told me,
in retrospect I probably should have said, gone out to one of my
colleagues and said this guy’s got issues, can you help me deal with
him? And [they] would’ve allocated someone else to come in and help
… But I was doing it all myself and it didn’t occur to me Olga
This is another example of ethics-on-the-run, like we saw Henrietta and Lucy
involved in earlier in the thesis (in Chapter Three). Many aspects of midwifery
involve active roles, actually doing things, where midwives do not have time
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to stand back and think, let alone reflect upon the situation at hand. They are
immersed in the moment, making decisions as best they can. If Olga had had
the luxury of being able to stand back and reflect upon what had been
happening in the room with Yasmin and Quentin, she may have approached
the situation differently. It may well have been possible from this different
angle, to notice just how angry and distressed Quentin was, and thus
remedial action could have been taken at that point, and perhaps prevented
further problems from arising. Like so many life circumstances, however, time
for reflection and discussion prior to decision making was simply not a
possibility. Olga was responsible for Yasmin’s care now. Yasmin was in
advanced labour and in need of constant attention. For Olga, that meant
caring for Yasmin and dealing with Quentin simultaneously. The end result
was that Olga bore the brunt of Quentin’s anger and, later, Yasmin’s as well.
It seems obvious that this would have an impact of some sort on Olga. How
could it not? The most obvious is that the story has stayed with Olga, again
affirming that midwives are “haunted” by some of their prior ethical
encounters. It would not be particularly helpful to merely remember the story
or the event. In this case, that would be not only “haunting”, but also
daunting. It would be quite disturbing, I should think, having Quentin’s anger
revisit you every time you thought of the situation. Olga said, “It probably
sticks in my mind mainly because it was [a] fairly traumatic time”.
We meet people, we interact with them in one way or another, and when the
interaction is significant, such as this encounter was for Olga, we do not
forget these meetings readily. In fact, as persons, we ourselves may well be
permanently changed after the experience. This is one of the ways in which
our stories are formative. As we live, each part of our life becomes a story
and the stories merge to become a bigger story. They merge also with the
stories of others and are continually formed and reformed. As previously
mentioned, Bruner (1991) refers to this joining of stories as narrative accrual,
and the result is the formation of cultures, traditions and histories. These
cultures, traditions and histories may be personal, professional or social.
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In the scenario that Olga relates to us, there is, no doubt, a wider story that
we are not privy to – that of her colleagues’ response to the situation and the
outcome. Many others were involved in the care of Yasmin and Quentin, and
would almost certainly have been (or become) aware of the complications
and difficulties that Yasmin, Quentin and Olga had faced. Whilst we are left to
postulate their response/s, it is likely that they also would have shared their
stories, and these would have informed and been added to the others
already told. As each of the stories was formed and told, heard and
interpreted, Olga’s story would have been interpreted and reinterpreted in
light of the new, emerging stories. The history and culture of the midwifery
setting where these events occurred would undoubtedly be affected by this
new larger story, the narrative accrual.
Fortunately, there were some more positive and very significant outcomes
from this event for Olga. Although she values being able to practise
independently (unless medical assistance is required), she recognizes that
there are times, such as in this situation with Quentin and Yasmin, when it is
important to involve midwifery colleagues in the care of her client/s. She now
knows what she would do. “I’ll say I need help here, someone come and deal
with him”, she told me with certainty, quite confident that she would identify
the problem much more readily should it occur again. Olga also sought and
underwent anger management training so as to gain some insight and skills
into how to best deal with angry people. Looking at this new understanding of
Olga’s in a purely objective manner, it is quite easy to see that there would
be an immediate, practical impact on her colleagues – they are going to be
asked to participate if the situation should arise again. Expectations have
changed.
Olga was quite clear that this had not been, in itself, a positive experience,
despite the fact that it had led her to make some positive changes. It had
been a learning experience. There were outcomes that were definitely
beneficial. Nonetheless, it was remembered as a particularly troublesome
time.
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that probably the learning makes, you know that was a big learning
curve for me. Like all things, bad things that happen are a learning
curve for me. You go back and re-go over every single thing, like every
… and it’s picked over with a fine tooth comb not just by me but through
the whole unit sort of thing. Olga
Like so many things, these are situations that have to be dealt with as they
arise, and made sense of later. Henrietta’s words come to mind, “ [It’s] not
that you can go and sit down and discuss it beforehand”. So, it gets
discussed later, and actions are taken to try and make it easier to deal with if
a similar situation arises again. Families are an integral part of midwifery. In
fact, as noted at the very beginning of this chapter, they are central, the very
reason that the practice exists, and they certainly make the practice
interesting.
Conclusion In this chapter four stories have been shared. We have seen how Gemma,
when working on her birthday, found that sharing some personal information
was a positive influence on her relationship with a young couple. The
professional friendship, which had been mentioned in Chapter Five, was
discussed, and it was noted that friendship between midwives and their
clients can be beneficial in developing rapport and fostering trust. Another
story from Gemma demonstrated how midwives can continue to care about
their clients, even though they are no longer caring for them, but also showed
how the events of a birth can have a lasting impact on a midwife’s practise.
We learnt that Gemma has a different attitude now toward the management
of the third stage of labour, so much so that it affects her physically.
Kelly told us a story of a woman she had assisted in birth fairly recently
before the interview. This story was significant in that it showed evidence of
the things she had mentioned in an earlier story relating to not being
supported by her colleague through a difficult time early in her career as a
midwife. Finally, Olga shared with us how effortful it can be to deal with angry
people in labour. In a labour that was fraught with complications, Olga ended
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up being at the receiving end of the couple’s anger because she happened to
be the person present.
In each of these challenging situations the midwife is amidst an ethical
encounter, engaging with others. As a member of a social practice, she is
endeavouring to care for the “other” in a context of gift, fidelity and trust
(Isaacs, 1993). She is trying to be a “good” midwife. In the next chapter the
discussion will move from looking at the midwives’ stories, to expand on
some of the topics and issues that have been raised but not yet fully
explicated.
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CHAPTER 7 “THIS PROFESSIONALISM” AND “POWER STRUGGLE”
… we strive for this professionalism but I think the biggest stumbling
block we have, we don’t all project ourselves as professionals … that’s
probably our biggest downfall. Henrietta
It’s a big power struggle and they’re more interested in budgeting and
um meetings than actually what’s going on with mothers and babies
and families. Natalie
Introduction Throughout this thesis we have engaged with many midwives’ stories. They
were chosen because of the main characters or interactions in the story, as I
interpreted the stories-as-told. The sharing and exploration of these
wonderful stories has highlighted a number of important aspects of midwives’
work and midwifery practice. The midwives’ interactions and relationships
have been brought to our attention, making it possible for us to enter into
their everyday world through some of these experiential stories.
The method chapter discussed how, in narrative research, it is reasonable,
and perhaps even necessary, for the researcher to bring their own ideas,
values and understandings to the research. It is acknowledged that, in all
interpretive research, these will, to some degree, have an influence on the
interpretations made, but contrary to being a negative influence, this can add
valuable perception and appreciation for the stories that are being examined.
This chapter will turn, therefore, from focussing on the midwives’ stories, to
some of the themes and implications that have been drawn from those
stories.
In order to identify what these stories mean for midwives, their practice and
their profession, it is first necessary to explore more fully some of the
concepts that have arisen within the thesis. Two particularly important issues
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that arose within many of the midwives’ stories were professionalism and the
use, or misuse, of power. So, to enable us to better understand what the
impacts of the encounters involving these were, it is first required to have an
adequate understanding of both professional and power relationships.
I will constitute these descriptions and understandings of profession, power
and the associated concepts not only from the valuable information available
in the literature, but also from the equally important ideas offered by
participants. Whilst not consciously including ideas from my own practice, it is
inevitable these will also have some bearing on my concept of a professional
and other practice issues.
Being Professional Setting the Scene It has been suggested that being a professional did, should, might, or could
have, affected the choices that a midwife (or midwives) made in some of the
stories that have been shared in this thesis. Several of the midwives
interviewed questioned the professionalism of some of their colleagues. This
is, perhaps, not an uncommon view, as J. Thompson notes that “Midwifery is
a profession, though one might argue that not all midwives are professionals”
(2007, p. 277). Perhaps it is the attitudes and behaviours of some midwives
that led her to state this. For example, some participants in this project saw
their colleagues’ unwillingness to change unhelpful or outdated practices as a
manifestation of this unprofessional behaviour. This was a source of
considerable frustration for those midwives who were continually working at
keeping their skills and practice knowledge as up to date as possible. Mary
was one such midwife. She shared the following with me.
I am challenging them professionally, because, you know, they’re doing
it this way, and yet evidence based practice tells you that this is the way
that you do it now … I think that we should all be aware of nursing and
the changing face of it. Like there’s no point saying OK I, this is the
way I did it ten years ago. Because ten years ago, it’s not relevant.
You know, it’s what we do today that’s relevant … and you get
animosity towards that, … you have got to be a strong person I think to
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do that, to be able to go there and know that they’re just saying, oh, do I
need this sort of? … it is just historical practice that you’re doing …
there is no rhyme or reason to what you are doing … I think eventually
they probably just gave in and they didn’t realise it, you know, but I
mean, I was hoping. I wrote in the communication book you know, I
gave them why we should be doing it, the reasons … we’re not up with
the current trends and therefore we can’t deliver nursing that’s current
and up to date. You’re not delivering good quality care. … You know,
anyway, you keep beating your head up against a brick wall. Mary
Olga was also of the opinion that some of the midwives she worked with did
not meet their professional obligations to keep their practices up to date,
saying,
Mmm. The base changes in midwifery. …There are midwives who
become midwives and haven’t moved since they did their training. …
You read journals, but there are people who simply don’t do that.
They’re stuck in the old groove of conducted second stages, not getting
women off the bed, having all the lights on, like they distinctly won’t
change their practice. Even through peer pressure, they don’t change
their practice. Even now, just to get any change in midwifery is an uphill
struggle. Even things like physiological management of third stage is
just a radical concept for some midwives and you just get the
impression that it’s a real non-acceptance of change. Olga
Another issue presented frequently was that of collegiality and support.
Sadly, these were more frequently reported in a negative sense than in the
positive manner one might envisage amongst health care professionals.
Midwives told stories of the lack of both much more often than of their
presence. This again brings into question the professional behaviour of some
of the people that they work with. Jenny, who hoped for and anticipated
collegiality amongst midwives as a manifestation of their professionalism –
but was disappointed to find this lacking in her workplace – provides us with
an example. She was accustomed to seeking advice and ideas from her
colleagues so as to provide the best care possible for her clients, but felt
inhibited from doing so in this particular environment.
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Yeah. But this is the thing that I, this is the way I like to practise. I like to
consult and run it by you, but if people then perceive that you don’t
actually know anything, then you don’t, you don’t do what is the best
thing, you know you stand back and, oh, I won’t say anything because
they, they do, they then think, “Oh shit, she doesn’t know anything.”
You can see that, you know. Jenny
In another example, Cherry rather pragmatically points out the difference
between other professions and nurses. She seems to imply that it is obvious
that midwives wouldn’t be regarded professionally because they don’t
behave like professionals.
… like you can understand why we’re not where we would like to be in
nursing, because basically as colleagues we don’t support each other
and that happens in ward situations as well. You look at the medical
group and they look after each other so well. Even with other
professions – you know there are other professions out there that just
support their professions and I just find that, nurses can be horrible to
each other sometimes. Cherry
Wanting to act in a professional manner, Lucy refrained from challenging the
senior midwife (Susan) on duty when she intervened in the care of her client
(Tara). We were first introduced to this story in Chapter Three. Lucy said,
then there’s also the other side, the professional side, that you want to
avoid conflict in your workplace. When you’re dealing with another
colleague, who perhaps is, you feel perhaps is a stronger character,
well, a bully I guess, you think, “Where’s this going to get me?” If I start
arguing, in some ways that makes it worse, doesn’t it? So there are
times, you know, perhaps, looking back now maybe I should, I should
have gone back and spoken with that midwife in charge and, you know,
discussed a few things, but then again, she was carrying out what the
doctor was saying. They were doctor’s orders … you know.
Lucy (italics added)
These are interesting thoughts of Lucy’s when we recall that both she and
Tara had been quite taken aback, to the point that they felt threatened, by the
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way Susan had intervened. Even though Susan’s professionalism is, I
suggest, definitely in question, Lucy does not want to create conflict or
challenge authority, as she sees this as being unprofessional. It is also
possible that there was a degree of self preservation in Lucy’s actions (or
inaction). Stating her case repeatedly may not have made any difference for
her client, and may have made her own situation more difficult.
These are just a few of the examples from the midwives’ stories where issues
of professionalism arose, and each of them had significant impacts on the
midwife involved. For example, even though she was sure of her
competence, Jenny lacked confidence at times, and was feeling uncertain of
the appropriateness of discussing issues with her colleagues. She had not
suffered from these insecurities in previous workplaces. Lucy was left feeling
that she had let her client down, even after a considerable amount of time
had passed, and that she had acted unprofessionally, by not being a better
advocate for Tara. Olga and Mary seemed to have a sense of swimming
against the tide. From their stories, it seems that being a midwife is rather
hard work for a lot of people due to professional issues. Were these
midwives expecting too much of their colleagues or of themselves?
Profession What then does it mean to be a professional? How are professionals
supposed to act? As a professional is a part of a profession, it will be helpful,
before addressing these questions, to turn to the literature and examine what
constitutes a profession. Professions are, I believe, continually evolving, and,
as such, cannot be defined, as this could constrain them. It is possible,
however, to give an account of a profession, and of the features we might
expect a profession to display, which is the intent here.
Having said that I do not believe that it is truly possible to define a profession,
I wish to start this account by presenting a definition. The following has been
offered by M. Davis (2002), and is his own adaptation of Roscoe Pound’s
definition of a profession:
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A profession is a number of individuals in the same occupation
voluntarily organized to earn a living by openly serving a certain moral
ideal in a morally-permissible way beyond what law, market, and
morality would otherwise require. M. Davis, 2002, p. 3
M. Davis (2002) suggests that professional responsibility might possibly be
reduced to simply following a well written, appropriately interpreted code of
ethics53. He claims that professions, although they are not morally required to
do so, seek to provide a service that is a moral ideal – something which is
“morally right conduct”. They serve the public, either directly, or indirectly. M.
Davis (2002) rejects the commonly held belief that members of a profession
must have a level of higher, theoretical learning, achieved at college or
university level, claiming that vocations that do not have this could, if they so
chose, meet the requirements of the above definition of a profession.
Langford would disagree strongly, saying that “Anyone wanting to enter a
profession has to continue his full-time education for several years after the
normal school leaving age and then embark upon an arduous course of
professional training” (1978, p. 9).
Bayles (2003) presents a concept of a profession that is closer to the more
commonly understood and widely accepted view than that presented above.
He says that professions have three distinctive features. These are extensive
training (usually a university degree or similar), possession of a unique body
of knowledge (normally gained through the special training), and the ability to
provide a service to the community that is “vital to the organized functioning
of society” (2003, p. 57).
Whilst not essential, there are many other features that are common to most
professions (Bayles, 2003). These include credentialing or licensing, and an
organisation of members. Another feature of professions is that their
members have autonomy in their work, but Bayles notes that this can be
limited for professionals who work in large organisations. Professions also
53 It is worth noting that M. Davis (2002) was concerned with professionals somewhat removed from the health care field (engineers, lawyers, police). Features of professions, however, are likely to be consistent across different disciplines.
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have control over both the provision of services and the entry into the
profession. That is, they hold a monopoly. This places obligations on the
professions. Being allowed to hold such a monopoly is a privilege – one is
allowed to undertake certain activities so long as he or she is appropriately
prepared. Bayles suggests that features of the professions such as self
regulation increase the potential for unethical practice if they were to be
“exercised improperly” (2003, p. 61).
Practice Professions can be viewed as social practices (Isaacs, 1993; Langford,1989).
A social practice can be identified by, and depends on, its overall purpose.
This overall purpose is shared by all the members of the social practice, and
each is aware of the others sharing the same goal, which is what makes it
possible for them to engage in the practice. Langford (1978) calls this
reciprocal self-awareness. Social practices possess histories – pasts,
presents and futures. These have an effect on the overall purpose of the
practice at any given time. This temporal dimension not only allows for the
development of tradition, but also allows for internal change whilst the unique
identity of the particular practice is maintained. How a practice is practised
can be significantly affected by its members’ beliefs and understanding,
hopes and aspirations for the practice. An important aspect of social
practices is that they do not exist in isolation, but within society. They
comprise a valuable part of, and are generally valued by, the wider
community.
Spichiger, Wallhagen and Benner (2005) have examined Taylor and
MacIntyre’s notions of practice whilst grappling with the concept of caring in
nursing, and have come to similar conclusions. A practice, to them, is a
shared, culturally based activity. It has a tradition and practitioners strive to
achieve the standards of excellence set down by the practice to which they
belong. In doing so, they collectively achieve their goals. “Practices, thereby,
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realize internal goods54 and extend their capacities to achieve these
standards while creating the standards themselves” (2005, p. 304).
Midwives have a strong sense of belonging to a particular social practice.
This is apparent by the manner in which many midwives identify as midwives
and not as nurses – having left the general nursing tradition behind them,
they have adopted the traditions of the subculture of which they are now a
part. Midwifery has become a social practice within the broader community of
another social practice – nursing. Both are social practices within the general
community, identified sometimes together and sometimes as discrete
entities, depending from whence they are viewed55 – one’s viewpoint or
stance being a very important factor, a fact to which Isaacs (1993) has
alerted us.
Looking at the medical profession, W. May (2000) discusses profession in
terms of a religious covenantal relationship, with the intrinsic elements of gift,
fidelity and moral obligation. Noting that the Hippocratic Oath supports a
covenantal relationship, W. May says that this fosters relationship building. It
is, therefore, responsive, and he asks what goals or human goods might be
pursued to “define the content” of a “covenantal ethic” (2000, p. 140). As he
is considering only one profession, medicine, he summarily concludes that it
is to care for the patient. This could, of course, be readily transposed to
midwifery, with clients being the central focus of a midwife’s working world.
W. May draws our attention to professional self-regulation and discipline56 –
professional accountability of oneself and one’s peers is an important aspect
of being a professional. Health care providers need to be true to their patient
and to their special body of knowledge. They “owe a double fidelity” (W. May,
54 Internal goods are those which can be identified, recognized and achieved only by persons engaging in the practice. MacIntyre differentiated between these and external goods such as wealth and status, which can be sought and obtained by persons outside of a practice (Massey, 1998; Spichiger et al., 2005). 55 For example, many of my neighbours and friends regard me as a nurse, but my nursing colleagues, families and close friends see me as a midwife. The latter group, know me and what I do well enough to identify the specifics within my professional role that distinguish me apart from nurses in other fields. 56 Doctors, according to W. May (2000), do not provide the best example of how to put this into action. This does not concern us here, for we are interested in professions generally, and midwives in particular.
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2000, p. 148). This adds weight to the words of midwives like Lucy and Mary,
who are concerned about some midwives’ apparent apathy when it comes to
keeping their knowledge up to date. Here Lucy and Mary suggest that their
colleagues are not paying the fidelity due to their midwifery knowledge.
Women, particularly first time mums, they rely on us and depend on us
to give them up to date, accurate information, so we have to be
accountable. We’re accountable. We’re front line. We’re the first people
that women come in contact with when they have their babies. We have
to be accountable for our practice and we need to keep our skills
updated and we need to keep our knowledge upgraded. I think that’s so
important and I don’t think it really happens in our work place. Lucy
I think you are accountable and you must make sure that you have
continued professional development. I mean there’re people out there
who just don’t want to do anything. I think you have to be that sort of
person that wants to do it, um, (long pause) but I mean, well I’m in that
category and I just like to keep learning. Mary
Mount (1990) and Isaacs (1993) have also identified the professional
relationship as a covenantal one. Mount suggests that being a member of a
profession can be a moral guide, with members of a profession having
covenantal relationships with the clients or groups they seek to serve. It is,
first and foremost, a relationship. It involves time and trust – an interest in the
“other”, and a commitment to pursue the good of the “other”. Isaacs (1993)
draws our attention to the fact that many authors including Langford (1978),
Camenisch (1983) and Cassell (1991) have made similar assertions.
Professions primarily seek to serve the interests of others. This being done
through a covenantal bond would mean that it happens “in a context of gift,
fidelity and trust” (Isaacs, 1993, p. 5).
Grundy also presents “seeking the good” as central to the professions,
saying that “part of what it means to be a professional in any field is to be a
protector of the meaning of the particular human ‘Good’ with which the
profession is concerned” (1989, p. 91). This requires things such as
prudence, judgement, deliberation and social interaction. For Grundy though,
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“the good” is seen as problematic. She asserts that “the good” of the client
can become clouded by the interests of the professions – assumptions are
made that the profession’s concept or perception of “the good” is the same
as “the good” as understood by the target group, although it may, in fact, not
be so.
Some of the difficulty with maintaining professionalism, Grundy says, is due
to the changing nature of our society. With its ever increasing
technologization, there is a demand for everything to be objectifiable, skill
based and assessable. Production and efficiency replace ethics as the
driving forces of practice. Due to the confounding nature of the uncertain
“good” and the new demands of our ever increasing technologies, a
practique rather than a profession – a form of critical praxis – may be more
appropriate for people aiming to work with people. A practique “is a form of
deliberative, prudent action which refuses to accept unquestioningly
embedded, static or consensually agreed ideas of what constitutes ‘the
Good’” (Grundy, 1989, p. 90). This type of critical reflection encourages
persons to move beyond tradition.
Grundy’s (1989) idea of the “good” being determined by the profession rather
than the group they serve does not fit well within the midwifery framework, at
least not within an ideal one. Midwives seek to work with their clients, and
seek their “good”, whatever that might be. In the vast majority of cases in
midwifery settings, I suggest, the “good” midwife would want “the good” to be
determined in a collaborative manner, with the client and all involved health
care providers. Just as this happens in midwifery, it surely could, should, and
does occur in other professions. Of course, it does not always happen in
midwifery settings, as is clearly evident within some of the midwives’ stories
in this thesis, and I am certain such collaboration does not always occur in
other settings.
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“Goods”
Generally, it could be imagined, a person enters a profession because they
wish to seek the particular “good” which that profession espouses – serving
the community “in a context of gift, fidelity and trust” (Isaacs, 1993, p. 5). In
contrast to Grundy’s (1989) assertions, I propose that in the vast majority of
cases this “good” does benefit the “other” (the clients or community) and not
the profession. It is reasonable to assume that a person would not choose to
enter a vocation that expected them to act in a manner that was in direct
conflict with their deeply held beliefs and values. For example, a person
would not enter a religious order if they were not a member of that faith
community and a person opposed to extending life at all costs would be
unlikely to train as an intensive care specialist doctor or nurse. This is not to
say that personal challenges are not met in practice, and many codes,
including The Code of Ethics for Nurses in Australia (ANC, ACNA and ANF,
2002) have principles or clauses to guide practitioners when this occurs. It is,
however, reasonable to think that most people enter into a profession
because they believe the “good” is worth pursuing. Women and childbearing
families are at the centre of midwifery, so concern for their health and well-
being is a primary “good” of the profession. So it would be expected that this
is something that midwives, and prospective midwives, value highly.
We have established that it is generally accepted that professionals seek to
serve an “other”, usually in a covenantal relationship (Bayles, 2003; Isaacs,
1993; Massey, 1998; W. May, 2000), and that they seek “the good”. There
are, however, different types of “good” (Massey, 1998). Naturally, each
profession differs in the “goods” it seeks to provide, according to the specific
training, expertise, and goal of that particular profession, but all professionals
are seeking the “good” of an “other” or “others”. In addition to this, as alluded
to above, there are different types of “goods” for persons within any given
profession.
Massey (1998), drawing on the work of MacIntyre (1984) and Flores (1988),
and Spichiger et al. (2005), with reference to Taylor and MacIntyre,
emphasize the significance of the difference between internal and external
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goods. External goods are those which are not unique to any given
profession or practice. Including things such as status, wealth and prestige,
these goods can be sought by individuals, and are not necessarily dependant
on their skills, nor their character. Furthermore, the seeking and attainment of
these goods does not benefit either the profession or the community in terms
of growth and nourishment. Internal goods, on the other hand, lead to growth
and nourishment of the profession and the community. We might refer to this
as flourishing. A practice is of little value, Massey (1998) asserts, if its
internal goods are not met. This being the case, the internal goods of a
profession can be understood to be those actions and qualities that
practitioners not only aspire to achieve, but are also inspired by. These
internal goods are not static. They need to be continually interpreted and
reinterpreted, appraised and reappraised. This is in keeping with Grundy’s
(1989) concept of refusing to unquestioningly accept whatever has been
posited as “the good” in the past, and Spichiger et al.’s (2005) claim that
practices need to extend themselves to both achieve their standards and
create them. Keeping the internal goods of the profession in mind can assist
a professional to make sound choices in the present, and to move forward
into the future. The internal goods enable the practice to be refined and
continually improved by the experts within informed, ideally, by those they
seek to serve.
Of course, few of us work in an ideal world. Political, institutional and fiscal
influences have resulted in other “goods” which may be different from, and
even conflict with, the ideals of individual practitioners, and the profession.
When Grundy (1989) said that, at times, the “goods” set by the profession
were not always in line with the “goods” of the group they were indeed trying
to help, it could be that these “goods” had been adapted in response to some
of these influences from outside of the profession itself. They can cause
professionals to seek other “goods” apart from those which are internal to the
profession for various reasons. Quite apart from the obvious external goods
which may be sought, sometimes these outside influences can lead to
professionals changing their practices simply to survive the system. Here
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Debbie tells us of how hospital policies have had an effect on her ability to
always follow what she believes is the best course of action for her clients.
in a sense we feel that that’s our, one of our protections is to work
within those guidelines, and if we don’t then we’re not protected. So it’s
that dilemma of what to do, and the policy as it is written may not
always be the right thing for the woman, so. Such as [doing] vaginal
examinations every four hours and then do something about it.
Debbie
Summary
These views of what a profession is span a time period of two and a half
decades. They demonstrate that the concept of a profession is far from clear
cut, and is not necessarily becoming clearer over time. There are common
threads, however, that run through most descriptions of professions.
Professions are essentially social constructions, the members being part of,
and having a sense of belonging to, a particular group. They have a moral
goal – their overall purpose is to meet the needs of a particular group in the
wider community, which is going to benefit that community in some way – a
“good” of some sort. There is general agreement that the professions believe
in their goals being “goods” worth pursuing for the community they are
seeking to serve. Professions exist to serve others and possess a knowledge
that is special, and usually of a higher level, than others not in their
profession. Influences peripheral to, but outside of the profession, can make
it challenging for professions to realise the “goods” of the clients.
Professional In its most basic sense, being a professional would simply mean being a
member of a profession. Being a professional is more though, than being
admitted to the role of a particular vocation by completing the required
training, passing the appropriate exams and obtaining the necessary
licence/s to practise. The responsibilities and obligations that come with
being a professional present every midwife with challenges, and they are not
necessarily all made clear as the steps above are negotiated.
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Some professional roles and expectations are “book taught” at university,
some are learnt as midwives are inducted and socialized into the profession
in their workplaces. Some are not so clear and, I suggest, are misinterpreted,
undervalued or just plain lost along the way. As previously mentioned,
midwives have several codes and guides to direct them in their professional
practice57. Equipped with the information above about professions, and
delving into the codes and guides available, M. Davis’ (2002) idea is rather
appealing. Perhaps he is correct and, to be professional, all that is needed is
to follow a well written, appropriately interpreted code of ethics? Not
withstanding the difficulties that this presents in knowing what is meant and
understood by “well written” and “appropriately interpreted”, and the fact that
we would need to ensure that all the practitioners were suitably virtuous58 to
want to follow the said code, it still seems to be a much easier task than to
adopt the position of a person in a covenantal relationship with others whom
they are seeking to serve, always seeking their “good”, and needing to be
knowledgeable, well trained, licensed, autonomous, self regulating and
aware of the contents of numerous codes and guides. Is this the case
though? Is the latter proposition really so difficult? Are the two really as
different as they seem?
Citing earlier work by Thompson and Thompson (1996), J. Thompson has
said that “To be professional is to be ethical and to be ethical is to be
professional” (2007, pp. 277, 278). She continues her discussion saying that
we are wholly, completely and continually involved in ethics education. It
involves our hearts, minds and souls and “is a womb to the tomb endeavour”
(2007, p. 278), a life-long, all encompassing activity. We might link all of
these ideas together and conclude that if we had ethical practitioners we
would have professionals. Why is there even a need for a code? All that
57 Codes and guidelines include those previously referred to such as the Code of ethics for nurses in Australia (ANC, RCNA and ANF, 2002); the Code of Ethics (ACMI, 2001); National Competency Standards for the Midwife (ANMC, 2006) and Guidelines for Registered Nurses and Enrolled Nurses regarding the boundaries of professional practice (University of New South Wales and NSW Nurses Registration Board, 1999), but there are many more covering various aspects of practice. 58 Virtues are discussed more fully later in this chapter.
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would be needed would be ethical, virtuous people. Indeed this is where
most professions began.
To argue for the other requirements of the professions is quite simple. For
example, an expert, unique body of knowledge is needed if our clients are to
trust us with caring for their needs. Why would we trust a lawyer to care for
our legal issues if s/he knew no more than we did about the law, a doctor to
perform surgery if s/he knew no more about anatomy than we ourselves, or a
midwife to assist in birthing our baby if we understood all there was to know
about birthing and she could bring no further knowledge to aid us?
Of course, we can view the simplistic equation of “ethical midwife equals
professional midwife” another way. A truly ethical midwife, a person who is
aware of her own beliefs and values, interested in other people’s beliefs and
values, and respectful of both, is highly likely to desire to be the very best
midwife she can be. This midwife would strive to be well and appropriately
trained, follow the guidelines and codes set down for her profession, keep
her competencies and knowledge up to date, and engage in covenantal
relationships with her clients. She would be concerned about the well-being
of the “other” and want to serve the “other”. So, by ensuring ethical
practitioners, the professions would, by implication, be ensuring well trained
practitioners. Are parameters needed to set a standard and define
professionalism?
The Professional Health Care Provider In the light of the multiple understandings of what a profession can be,
including those outlined above, I would like to offer an account of what we
might expect of a professional in a health care setting. This is not intended to
be a definitive account, for in a changing world, so too the roles we all take
must evolve in response to the events and people around us. To that end, I
am very much in agreement with Grundy’s (1989) idea of a practique, which
does not complacently accept the traditional goals of a practice. A profession
that is continually seeking to reach its internal goods, however, is acting in
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accord with this, for it is not complacently accepting goals, but reviewing and
reappraising those goals. This is how traditions within social practices
change over time, yet remain coherent.
Since she equates being professional with being ethical, it is no surprise to
find that, according to J. Thompson (2007), a professional midwife is an
ethical midwife – one who practises ethical midwifery, the goal of which is to
do the right thing for the right reason. This facilitates the promotion of health
and well-being within the community for women and childbearing families,
which is the overall goal of midwifery. She says that “Professionals make
their own decisions based on solid rationale and understand how technology
works, including its limitations and risks, before using it on others” (2007, p.
281). In this one simple sentence she draws out the autonomous nature of a
midwife’s work, the need for advanced knowledge, accountability,
responsibility, and the intermingling of the technological and relational
aspects – the “other”, present in virtually every midwifery encounter.
Through the stories they told, it was apparent that the participants in this
project cared about their clients, the way they practised midwifery, and
midwifery practice. They were concerned, it seems, about every aspect of the
profession. They were eager to “do the right thing”, worried and frustrated
when they perceived or were aware of situations where “the right thing” was
not being done, wanted to, and went about, assisting others to do “the right
thing”.
Here Olga tells us how the midwives she knows strive to assist the women
they work with to achieve the birth that they would like. Gemma explains
about the importance of giving people an opportunity to air their grievances,
and Irena tells of a man whose partner had died – an unusual and
fortunately rare event in childbirth these days, but not unheard of. This new
father was subjected to conversations regarding the importance of
breastfeeding and the disadvantages of formula feeding. Although these
conversations were not directed at him, they occurred around him –
instigated by people Irena calls “nipple Nazis” – or breast feeding fanatics.
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Obviously, in this infant’s case, there was no other choice other than to
formula feed. Irena was distressed that he was inadequately educated as to
how to formula feed his baby and he was made to feel guilty that his child
would not be breastfed. She thinks he was treated unfairly.
Well obviously all the midwives I know are midwives because that’s
their chosen field and we’re there to get the woman the delivery or
outcome that she desires. I think it’s just that we care about the
outcome as far as what she perceives is what she, you know about
having a normal, natural, safe delivery for her and a happy, well baby at
the end. Olga
I found in my practice that it’s actually if you have births that don’t go
exactly as the birth plan, it’s good to go and talk to them about it
because it helps them and I think it helps you too, to clarify and that
goes either way, you know. I think sometimes we think we’ve done a
pretty good job and you see them and they’ve actually got complaints. I
think that it can go both ways. Gemma
Staff need to be aware that this Dad has to do this on his own. Umm…
Granny lives a thousand miles away. Err.. he’s relying on a neighbour
or community health or something. Umm… it’s a bad time for the nipple
nazis to come by and have too much to say. Irena
Making the “right” choice, and doing “good”, seeking the “good” of the other,
as defined by the profession, or as the other determines, are not simple
matters, and yet this is what is asked of all professionals. Indeed, it is what
they ask of themselves. Hunt (1997) notes that whilst the presence of
guidelines is a mark of professionalism, having more of them does not
equate to a better practice. It is erroneous to assume that, to solve a problem
that has been encountered which is not covered by existing guidelines, “all
that is needed to put things right is another procedure or subprocedure or
sub-subprocedure” (1997, p.522). Imagine if, in the situation drawn to our
attention by Irena, a rule of some type was made that midwives could not talk
about breastfeeding when fathers were present in the room as a result of this
encounter. This would be non-sensical. Quite apart from the impracticality,
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most fathers actually benefit from breastfeeding knowledge. Unfortunately,
even the best written, most definitive and extensive catalogue of guidelines
could never cover every eventuality in an activity which involves persons.
Furthermore, they can only ever be guidelines, for they, simply words on
pages, cannot be sensitive to the nuances of individual persons and
contexts, each of them unique, with different concerns, relationships,
knowledge and needs.
Hunt is concerned that there is a “fatal attraction of procedure” (1997, p. 522)
which has a firm hold on professionals. As Debbie pointed out earlier,
guidelines exist to protect us in our practice. How simple it would be if being
a good midwife was as easy as following the rules. If strict adherence to the
codes, guidelines and procedural rules meant they were always doing the
right thing, legally, professionally and ethically, midwives would rejoice in the
straightforwardness of their decision making. Many of these can be extremely
useful in guiding and instructing professionals and it is not suggested here
that they are neither unnecessary nor unhelpful. In these times of increasing
legal awareness and accountability, we must be able to have some
structures to enable us to ensure safe practices have been followed. Formal
documents such as these are a method of managing this. However, “One
cannot in truth escape from the need for a little wisdom in one’s dealings”
and though procedures can be taught, wisdom is more readily gained as life
is lived “in an open and responsive spirit” (Hunt, 1997, p. 522). This raises
questions regarding “the kinds of things I ought to do” and “the kind of person
I ought to be”. What we need are people who are sensitive to the nuances of
individual persons and contexts, so that they might respond to troubling
situations wisely.
Virtues An ethical midwife, the kind of midwife J. Thompson (2007) suggests is a
professional midwife, would be likely to possess some virtues, a point I have
alluded to earlier. Fry and Johnstone (2002) and Tuckett (2003) discuss the
differences between deontological and consequential based ethical theories,
which focus on the question, “what ought I do?” as opposed to “who ought I
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be?”. The latter would be the central question in virtue based theory. It is
suggested here, that to gain wisdom, a certain disposition is required – “an
open and responsive spirit” (Hunt, 1997, p. 522) – which, arguably, is a
characteristic of a virtuous person.
The valuing of virtues is not new. Beauchamp and Childress (1994),
MacIntyre (1984) and F. Thompson (2004) have all identified the importance
of virtue ethics and provided accounts of its beginnings. Virtue ethics
“focuses on the goodness or badness of people’s characters, not the
rightness or wrongness of people’s actions” (F. Thompson, 2004, p. 65, 66).
Developed by Aristotle in the fourth century BC, theories of virtue ethics have
evolved and developed over the ensuing centuries. Aristotle did not believe
all virtues to be moral virtues, some were intellectual. He upheld the
importance of phronesis (practical wisdom) which encompassed a person’s
intelligence and ability to discern. This practical wisdom, requiring deliberate
thought, although an important virtue, was separate and different from moral
virtues. Moral virtues, rather than calling for rational contemplation, became a
part of a person’s character so that they were disposed to act in a particular
way, often without thought or effort – “almost spontaneously”, F. Thompson
(2004, p.66) says. Hunt’s (1997) idea of wisdom can be aligned with
phronesis. It is likely, though not necessary, that a certain type of person is
most likely to gain and possess wisdom and discernment. That type of
person, it is suggested here, would be seeking to develop moral virtues; a
virtuous person. These virtues are helpful and perhaps even necessary for
professional life.
Virtues are dispositions which sustain the relationships required for
practices, and the relationships from the past, present and future. They
enable us to achieve the ‘goods’ that are internal to practices as well as
overcoming harm, danger, temptation and distraction.
F. Thompson, 2004, p. 68
Beauchamp and Childress (1994) offer a helpful account of virtues.
Acknowledging that professionals often work in institutional settings, and are
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members of professional bodies, the authors note that these organisations
have an effect on the professions. Beauchamp and Childress say that the
cultivation of certain virtues is required due to the culture and tradition of the
practice to which those professionals belong.
Virtues are largely individually developed, although significantly constituted
by the contexts in which an individual lives and works. Traditions, such as
those held by the social practice of midwifery, are wholly socially constituted,
influenced not only by the members that constitute the practice, but also by
the context/s in which the practice occurs. The increasingly medical and
technological approach to midwifery,59 movement of birthing to institutional
settings and a focus on making health care affordable for both providers and
recipients have resulted in the midwifery profession being exposed to a vast
array of influences. The internal goods of midwifery are no longer the only
driving force of the profession. The traditions of the practice have, perhaps,
evolved as a result of these influences. Could it be that midwifery and
virtuous midwives no longer fit well together? To put it another way; has it
become the case that it is now difficult to build, maintain and uphold one’s
virtues within institutional settings? The virtuous midwife may feel (or be) out
of place in the modern institution. Being conscientious, doing something
really well, for example, may not be time or cost efficient, particularly if it does
not make a difference to the outcome. Hunt put this in a simpler way, asking
“Is the professional behaviour that leaves no space at all for ‘personal
concern’ really professional at all?” (1997, p. 522). Chambliss (1996) claims
that there is an inherent conflict in the demands made of nurses to be caring,
professional and “a relatively subordinate member of the organization” and
says “I want to do good, but my boss won’t let me. The directives conflict: be
caring and yet professional, be subordinate and yet professional, be diffusely
accountable for a patient’s total well-being and yet oriented to the hospital as
an economic employer” (1996, p.62).
59 A very simple example from my own practice is the routine use of an electronic device (a Doppler) instead of a foetal stethoscope to listen to foetal heart beats. In my midwifery training, in 1988, this was only utilised if necessary, whereas now, due to its speed and simplicity, it is used routinely, every time a foetal heart is auscultated.
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Brody (1998) informs us that virtue should be valued highly. He claims that
the character of a “healing sort of person” is just as important as their
knowledge and skills. There are, he says, three virtues necessary for the
“ideal family physician” – humility, compassion and forgiveness (1998, p.
589). It is easy to see that these are virtues that could be appropriate for
midwives and other health care professionals as well, since we might think of
them as “healing sorts” of people. Interestingly, to be registered as a nurse in
the United Kingdom, it is necessary that another registered nurse signs a
declaration stating that you are a person of “good character” (Sellman, 2007).
Although the outline of “good character” given for this purpose is rather broad
and non specific, we might imagine a person of good character to be morally
virtuous.
Being virtuous is about the motivation behind why you do something – not
just doing the “right thing”, but also having the right motivation – truly caring,
for example, not simply providing care (Beauchamp and Childress, 1994; Fry
and Johnstone, 2002). It is quite possible to provide good “care”, in a
technical sense, without caring at all about the “care” given – or caring only in
as much as to ensure professional and legal obligations are met. This
suggests a greater concern for the carer’s wellbeing rather than that of the
client or the one being cared for. Many a client would, arguably, assert that
they were aware of a perceptible difference, even though the actual “care”
provided were the same. The possession of certain virtues would alter the
disposition of the caregiver, and the way in which they administered the
“care”. Some of the virtues that professional midwives might be expected to
strive to develop, or have, will be briefly discussed below.
Integrity and Identity
Professionals working in health care settings are dealing with a vulnerable
population (Isaacs, 1996). There are three ways in which Isaacs informs us
that this vulnerability arises. Firstly, if ill or in pain, they are incapacitated to
some degree, and are thus deprived of their usual independence. Secondly,
they may require help – this might be advice or physical help, but this creates
a dependence and further vulnerability. Thirdly, clients are in unfamiliar
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surroundings and this factor alone causes them to be vulnerable. They come
seeking help – advice or assistance for something which they are not able to
address themselves. The professional has a power which the client does not
– the power of particular, specialised knowledge and abilities. It is of prime
importance then that the professional is a person of integrity. Ideally, they
would have both moral integrity and professional integrity.
That midwives should be of good moral character, honest, and highly unlikely
to abuse the power they hold, is of great importance. C. Miller and Brody
(1996) say that integrity provides a fit between conduct and character, whilst
Oberle and Davies (1993) inform us that that it is necessary to have integrity
and to uphold one’s personal values so that a sense of wholeness and
personal worth can be maintained. There are consequences when integrity is
threatened – when professionals are unable or unwilling to act according to
how they believe they ought.
We have seen some evidence of this (in Lucy’s story, in Chapter Three for
example), and know that professional identity, emotional well-being and even
fragmentation of the self can be threatened and adversely affected when
one’s integrity is challenged (Beauchamp and Childress, 1994; Fagermoen,
1997; Hunter, 2005; Kinnane, 1996). This moral virtue is, I suggest, a
foundational requirement to continued professional practice. Not only does a
person require integrity in order to be a professional, others must respect that
integrity in order for the professional to continue their practice – and thus for
the profession to continue to exist. This would be necessary, at least, for
these things to occur in a condition of relative harmony.
Integrity asks us to be honest, fair and truthful to ourselves. Professional
integrity, asking us to be faithful to the goals, standards and responsibilities
of our profession, is neither a simple matter, nor a discrete entity. It cannot be
neatly separated from personal integrity. This idea is tidily summed up by L.
May (1996) when he informs us that professionals need to be true to
themselves in many different ways. Not only do they need to be mindful of
the principles upheld by their profession, but also those societal and family
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principles which are important to them, and any life plans deemed significant.
It is hardly surprising that this sometimes requires a “difficult balancing act”
(L. May, 1996, p. 122). Many examples were provided by the midwives in this
study. Betty shares how shift work, an unfortunately necessary aspect of
midwifery, impacts on her family.
When I work…. I split my night duty up. I do two, two and two.
Sometimes I do two, two and three. Because it has less impact on our
family. Like my husband’s a ragged mess if I work five or six night
duties in a row. He doesn’t handle it well. I’m a ragged mess. So I do
it so, almost every week I’m on night duty. And if you look at that I’ve
got to the age of 53, every week I’m doing night duty. You know. I
don’t know. There are some things I like about night duty, but not very
much. Betty
It is recognised that many professionals nowadays work not for themselves,
but for a company or institution (Bayles, 2003; Massey, 1998; L. May, 1996).
This can limit their autonomy and has a significant impact on their ability to
choose for themselves regarding the way in which they practise. Chambliss
powerfully expresses this when he says that “nurses often feel actively
thwarted in their jobs, blocked from doing the meaningful work that was
promised to them. They feel that their professional birthright has been
violated by administrators, by physicians, sometimes by government policies”
(1996, p.2). There is general agreement, however, that professionals retain
some autonomy over the way they carry out their work, influenced by the
codes and/ or guidelines set down by their professional body.
For professionals, being able to make their own decisions, based on their
professional judgement, is both significant and important. Having these
decisions respected is essential to ongoing personal and professional well-
being. Consider, for example, the difference between Kelly’s story in Chapter
Five where she was “fighting off doctors at the door” to prevent them from
rupturing Penny’s membranes when there was, in her professional opinion,
no indication to do so and Cherry’s story, earlier in the same chapter, where
she had experienced working with a doctor who “had the utmost respect for
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midwives”. The first story conveyed a sense of frustrating battle, whereas the
second story told of a rewarding, enriching experience. Whereas Kelly had
had to struggle to have her decision regarding treatment (made in
conjunction with her client) respected, Cherry has us imagining a quite
different work environment. Here, perhaps, we might envisage a colleague
knocking at the door and politely asking if any assistance was required.
Professional integrity is tied to the concept of the professional – its meaning
is dependant upon the way that the profession is viewed and understood
both from within, by the professionals themselves, and from without, by the
community within which it is situated. L. May (1996) says that professional
integrity is often taken to mean that there are professional standards and
responsibilities that must not be violated for any reason. He convincingly
argues that this is not the case, for professionals are people, and there are
some times when other aspects of their lives might reasonably take
precedence over a professional responsibility – he cites the case that it may
not be required for a professional to risk his or her job by acting in
accordance with professional expectations, when the relevant professional
principles conflict with those of the employing agency. L. May does not
question the correctness of the professional’s desire to act according to the
recommended professional behaviour. Rather, he questions if it is
reasonable of a profession to ask of its members to act in this way, when the
(personal or economic) cost is high – and they cannot, in many cases, expect
the support of the professional body that insisted on adherence to codes of
professional behaviour. Regardless of the pathway they choose, to follow
what they believe to be the correct path of action, or to do as the hierarchy is
requesting (or, in some cases, demanding), I would like to suggest that
situations such as this are highly problematic for the professional midwife.
They need to be true to themselves which, of course, incorporates their
professional selves.
A professional’s identity centres around, or is built upon, the beliefs and
values that they hold which consequently guide their thoughts, actions and
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interactions with their clients (Fagermoen, 1997). Our personal and
professional beliefs and values determine who we are and who we become.
…values are personal and subjective standards that involve an
individual’s most basic beliefs about themselves and their relationships
with others. Values determine human action and personality. The
significance an individual places on a value determines its importance
and serves as a criteria [sic] to rationalize the rightness or wrongness of
a choice, action or behaviour. Thus, values are internalized and
contribute to the individual’s sense of self. Raines, 1993, p. 537
Bruner asserts that a person’s “self” is developed narratively. We construct
our lives as we tell and retell our life stories, and as they are interpreted and
reinterpreted, both by ourselves and by others (Bruner, 1987; Massey, 2005).
A person’s values and beliefs must therefore fit coherently within the
framework of the life they are building for themselves. These beliefs and
values will be largely those of the profession to which they belong, which they
have adopted as part of the education and inductive processes of becoming
a part of that particular social practice (Langford, 1978; Isaacs, 1993;
Massey, 1998). However, as L. May (1996) has pointed out, no person lives
their professional life in isolation from the rest of their being-in-the-world. So it
is inevitable that personal beliefs and values will also constitute a part of a
midwife’s professional identity. It therefore follows that this combination of
professional and personal values and beliefs constitutes understandings of
professional integrity, and the importance placed upon staying true to those
basic tenets on which practice is based – but without violating the values and
beliefs which are held to be deeply meaningful to the individual that are
“outside of the practice”.
Care
Care or caring could be seen as a virtue itself. Being a concept which has
been very frequently defined, but never in the same way, makes it immensely
difficult to be able to say that this “caring”, is in fact a virtue. Spichiger et al.
(2005) have provided an excellent review of the literature on caring in
nursing. They note perspectives on caring identified by Morse et al., which
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include “a human trait, a moral imperative or ideal, an affect, an interpersonal
relationship, and a therapeutic intervention” (2005, p. 305), Sherwood’s
patterns of nurses’ caring which included knowledge, interaction and
therapeutic outcomes, and Swanson’s review of studies on caring which
identified five levels of caring knowledge. The authors point out the problem
of quantifying caring and say “if stripped of their context, variables delineating
caring (e.g. compassion) cannot be defined in measurable terms any better
than caring itself” (Spichiger et al., 2005, p. 305).
Bolton informs us that both clients and nurses see “authentic caring” as being
a distinguishing feature of nursing (2000, p. 583). In her study she examines
caring in the context of emotion work and gift, and it fits well with the
covenantal commitment of the professional. It seems caring is highly unlikely
to ever have an agreed upon definition. As a complex concept, caring is very
difficult to encapsulate, but perhaps it is meant to be a fluid concept. One
feature of care that we can be sure of, however, is that it is perceptible. Most
people are able to distinguish between uncaring, indifferent and caring
dispositions.
I prefer to think of caring as any combination of thoughts, dispositions or
actions that come together to make either the provider or the recipient of the
“care” ( or both) feel nurtured, nourished, more comfortable and/ or less
alone than they did before – physically, mentally or spiritually. Although it
seems impossible to truly capture “care” in a definition, it is very likely that the
recipient of that care will capture the spirit in which the care was given. For
example, it was mentioned above that a client could receive the same care,
given in a caring attitude and a non-caring attitude, and perceive the
difference. The touch experienced during a back rub, given with a genuine
concern and desire to relieve a woman’s labour pain would be, I suggest,
different from the touch felt when a midwife gave a back rub because she felt
she ought to. One can have similar experiences in the non-midwifery world. A
piano can be played technically perfectly, but the same piece can be played
much better if it is played with feeling. If the player cares about the music.
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Regardless of the definition or description of caring one chooses, it is a
positive character trait. It is something that would be indicative of excellence
of character, and that is a virtue. Caring is “good”. Profound caring can be
very simple – staying with someone, just being there without doing or saying
anything at all, can make an enormous difference to someone in pain or
distress. Conversely, simple caring can be very complex such as in situation
where a client’s trust must be earned due to fear.
Compassion
Compassion engenders feelings of sympathy and tenderness. One who has
compassion is inclined toward acts that will provide comfort for the one who
suffers. Expressions of compassion are reassuring. It requires a certain
vulnerability, a willingness to suffer alongside (Beauchamp and Childress,
1994; Brody, 1998). We can experience the compassion shown in Irena’s
story, shared here for the first time.
The other thing we’ve progressed … a huge step forward … dying
babies. … we’re no longer sticking them in the back corner and letting
them die on their own. … we have very few deaths, but there’s odd
baby … recently, a little one who was a microcephalic … his parents
would not accept him at all. … he lived oh probably 6 or 7 days, and in
that time he hardly hit the cot, because everybody took turns in carrying
him. And he was beautifully dressed with a bonnet so that he looked
lovely60. And even the doctors would sit at the desk writing notes
holding this baby. So he got lots of love and umm… that’s probably
why he lived as long as he did. Irena
Courage
Courage is “the state or quality of mind or spirit that enables one to face
danger, fear, or vicissitudes with self-possession, confidence, and resolution”
(http://dictionary.reference.com/browse/courage - accessed 22.09.07).
Identified but not expanded upon by Fry and Johnstone (2002), it is a virtue
that could be of increasing need for midwives in the future. I think of the
courage displayed by Kelly, in Chapter Five, who “was fighting off doctors at 60 Microcephalic babies look strange because they have a very small head, usually associated with marked underdevelopment of the brain. The condition is not always fatal.
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the door to come into the room and rupture the membranes”, and the
immense courage that will be needed for midwives to have their valid,
professional judgements given a fair hearing by other professionals, including
their peers, so that they don’t have “to bow and scrape to obey their wishes
even if we don’t feel it’s the best way for the patient to go” as in Emily’s case
with some obstetricians in Chapter Five.
Generosity
We can be generous with our possessions, but we can also be generous in
spirit. As a moral virtue, both would be significant. Examples of generosity
shown by the midwives in this study include the many times they continued
caring about their clients well beyond the time when their professional and
legal responsibilities had passed. When Gemma cared for Jane (in Chapter
Six), and followed her progress (but was not responsible for her care) as she
had a long illness and recuperation, her generosity of spirit was clearly
evident. She allowed Jane’s husband and family to contact her in the early
days after the birth, and kept in contact throughout Jane’s recovery. Despite
the fact that she found it quite draining and there was no requirement for her
to do so, Gemma gave all the support and encouragement she could to this
new father.
Trustworthiness
Beauchamp and Childress (1994) inform us that this is a prominent virtue in
health care. Trust means that we can have confidence in the other. In the
context of health care, we would believe in the providers’ ability to care for
us61 and in their doing so with our best interests at heart. They would also be
able to trust us not to issue blame; just as close friends or family know that
when things do not go quite to plan, each would know that the other had
acted from a morally sound base. The cared for (client) would be able to trust
that their carer had acted only in their best interest, even if something went
61 Note that this does not include a requirement for the professional to care about us. This is one of the reasons why it is intriguing that so many of the midwives in this study care about their clients as they do.
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awry, and would have no cause for complaint. It is on this kind of trust that a
covenantal relationship is built.
Other Virtues
There are many other virtues which would be desirable in a healthcare
practitioner. These have been noted to include faithfulness, respectfulness,
sincerity, moral integrity (fidelity to moral norms), humility, and
conscientiousness (Beauchamp and Childress, 1994; Brody, 1998; Fry and
Johnstone, 2002). If these virtues were strongly valued, fostered and built
within our midwifery community, a great depth of trust, compassion and
truthfulness would develop. Discernment, courage, conscientiousness and so
forth would be easier virtues to develop and maintain within a practice that
treasured the virtues of respectfulness, integrity and compassion. The
midwifery profession and its members would flourish. The circumstances,
interactions and relationships that midwives deal with would, arguably, be
different from those which dominated the narratives related by the
participants in this study. This is not to say the virtues are absent in midwives
and midwifery practice. Rather, it is to emphasize the importance or, I would
argue, necessity of fostering excellence of character in midwives. Neither do I
claim that a principle based approach is entirely wrong, or even misplaced,
when utilised in attempting to practise “good” midwifery.
Principles
Principles are not virtues, but a virtuous person might be inclined to follow
some principles within their practice. Much, in fact most, early nursing ethics
grew from bioethics and was largely based on a principle based approach.
This was concerned with the four principles of autonomy (or respect for
autonomy), beneficence (above all, do good), non-maleficence (above all, do
no harm), and justice (or fairness). Discussions of these principles can be
found in most early nursing ethics texts from the 1980s and 1990s. A good
example is that provided by Megan-Jane Johnstone (1989, pp. 76-83).
Although principles such as these provide suitable guidelines for ethical
decision making, they have some definite limitations, and even, at times,
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conflict, as has been noted earlier in this thesis. DuBose, Hamel and
O’Connell (1994) have compiled a book of essays that discuss some of these
potential limitations. They say that “almost all of the authors of these essays
see principlism as too fragile, too constrained a structure to sustain the large
issues that bioethics must consider” (1994, p.ix). In his contribution to this
book, Childress notes that many principles have been identified within the
literature and gives a particularly helpful summary. He says
Whatever the principles in biomedical ethics are called, they represent
the following sorts of general moral considerations: obligations to
respect the wishes of competent persons (respect for persons or
autonomy); obligations not to harm others, including not killing them or
treating them cruelly (nonmaleficence); obligations to benefit others
(beneficence); obligations to produce a net balance of benefits over
harm (utility); obligations to distribute benefits and harms fairly (justice);
obligations to keep promises and contracts (fidelity); obligations of
truthfulness; obligations to disclose information; and obligations to
respect privacy and protect confidential information (confidentiality).”
Childress 1994, pp.74,75
When we consider this summary provided by Childress, we can only see
principles in a positive light. It is also clear that they overlap, in many cases,
with virtues. Later in his chapter, Childress acknowledges that principles
cannot be applied a-contextually – the importance they carry is dependant on
the situation.
Summary
F. Thompson notes that “ethical practice is based on human engagement in
relationship, not merely on abstract principles” (2005, p. 17). It is inevitable,
therefore, that the virtues of the persons involved in those relationships will
have a significant bearing on the quality of that engagement. It is not difficult
to acknowledge that certain virtues such as those outlined above would be
appropriate for every midwife – and indeed every person – to aspire to.
Knowledge of and appropriate application of principles would also, no doubt,
be beneficial. From the stories that the midwives in this project have told it is
evident that many midwives continue to strive for and retain these virtues,
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whether they realize it or not. It is effortful though – seeming to be almost
impossible at times. What has made it so hard for midwives to retain their
moral and personal integrity? In short, why is it, in some situations and
apparently not infrequently, so immensely difficult to be a professional
midwife? This question is of great significance, since to be professional is to
be ethical and to be either of these, a person needs to be a person of
integrity. If they are unable to be all of these – the persons and the profession
are likely to be adversely impacted upon.
Power One of the ways midwives in this study told of their professional behaviour
being limited and controlled was through the use and abuse of power. This
was sometime overt, but more often subtle – such as in the expectation that
midwives would follow hospital policies and doctors’ orders without question,
even if they did not believe they were acting in the best interest of the women
they were caring for.
Power within relationships is as inevitable as ethics. Where there are two or
more people, there is a power relationship, just as there is an ethical one.
Nyberg informs us that “the minimum and necessary conditions of power are
two people and one plan for action” (1981, p. 40). These conditions mean
that power is both psychological and social and, Nyberg notes, it is not
possible to conceive of a hermit as powerful. How this power is held, wielded,
shared, used and abused is profoundly significant. It has potential to affect
everything – the people in the relationship, the people influenced and
affected by that relationship, the happenings in the context where the
interaction took place. We might, for example, consider a midwife and her
colleague, her co-workers (both midwives and other professionals), clients
and their significant others, and then the ward in which she works,
respectively. Like a snow ball gathering momentum as it moves rapidly down
the slope, the good in a positive power relationship gathers lovely snow
flakes to spread amongst the masses, but if the power relationship has been
of another type, it can readily absorb snow flakes of another kind –
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resentment or fear, anger or hurt – and these will spread in a flurry, as snow
is wont to do.
Rollo May’s (1972) five types of power – exploitative (power to force),
manipulative (power over), competitive (power against), nutrient (power for)
and integrative (power with) – have been introduced earlier in the thesis, in
Chapters Four and Five. There we learned that power is “the ability to cause
or prevent change” (R. May, 1972, p. 99). Davidhizar’s (2005) concept of
benevolent power, where one utilises the power they have to benefit another,
was also introduced. These types of power are helpful as we try to grasp an
understanding of the ways in which power is being used in real life situations,
and why people are reacting as they are to those situations.
Power and ethics are not only both inevitable, they are inseparable. It is wise
to note that, “in a fundamental sense ethics is concerned with power, power
relationships, and power-sharing – with the use and abuse of power in one’s
personal life, human relationships and in social institutions” (I. Thompson,
Melia and Boyd, 1994, p.44). Naturally, ethics is not only about power, it is
also about values. These are the things that enable us to be and become the
person that we want to be. Nurses (and therefore midwives) need to
consider ethics and power at three levels – the individual, the interpersonal
and the social (I. Thompson, Melia and Boyd, 1994).
On an individual level, ethics is about achieving one’s full potential as a
human being and the development of individual powers of being (virtues) – or
working out what might be inhibiting this (I. Thompson, Melia and Boyd,
1994). Many have noted that this is facilitated through sound ethics
education, personal understanding of one’s own values, knowledge and
understanding of moral principles, socialisation and induction into the
profession.62 Mount informs us that
62 see, for example, Fry and Johnstone, 2002; I. Thompson, Melia and Boyd, 1994; F. Thompson, 2004.
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Our pasts precede us, our futures lie before us, our cultures surround
us, our values infuse us, our absorbed images shape us, and our
myths63 and worldviews locate us. We become more ethically
perceptive and sensitive people when we understand ourselves in our
layers of contexts and understand what creates and changes those
contexts. Mount, 1990, p.26
The development of virtues, and indeed being an ethical person, is often
thought of as an “other regarding” exercise. It is important to note a
significant aspect of being ethical is respecting all persons, including oneself
(Isaacs, 1998). I. Thompson, Melia and Boyd (1994) note the particular
relevance of this to nursing. If a nurse or midwife does not gain personal
fulfilment and job satisfaction from her work, ultimately patient care could
suffer.64 They need to be aware of and respect their own needs as well as
those of their clients. Ethical behaviour takes into consideration the good of
all. So, let us move on to interpersonal relationships. Betty and Irena told me some stories that suggest there is some work to be
done to improve this area of midwifery practice. On occasions these stories
conveyed the sense that co-workers and superiors went out of their way to
make midwives’ lives difficult. In the brief examples below Irena tells of a
colleague deliberately and unnecessarily delaying mealtime for a person she
dislikes and Betty comments that superiors are willing to force staff to do
something they are not doing themselves, even though they know it is
causing immense unhappiness. Both suggest a lack of understanding and an
unequal power relationship.
Attitudes… attitudes umm, body language, you know, we’re all aware of
these sort of things. The person comes in, they’re not spoken to, they
say hello and nobody answers. I mean that sort of thing is all due to
the person’s self worth, and self esteem. Umm… if a person says, look
63 Some aspects of midwifery, as experienced by the midwives in this study, might be seen to fall into the category of “myth”. For example, “professional midwife”, “autonomous midwife”, “collegial practice”, “client autonomy” were all expectations of normal midwifery practice for the midwives, but were not the reality in the stories conveyed. 64 The authors suggest that a reduction in both competence and efficiency is likely to result from the frustration and lowered morale that staff would experience.
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you know, okay it’s tea time, just little things, and it’s the little things that
count, it’s the little things that start to get to them. And the team leader
who doesn’t like them says “Oh no, you can’t go yet, I’m doing such and
such and won’t let them go until 7.30 at night or something, you know.
And that happens, and mainly because they’re fiddling around. Irena
Oh you know, in a way, yes. Yes, there’s no respect. There’s no
respect umm… on a personal or professional level. And I think too
probably what gets up my nose, is that the people mainly who are
enforcing it umm… are not doing it themselves. It’s not something that
they are going to do themselves either, you know. But they are happy
to foist it on other people and don’t seem to really care Betty
Interpersonal relationships are discussed by I. Thompson, Melia and Boyd
(1994) in the context of the professional. They suggest there are three types
of relationships that may be appropriate – code, contract and covenant, and
seem to be thinking of these relationships mostly in the context of the
professional/client relationship. Although I have suggested that professionals
generally have a covenantal relationship with their clients, a brief look at what
these authors say is worthwhile, for the power relationship is significantly
different in each of the three cases mentioned. Codes are a two way street –
directing the practitioner how to act, but also protecting them from legal
action if they have acted within the code. In emergency situations, when the
professional needs to be in control, with a client who is totally or highly
dependant, codes allow professionals to exercise power guided by the
principle of beneficence. The professional holds all the power. A contract is
based on the principle of justice, where an independent and competent client
seeks the services of a professional. The professional offers a service,
usually for a fee, which the client honours. There is mutual respect by each of
the rights and responsibilities of the other party. The professional holds most
of the power. In the covenantal model, respect for persons is the central
principle. It is suited, the authors suggest, to persons who are “self-directed,
seeking support, companionship, partnership” (I. Thompson, Melia and Boyd,
1994, p. 49). In this model power is shared, with the rights of client and carer
taken into consideration. The professional adopts more of a partnership role,
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aiming to promote autonomy. It is interesting to note that this account of a
covenantal model differs a little from that offered earlier in this chapter, where
the professional seeks to serve the other in a context of gift, pursuing the
“good” of the other, with a sense of moral obligation and a willingness to
invest time and develop trust (Isaacs, 1993 and W. May, 2000). Although
similar, Isaacs and W. May offer an account of a more giving professional
relationship.
There are many ways that midwives can envisage their relationships with
their clients, their peers, colleagues from other professions and their
superiors. The covenantal relationship certainly seems the most appropriate
for the midwifery setting. There is still a third level at which I. Thompson,
Melia and Boyd (1994) say nurses need to be aware of ethics and power –
the social, or put another way, community responsibility. They mention
command, critical enquiry and community responsibility. These are the areas
of power involving management (command), research and further learning
(critical enquiry) and involvement in the wider community and political action
(community action). The first two featured in a number of the midwives’
stories in this study.
There is no doubt that power and power relations have been a long standing
concern to nurses and midwives, and this is evident in the literature. The
rather large amount of research into and discussion surrounding horizontal
violence gives testimony to the degree of concern it causes65. What is less
evident within the current nursing literature is the intrinsic relationship
between power and ethics. It is quite clear that the midwives in this project
were aware of both power and ethics, and wanted to be “good” midwives.
Some of them, however, were finding the cost very high. As we have heard in
their stories, whilst seeking to exercise their professional commitments, these
midwives encountered many obstacles including the exercise of power over
and against them by other midwives, doctors and management.
65 See, for example Hastie, 2006; Hutchinson et al., 2006; Keeling et al., 2006 and Vonfrolio, 2005.
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A significant number of the participants were unhappy in some way with
“management” or the way in which other staff members interacted with them.
Many of them also noted that happy staff members are productive. Whilst it
seems obvious that professionals would not treat each other in a
disrespectful manner, it is apparent, from the midwives’ stories, that this is
just what happens. It is important that people know why they are expected to
do what they are expected to do. Nyberg notes that this will change the way
in which they approach their work.
If people are treated merely as behaving organisms, as operational
units, with no regard for their sense of purpose and their need to know,
all that can be expected is temporary compliance and a tendency
toward minimising every effort – except the effort to escape from the
power relationship. If people understand, or at least think they
understand what is going on, why it is going on, and what part they play
in a system of purposeful activity, the chances that cooperation will
replace compliance will increase considerably. Nyberg, 1981, p.51
The excerpts below from some of the midwives’ stories demonstrate how
power relationships entered into many of their everyday situations.
Like around in, in delivery suites, I mean, they don’t, they don’t do, like
scalp ph’s or cord gases66 or anything like that and … it’s “oh, we’ll just
move them off and do a caesar”. And you say, “well why are you going
to do that?” ... “Oh well, I will just section it67 ’cause it is easier”, and
like, and that really annoys me. It is something you know, you can’t
fight against the doctor, you have just got to go with it. Mary
Mary questioned the doctor, but felt that she received an unsatisfactory
response. There was no certainty that a caesarean was indicated, and Mary
went on to say that she thought the client was (possibly) being subjected to
unnecessary surgery – that she was powerless to do anything about.
Perhaps she would have been happier to participate in preparing the woman 66 These tests enable an assessment of the condition of the baby so that a determination can be made as to the appropriate course of action. A caesarean may not be necessary if the baby is coping with the labour. 67 I was interested to note the impersonal “it” here, when Mary relates the doctor’s statement, as if the doctor objectifies the client.
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for a caesarean if she had known why it was required (assuming it was)?
Below, Jenny is in a similar situation, but she finds herself unable to
challenge the doctor, such is the power the doctor holds in the situation.
… when I’m the midwife caring for the woman it’s very difficult for me to
say, “Oh no. Don’t do that. You want to try a little further,” because he is
the person that she has put her trust in and you can just see that, … I
wish I had the umph to stand up and say, “Can’t we just keep trying for
a bit?” Jenny
Sometimes people showed that they held the power in the relationship by not
valuing the views or opinions of the midwife. In the examples below, Emily
was concerned about a client in labour and had asked an obstetrician to
review her, and Henrietta explains that some midwives treat others within the
profession with a lack of respect.
Hmm, well yesterday I, I actually felt umm, quite frustrated that, umm,
you know, this obstetrician was only two minutes away over in the, in
one of the medical centres and umm and kind of, I don’t know, they
blow you off basically for want of a better word, but I, you know?
Emily
There will be some midwives that, that will be not as respectful to the
community midwives because they, you know, they think they’re better
or worse or they think they’re, why do they get this point rather, ra, ra,
ra. Henrietta
Refreshingly, some midwives told stories that evidenced covenantal
relationships. One such story, from Debbie, is shared below. In this story we
can see that there was mutual respect between midwife, client and doctors.
there still wasn’t the appropriate progress and I ruptured her
membranes, so I therefore had the duty to ring the doctors and let them
know that the progress was what was considered a bit slow, but when I
did that I also wanted to let them know, both the Resident and
Registrar, that I felt that she could, that things would be okay. That
there was no need to put up a drip, Synto, to get things moving more
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quickly68, and they seemed to trust my judgement, and that really
pleased me, not only for my sake but also for the woman’s sake, that I
was listened to and then, within the appropriate time-frame and after
her membranes were ruptured at that examination, she then, her
contractions increased, she went on to deliver at an appropriate time
and ah, everything was wonderful, and I was just really glad that I could
be open with the doctor and tell them what I had found and also that,
and provide my suggestion that things should take their natural course,
and that they listened to me and that the outcome was really good.
Debbie
Conclusion Striving to be a professional midwife in an institutional setting certainly
presented some difficulties for the midwives in this study. Even in the above
situation, Debbie had to be brave enough to challenge the routine, which is
not an easy thing to do. Policies are powerful, and the people that midwives
dare to challenge are not always so receptive. Power relationships play a
significant part in the challenges midwives face in their everyday practice,
and a large number of issues carrying ethical weight were identified within
the midwives’ stories. In the final chapter, we will consider some implications
of the issues that have been identified and discussed.
68 Augmenting labour with a syntocinon infusion would be considered, by many doctors, to be routine in this situation.
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CHAPTER 8 CONCEPTUALISING MIDWIFERY PRACTICE
The certain thing one can know about an easy answer to a complex
problem is that it is wrong. Kritek, 2002, p. 174
Introduction Being a member of a profession, Isaacs (1993) suggests, carries with it
certain obligations. The obligations identified will depend on the perspective
taken when looking upon the profession – from outside, or from within. In the
former instance, Isaacs says the main relational focus is between the
profession and the broader community, whereas the latter case, which he
calls an internal perspective, concerns the obligations of an individual
professional to their clients and their profession. Both these stances are
necessarily ethically laden, for they each involve people – sometimes many,
sometimes few. It is, however, in grasping the intensely people oriented
focus of midwifery practice, no matter which angle you view it from, that it is
possible to begin to comprehend the profoundly moral nature of the practice.
This is why, in so many of the stories shared, a moral concept, principle or
notion was frequently easily identified even though I had not asked the
participants to tell me stories relating to ethics or ethical concerns.
Some of the ethical concepts that arose in the midwives’ stories were
anticipated. These included client and care provider autonomy,
accountability, responsibility, advocacy, professionalism, confidentiality, trust
and having a sound knowledge base. Some were less expected, at least to
the degree and in the manner in which they arose. Examples from this group
included the difference between caring for and caring about; the extreme
importance placed on having “good” relationships; the problem of power; and
having to do “ethics on the run”. Having integrity, being able (or not being
able) “to do the right thing” and having divided loyalties all presented
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significant dilemmas for the midwives. Ethics is as much a part of midwifery
as are mothers and babies.
If a picture were to be painted of a professional, ethical midwife, it might look
a little like this. She would be a particularly aware person. She would be
aware of her own values and beliefs, morally virtuous and have a sound
midwifery knowledge base and practical skills. She would also be aware of
her limitations, responsibilities, and the appropriate codes, guidelines and
ethical principles that are available to guide her practice, and she would also
be aware that these have limitations. Perhaps most importantly, she would
be respectful, respecting herself and others, and would know that she is
equally worthy of respect. This midwife would be well positioned to pursue
the goals of midwifery – to participate in the many activities that together
promote and work toward optimising the health and well-being of women and
childbearing families.
From earlier discussion on professions and social practice, we are aware that
midwifery occurs in a social context. As it is a social practice, members share
and are reciprocally aware of sharing the same goals (Isaacs, 1993,
Langford, 1978) – or at least that is how it ought to be for a social practice to
remain coherent and move forward. Yet it is apparent from some of the
stories shared that the participants in this study did not always feel that they
were sharing the same goals as some of their colleagues. For example, if we
think again of Tara (client), Susan (midwife-in-charge) and Lucy (midwife) in
Chapter Three, Lucy was seeking to follow Tara’s wishes for minimal
intervention, best practice when there is no indication to do otherwise. Susan,
however, did not have the same goal in sight. She was on a different
pathway.
A significant and confounding problem, I suggest, is that midwifery is largely
practised in institutional settings69. As has been discussed earlier, it is
69 All of the midwives interviewed in this study were working in hospital settings, and it must be acknowledged that it is, therefore, only possible to comment on the issues that relate to this context.
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possible, and here I assert that it is probable, that policies and financial
considerations can and do interfere with midwives’ abilities to provide optimal
care. Political and practical issues also have a very real impact. Consider
what Betty has to say here. How can optimal care be provided when there is
inadequate staff?
So that, you know, I suppose umm.. that the thing that I find very
stressful, working as a midwife is… the way that we’re affected so …
intensely by management and their decisions and at the moment we’ve
got such an acute staff shortage and they’ve got policies… that affect
us on a daily basis, like … they didn’t want to replace sick leave. You
would come to work so many times, you’d come to work and you’d be
working one down. Betty
Further challenges are created for midwives trying to practise as
professionals and make autonomous decisions in the best interest of their
clients because they are, as Chambliss (1996) astutely pointed out, still in a
relatively subordinate position within the health care setting. Midwives work
as a part of an interdisciplinary team. In an institutional setting it is particularly
important for midwives to work closely with other midwives and doctors. It
has been apparent in many of the participants’ stories that, when a doctor or
senior midwife says to do something (rupture a woman’s membranes, for
example) a midwife is expected to do it, even if she does not agree with the
directive.
This is not necessarily right, but in many settings, it is expected. Doctors and
midwives come from quite different paradigms. So different that, when it
comes to matters of pregnancy and birth, midwives are “expert in normal”,
and obstetricians “expert in pathology” (El Halta, 1998, p.9). They are taught
different values, socialized into entirely different practices. Doctors have been
inducted into a social practice of illness and disease and many were taught
that nurses were there to assist them. Midwives’ knowledge base and
approach to birthing is significantly different to that of doctors. It is a difficult
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task for midwives to convince them that birthing is actually a normal part of
life for many women, and that midwives are professionals in their own right70.
Midwives and their Practice Clearly the many everyday encounters that the midwives have so generously
shared with us have had some effect on the individuals involved and their
practice. So many emotions were brought forth, both positive and negative.
People were sad, disappointed, cut up, frustrated, challenged, disturbed and
tired out. They found themselves working “phenomenal” hours, unable to give
the kind of care they felt they should, over taxed, ill and bound up in red tape.
Fortunately, they also found their work rewarding at times, and there were
happy times, moments of joy, and occasions when colleagues worked
together and gave tremendous support. Sadly, the latter situations tended to
be sparse.
The relationships that the midwives had during their everyday practice were
of enormous significance. The quality of the relationships had the ability to
make a bad situation “good” or a good situation “bad”. Henrietta’s story in
Chapter Three where the baby had died in utero comes to mind, as does
Cherry’s story in Chapter Five. In Henrietta’s case, an obviously very
distressing situation was made much easier to work through, because
everyone involved communicated well and worked together harmoniously.
Cherry was involved in a situation that could have caused considerable
friction; none was present though, because of the mutual respect and
willingness to listen by all. The positive relationships in these two situations
enabled the midwives to negotiate their way through the challenging births.
Felicity expressed what made a day good for her – it was a day where she
had entered into a meaningful relationship with a client.
the type of day that really I love working is where I have bonded with a
particular person, no matter whether it’s in the post-natal or in delivery
suite and you felt that what you had said has made a difference, and 70 I would like to point out that, fortunately, an increasing number of doctors are becoming very supportive of midwives and work together with them in collegial and harmonious relationships, as was noted in Debbie’s story in the preceding chapter.
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the care that you have given is something that they appreciate as, as
something that’s a little bit more. Felicity
Debbie expressed similar sentiments.
it’s like being able to come home and feeling really great that you’ve,
you’ve done something that not only reaffirmed who you are and what
you believe in and what feels right, but you’ve also been able to do
something that’s been constructive and positive to support a woman in
labour. Debbie
On the other hand, developing a relationship with a client could prove to be a
big commitment when the woman became very ill, Gemma found
it was pretty, you know, pretty horrific. That was emotionally, … so that
was pretty draining on me as well, I had a lot to do with her. I used to
go and see her afterwards
Gemma
She did not, however, begrudge this. Gemma was keen to follow her client’s
progress. This provided an excellent example of how many of the midwives
did not simply care for their clients, they cared about them. Sadly, many
midwives experienced relationships that were not so pleasing. These were
mostly with midwifery, nursing or medical colleagues. Natalie was very
distressed by the encounter she relates below, a small part of a much longer
story.
…I’d had a confrontation with her… she’d yelled at me in front of a
mother and I was very upset, I cried, which I don’t believe anyone has
the right to make another person cry, deliberately. However she made
me cry and then I went home and then I cooled down a bit. I rang and
made an appointment to come in and see her. Natalie
Sadly, the said appointment had a rather unsatisfactory outcome. Lucy, in a
not dissimilar situation, simply decided not to bother with the confrontation.
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the professional side, that, you know, you want to avoid conflict in your
workplace. And when you’re dealing with another colleague, who
perhaps is, you feel perhaps is a stronger character, well, a bully I
guess, you think, “Where’s this going to get me?” If I, if I start arguing
and in some ways that makes it worse, doesn’t it? Lucy
The midwives’ stories clearly demonstrate that the nature and quality of the
relationships they have at work with clients, midwives, doctors and
administrators are extremely significant. They can define a good day, make a
situation workable or untenable. Many of the participants spoke of being
respected, or not, and how this impacted on their sense of self and their
practice. For some it caused a loss of confidence, and insecurities. Even
though they knew that they were competent, they would question their own
knowledge and have to work hard to regain their faith in themselves. Others
related stories where relationships, which they felt were disrespectful, had
caused deep unhappiness and discontent, and robbed them of the joy they
used to experience in their practice. This had led some of them to leave
midwifery. So, what is to become of midwives?
Future of the Practice As we know, the members of a social practice are significantly influenced by
the past, present and anticipated future of the practice. This temporal aspect
of a social practice, its history, affects its overall purpose. The midwives in
this study did not have a very optimistic outlook for the future of midwifery as
they knew it. This could be, at least in part, because the past and the
present, what they saw as the goals – the “good” – of midwifery, did not fit
with the anticipated future. They were struggling to make sense of it in their
present day practice and could not see that it was sustainable. Many of them
were discouraged in their midwifery work, feeling unsupported, disappointed
and disrespected. For many, the future of midwifery, both personally and as a
profession, did not look promising. Some of the problems came from within,
from midwives on the same level as themselves, reflected in what Henrietta
says below.
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we don’t all project ourselves as professionals and I think that’s
probably our biggest downfall. … I don’t think the individuals value their
service so why should other people. I think if you value the service that
you give … I think if you stand up and say “I think that I’m providing a
service that not a lot of people can do. I’ve studied. I’ve gathered the
information. I’m continually working through information so I can upskill
or maintain my skills” Henrietta
Sometimes, however, this pressure came from a midwife at a higher level in
the nursing staff, or a member of an entirely different profession. An example
is given here from Natalie’s interview. Natalie is particularly affronted
because, not only did the staff member cause a number of staff sufficient
distress that they left the workplace, but also, she was apparently rewarded
by promotion to “bigger and better things”.
I mean I knew I was unhappy but I didn’t realise just how bad it was. ...
People have tried. I think 13 staff when I was in the [ward] had left as a
direct result of this person. And she’s just gone on to bigger and better
things. Natalie
Rarely, but on occasions, client expectations caused midwives to question
where the practice of midwifery is heading. Emily was concerned that the
autonomy of clients ought to be respected, but not to their detriment. She
feared that the push for client autonomy had become so strong that it had
begun to undervalue or even disregard the knowledge of the midwife about
pregnancy and childbirth. Whether the client definitely wants, or definitely
does not want, some particular intervention or procedure, being able to be a
“good” midwife becomes increasingly difficult as she tries to respect the
client’s autonomous decision and practise according to the sound knowledge
base that informs her that all procedures and interventions should be utilized
when indicated.
our practice is patient driven and we’re, we’re actually sort of tending to
practise probably in a fashion that we are not all that entirely
comfortable with and that is because the patients have set ideas about
how they would manage their care. And I am not saying for a minute
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that they can’t have that say, but it’s the ill informed or you know they
have a perception that for example, induction or a caesar is the way to
go and that, you know, haven’t really looked at the whole process as
being really a natural thing that women have been doing for donkey’s
years you know. All of a sudden they want what they want on demand
and I don’t think they have the foresight or have the information
Emily
Many authors, including Bayles (2003), Massey (1998) and L. May (1996)
have noted that professionals are no longer independent practitioners, but
now work in and for large institutions and organizations. This has led to new
challenges and difficulties for the members of the professions. Massey
discusses “professional abuse” as “a process of deprofessionalisation” (1998,
p 12). This is particularly relevant to this study for the two key elements he
identifies as a part of this process are (i) not treating professionals
professionally and (ii) not allowing professionals to fulfil their roles by denying
them their rights and entitlements. These two statements seem to resonate
well with what many of the participants in this study said.
If I was initially sceptical that many midwives had considered ethics beyond
the “neon light issues”, this scepticism was fleeting. All fifteen midwives were
cognisant of the fact that ethics is inherent within all of their relationships and
the importance of those relationships being of the highest quality possible.
Just as midwifery clients do not have all the midwifery language, so too, the
midwives did not possess all the ethics language. As has been identified in
the preceding chapters, however, a vast array of ethical principles, concepts
and issues were embedded in their stories. The depth and breadth of their
stories affirmed the belief I held – many midwives have stories that haunt
them.
I contend that the frequent challenges to the professional status of midwives
could be one of the reasons for the considerable discontent expressed by
many. If the profession is to continue and flourish, the members of the
profession need to be able to flourish. This can only be achieved in
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environments where there is mutual respect, where midwives’ achievements,
wisdom and limitations are acknowledged. There needs to be a safe and
open forum for midwives to express their learning needs, and midwives
equally need to have open minds to acknowledge their knowledge deficits,
and a willingness to move into new ways of doing and being as midwifery
practice changes. Equally, the immense knowledge and wisdom that
midwives already possess, gained through education and experience, is both
worthy and deserving of respect and acknowledgement in all that they do –
and from all that they work with and for.
Narratively Speaking A great many stories have been shared in the building of this thesis, and
before closing I would like to consider the importance of these, and all
stories, to midwives. Jerome Bruner says that “The story of one’s own life is,
of course, a privileged but troubled narrative in the sense that it is reflexive:
the narrator and the central figure in the narrative are the same” (1987, p.
13). It is not possible, as has been mentioned previously, to separate life as
lived from life as told. As we reflect on them, is it possible to identify the type
of stories that the participants told. Might they fit into some recognisable
genres? Farce? Tragedy? Saga? Adventure story?
Bruner (1987) says that every culture has some canonical life narratives.
Some examples of canonical narratives in midwifery might include stories of
warm, reciprocal and supportive collegial relationships; or stories of midwives
assisting women and their partners though normal labours, with medical staff
trusting the midwife’s assessments and knowledge, intervening and assisting
only when indicated. It was pleasing to hear some stories like this, and gives
much pleasure to be able to share them again. With the telling and retelling
of such stories the true ethos of midwifery can be conveyed.
For a story to be worth telling though, Bruner (1991, 1992, 1994) asserts that
a canonical narrative needs to be violated or breached. This is doubtless why
stories of the above type were few and far between in this study, and those
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that were shared tended to be particularly good stories. That is, in order to be
worthy of being told, such stories needed to breach the canonical state by the
fact that, either, the midwives no longer expect to be treated this way, or, by
being a particularly positive and heart-warming experience. We have to
remember that trouble drives stories (Bruner, 1987), so it is hardly strange
that most stories are full of trouble. What I find troubling, is that most
midwives seem to be so full of such stories.
Bruner says “that stories are about the vicissitudes of human intention”
(1987, p. 18) and come about due to the mismatch between (at least) two of
the five constituent factors – action, goal, setting, instrument and trouble. In
the participants’ stories different instigators of the story could be identified.
For example, the goal of keeping labour normal often did not match with the
setting due to policy, someone else’s goal, other’s actions etc. This led to
trouble, and a story was born.
Many of the midwives could not make sense of some of their stories, even
years later. This confirmed my belief that some are indeed haunted by
previous experiences. Debbie summed up nicely, saying,
I think whether it’s positive or negative, that all our experiences can
impact on us, and who we are and what we do and what we believe
and how we feel about ourselves Debbie
This means that our stories are significant, our experiences are important
and our relationships are vital. The midwives in this research project found
that their work was often made easier or more difficult, and thus better or
worse, as a result of the interactions they had with various people. This
included those they worked with and those they worked for; clients,
colleagues and managers. These interactions changed how they practised –
whom they would approach with a question, or even, in some cases, if they
would ask a question, for example. Some midwives had been adversely
affected by their interpersonal interactions and expressed a deep
unhappiness that created a kind of inner conflict. Whilst they loved families,
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mothers and babies, they had learned to really dislike working in the current
midwifery environment. It created for them a very real dilemma. How could
they continue to do the work they both believed they should do and wanted
to do, yet avoid the personal difficulties and anxieties which were making it
increasingly difficult to do the job well? It seemed to some that they were
chasing an impossible dream. How could they possibly be a good midwife in
the current system? These stories told of a “new midwifery reality”. This way
of practising midwifery, with challenging relationships and altered values, did
not resonate with the midwives’ values and their understanding of midwifery’s
professional goals. The stories challenged this, and sought to restore the
norm, where people were important and clients were central.
On many occasions there was not time, collegial support was not
forthcoming, a supportive, learning, mentoring environment was not evident.
They felt that their concerns were not listened to. They were not valued and
respected. They were worn out and felt that the battle had been lost. There
was a strong sense that, if these midwives, and midwifery generally, were to
continue into the future, something would have to change. People need to be
valued and respected as persons and as professionals, to gain satisfaction
from their work, and to be able to respect those around them if midwifery is
going to survive as a social practice with common goals and covenantal
relationships.
Social Practice with Common Goals?
It seems, from the participants’ stories that, perhaps, midwives do not share
common goals, although they are members of a profession and thus a social
practice. A significant influencing factor is, quite likely, the fact that
institutions do not prioritise the same goals and outcomes as midwives (cost
efficient, time effective care versus individualised, detailed nursing care; for
example). Midwives in administrative positions are caught between the
business goals and the midwifery goals. Midwives from the “old school” are
convinced that effective, but outdated, modes of treatment should not be
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changed – research might say there is a better way, but they have not seen
the proof. New midwives lack confidence, and are not certain that they
remember that research base correctly – that seasoned midwife surely
knows better than I?
For the practice to be coherent and effective, midwives need to embrace their
common goals and work together to achieve them. There is, of course, one
goal that midwives would be easily able to agree upon – that they are there
to care for childbearing women and their families. Midwifery is all about being
“with women”. This would be a good starting point. Simply by focussing on
this would draw all midwives back to the same common ground and they
would be heading in the same direction. From here, open minds and
education are the keys.
As midwives are natural story-tellers, utilising narratives in everyday practice
would be an excellent way to begin to work together and gain new
perspectives. With a renewed understanding of the importance of our stories,
midwives could benefit from engaging in reflective practice. The use of
narrative to enhance reflective practice has proven effective as a teaching
tool for nursing students (Levett-Jones, 2007). It is important to realise that
our learning is only just beginning when we complete our training, and
midwives can benefit from what the students know – reflecting, using
narrative, is a worthwhile exercise.
Reflecting on practice through the use of story can be done formally or
informally, verbally or on paper, individually or collectively. Ideally, to gain the
most from a story, particularly if it were a troubling one, a midwife would
spend some time reflecting privately and then share it with the others
involved. Shared stories provide an excellent opportunity for midwives to
review events. As a story is interpreted and reinterpreted by both story-teller
and listeners, different perspectives can shed light on the events, actions,
interaction and responses of the different persons involved. In an open and
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responsive environment this can afford each person a chance to view the
situation from the others’ perspective and significantly enhance
understanding. When midwives from different backgrounds and with different
levels of responsibility begin to share openly and honestly with each other, in
a non-threatening environment, it is likely that goals will begin to converge.
It is natural for the goals of a social practice to change over time, but not for
them to be disparate from member to member. With shared understandings
and common goals – or at least working toward developing common goals –
the members of a social practice are able to work together to attain those
goals. The practice will then evolve and flourish.
It Is Not All Bad There are certainly a great many challenges facing midwives and midwifery
in the future. The aging workforce, staff shortages and the associated
pressures, changes to institutional settings and requirements and client
expectations to mention some. Within the thesis we did hear some positive
stories. Fewer, certainly, than those that conveyed challenges or discomforts,
but this is to be expected, for trouble is the engine of a story (Bruner, 1987;
1997). Not all the midwives have left though. Why not? Well, it is a great
vocation. Listen to what Mary has to say.
I mean if you didn’t feel that you could make a difference then you
wouldn’t do it, and you wouldn’t have that personal anguish that, you
know, you are trying to achieve something, you are banging your head
against a brick wall, um and it would be just easier if you just said, okay,
well I will just roll with the flow. I mean life would be so much easier
that way but I mean if everybody rolled with the flow, nothing would get
changed. Mary
And Mary is not alone…there’s Debbie
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Yes. So, yeh, it does, and you know, you come home and you feel
good about yourself and about what you are able to achieve and, and
you know, it reinforces the reason that you were there in the first place,
to support a woman and to be there with her. Debbie
And Irena…
Oh very. Oh. It made me realise that hey, I do this because I love it.
And umm…. And I really do, I just love it. But, no she came back and
she said that I had made such a difference. Irena
They are not giving in. They are planning to continue to do good midwifery.
Holding out hope for the future. Many of the participants showed little
glimmers of hope and love for the profession they are a part of. We should
too, for women are amazing, and so are midwives. There will always be
childbearing families, and they will always need midwives. This research has
shown that midwives are concerned about the relationships they have in their
practice at all levels. This includes both direct and indirect relationships with
their administrators and managers, midwifery and medical colleagues, clients
and their families, and even the wider community. It seemed to be the quality
of these relationships that had the most significant effect on the midwives’
perception on how a situation was viewed. There is hope if these
relationships can be built.
Conclusion Midwifery, certainly in the eyes of the participants in this research, is going
through a turbulent period. This study has shown that, if it is to survive and
flourish as a social practice, it is vital that the key role relationships play is
recognized and acknowledged. Our attention also has been drawn to the way
in which ethics is embedded in midwifery work. This indicates a need,
arguably, for a relational, contextual ethics approach when interpreting,
appraising and seeking to positively transform the practice. Everyone who
needs a midwife deserves a good midwife, and every good midwife should
272
be able to practise good midwifery in a safe, supportive, collegial
environment. For evermore, everyday midwives will continue to experience
tribulation and triumph in their everyday encounters. As our understanding of
each other grows through the sharing of our stories, my hope is that their
tribulation will be due to the vagaries of nature rather than the vicissitudes of
the people they work with.
273
POSTSCRIPT
This research presents a different way of looking at ethics in midwifery to that
which has been frequently adopted in the past. Nursing, and then midwifery,
have “borrowed” from medical ethics, and adopted principlism (Beauchamp
and Childress, 1994) as the basic approach to ethics. There has,
characteristically, been some effort to separate the ethical component of
situations from the contexts in which they were occurring – as if the
particulars were not particularly important. One case might, therefore, easily
be treated in the same manner as another similar case without difficulty. This
is, however, not the case. Although they can provide some guidance, ethical
principles applied a-contextually are frequently unable to resolve ethical
questions. Nor is it possible to apply one principle without regard for the
others, for they are not discrete, one from the other71.
In this research it is evident that ethics is very much contextual, relational and
embedded in practice. Everything that midwives do, every time they
encounter an “other”, they are in the midst of an ethical encounter. A view of
ethics as an everyday activity is presented, where midwifery ethics becomes
more a question of who midwives are and where their motivation comes
from, than an arbitrary question of following rules, codes or principles. I have
suggested, for example, that ethical midwives might be morally virtuous,
posses some practical wisdom, and be seeking a common goal.
Already there is some evidence of apparency, verisimilitude, and
transferabilty from this research. Midwives, mothers and others, who were
not involved in the research project, listen to presentations or read brief
excerpts from the thesis. They nod and comment how they can identify with
being in that situation, how their birth was “just like that” or they “know just
how that midwife feels”. Sometimes a vial story is begun. As the research is
shared a member of the audience identifies with a story and, adding his or
71 For further discussion on principlism see Childress (1994) and DuBose, Hamel, and O'Connell, (1994).
274
her own interpretation, and often his/ her own story, creates a new story with
new meanings and understandings from which all present can learn. So it is
that the stories continue and this new way of understanding ethics as an
intrinsic component of the everyday relationships and interactions of
midwives will grow.
275
APPENDIX A
Introductory Letter – Large Private Hospital
(Qut Letterhead)
Joanne Kinnane Centre for Nursing Research School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove Q 4059 Phone: provided Work: provided Mobile: provided Email: [email protected] 20.06.01 Dear Participant, I am writing to introduce myself and my research project to you. As a midwife, I am very interested in the issues that concern midwives in clinical areas and am currently working towards my Doctor of Philosophy at QUT. I would like to invite you to be involved in my research. Enclosed you will find an outline of my research project, The Impact of Ethical Encounters upon Midwives. This will provide you with further details of the project and what would be required of you should you be decide to assist me by being involved. I would be most grateful if you would read this information and consider your involvement. If you would like more information and/ or are willing to be involved in this research project, it would be helpful if you could provide some contact details. At present I know only your name and that you work at [name] Hospital. I will endeavour to make personal contact with you within two to three weeks. I would really appreciate the return of the enclosed response sheet in the stamped, addressed envelope provided. This will enable me to contact you at home, at work, on your mobile or by e-mail, according to your preference. Should you require any further information, or if you have any questions about the research project, you are welcome to contact me or my Principal Supervisor. Our contact details appear at the top of the information sheet. Thank you for your time and interest. Jo Kinnane
276
APPENDIX B Information Sheet
(QUT Letterhead)
The Impact of Ethical Encounters Upon Midwives
Information for Participants
Researcher Principal Supervisor Joanne Kinnane David Massey Centre for Nursing Research Centre for the Study of Ethics School of Nursing School of Humanities and Social Science Queensland University of Technology Queensland University of Technology Victoria Part Road Beams Road Kelvin Grove Q 4059 Carseldine Q 4034 Phone: provided Phone: provided Email: [email protected] Email: [email protected] My name is Joanne Kinnane. I am a practising Midwife currently studying toward my Doctor of Philosophy degree (PhD) within the Centre for Nursing Research at the Queensland University of Technology. This document will provide you with information about the above named research project that is being conducted as a part of my studies. Purpose The purpose of this study is to further the understanding of ethics in Midwifery practice, to discover how Midwives are affected by their ethical encounters, and to investigate what this means for both the individual and the profession. Potential Participants In order to participate in this study you will need to be a Midwife currently practicing in a midwifery setting in Queensland. You will need to have been working as a midwife for the past twelve months. These are the only criteria required for participation in the study. You have been contacted because you were randomly selected from a list of Midwives provided to me by your employer. Random selection has been utilised to ensure that a broad cross section of Midwives is approached and invited to participate in the study. The involvement of both full and part time Midwives will be valued. Requirements of Participants If you agree to be involved in the study, you will be asked to participate in an individual interview with the researcher named above. It is anticipated that each interview will last between one and two hours. Interviews will be conducted at a time and place suitable to, and arranged in consultation with, you. Most participants will be interviewed once, although you may be invited to participate in a subsequent interview. All interviews will be audio taped and later transcribed. The audio taping of interviews is an integral part of the research to facilitate an accurate record of what was said. It is not possible to be involved in the research if you do not wish the interview to be audio taped. The audio tapes and the information thereon will not be used for any other purpose other than for this research. The recordings will be destroyed at the completion of the study.
277
Expected Outcomes Your involvement in this project will contribute to the ethical practice of midwifery. Discoveries made may lead to some practices being challenged or changed. The research will promote ethical discussion within Midwifery. Results of this research will be published. Benefits Through your participation in this project, you may gain many important insights about ethics in your practice (or Midwifery generally). You may also benefit from the dissemination of information and knowledge discovered and developed from this research. It is possible that you yourself will not gain any direct benefit. Your involvement, however, will make a significant contribution to knowledge of Midwifery ethics. Risk There are no anticipated or likely risks for or to you as a participant in this research project. Confidentiality The only persons who will have access to the information you provide will be members of the research team. All information collected, whether on cassette or after having been transcribed, will be stored in locked cabinets. Identifying material, such as your details, will be stored separately to the tapes/ transcripts. This identifying material will be accessible only to the researcher. Other members of the research team will not be able to link you to your interview data. In order to further safeguard your anonymity and confidentiality, pseudonyms will be used in the presentation and publication of results. Voluntary Participation Whilst your participation in this research project will be highly valued, your involvement is entirely voluntary. You are free to withdraw at any time without comment or penalty. You do not have to provide a reason for your withdrawal. Feedback It is anticipated that the research project will be completed towards the end of 2002. Should you wish to obtain information about the results of the research project, please feel free to contact me with your requests at that time. A seminar will be offered to present results to interested persons. An invitation will be extended to you, towards the end of 2002, to attend this presentation. You will also be able to access published results. Questions or Further Information Should you require any further information, or if you have any questions about the research project, you are welcome to contact me or my Principal Supervisor. Our contact details appear at the top of the first page. Concerns or Complaints If you have any concerns or complaints about the ethical conduct of this project, you should contact the Secretary of the University Human Research Ethics Committee on 3864 2902. Than you for taking the time to read this information and to consider your involvement in this research project. I look forward to being in contact with you soon.
278
APPENDIX C
(QUT Letterhead)
The Impact of Ethical Encounters Upon Midwives
Participant Response Sheet
Researcher Principal Supervisor Joanne Kinnane David Massey Centre for Nursing Research Centre for the Study of Ethics School of Nursing School of Humanities and Social Science Queensland University of Technology Queensland University of Technology Victoria Park Road Beams Road Kelvin Grove Q 4059 Carseldine Q 4034 Phone: provided Phone: provided Email: [email protected] Email: [email protected] Please tick the appropriate box/es □ I am willing to participate in the study □ I would like further information Please complete the following if you are willing to participate or if you would like further information: Name: Address: Phone - Work: Phone - Home: Phone - Mobile: E-mail: Preferred method/ place for me to contact you:
279
APPENDIX D Introductory Letter – Smaller Public Hospital
(QUT Letterhead)
Joanne Kinnane Centre for Nursing Research School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove Q 4059 Phone: provided Work: provided Mobile: provided Email: [email protected] Dear Midwife, I am writing to introduce myself and my research project to you. As a midwife, I am very interested in the issues that concern midwives in clinical areas and am currently working towards my Doctor of Philosophy at QUT. I would like to invite you to be involved in my research. Enclosed you will find an outline of my research project. This will provide you with further details of the project and what would be required of you should you decide to assist me by being involved. I would be most grateful if you would read this information and consider your involvement. Depending on the number of midwives willing to be interviewed, it may not be possible for everyone who agrees to be involved to participate in this way. This information package has been distributed through the assistance of Nursing Administration and staff at the hospital where you work, and I do not know who you are, where or how to contact you. Therefore, if you would like more information and/ or would like to be involved in this research project, it is important that you provide some contact details. A response sheet is enclosed. Whatever you decide, I would really appreciate the return of the response sheet in the reply paid, addressed envelope provided by 18.5.01. If you do not wish to participate, you need only return the response sheet with the appropriate box ticked. Should you require any further information, or if you have any questions about the research project, you are welcome to contact me or my Principal Supervisor. Our contact details appear at the top of the information sheet. Thank you for your time and interest. Jo Kinnane
280
APPENDIX E Advertisement for Participants at Large Public Hospital
ARE YOU • a midwife with 12 months or more experience? • interested in midwifery practice and furthering the
profession through research? If you answered yes to the above COULD YOU
• Spare approximately 2 hours? • Speak with another midwife about your
experiences? THEN
• I would be delighted if you would participate in my research project “The Impact of Ethical Encounters Upon Midwives”
• Please contact me – Jo Kinnane At Work: contact details provided Email: [email protected]
Further Information is available. I would be very happy to supply you with “Information for Participants” and discuss my project with you. THANK YOU Jo Kinnane, PhD Student, School of Nursing, QUT.
281
APPENDIX F
Covering Letter for Recruiting Participants at Large Public Hospital
(QUT Letterhead)
Joanne Kinnane Centre for Nursing Research School of Nursing Queensland University of Technology Victoria Park Road Kelvin Grove Q 4059 Phone: provided Work: provided Mobile: provided Email: [email protected] August 5th, 2003 Dear CNC/ NPC, I am presently studying towards my Doctor of Philosophy Degree (PhD) within the School of Nursing at the Queensland University of Technology (QUT). My particular interest is in midwifery ethics and my study involves interviewing midwives. My project was deemed exempt from the need for Ethical Clearance by QUT’s Human Research Ethics Committee and has been given clearance by the Ethics Committee at [name] Hospital. One of the requirements of the hospital’s Ethics Committee is that I “advertise” for participants, rather than using the random selection and invitation method that I had originally outlined in my proposal. To this end I am writing to request your assistance. Enclosed you will find an A4 sheet inviting midwives to participate in my project. I would be grateful if you could display this in a prominent place where midwives will be able to see it. I have included three copies of my “Information for Participants” for interested persons to read. Although I am easily contactable by telephone, email, internal mail or in person at work, I have also included three responses sheets for interested persons to use if they prefer. More of any of these documents can be readily supplied if required. Thank you for your assistance. Yours faithfully, Jo Kinnane
282
APPENDIX G
Consent Form
(QUT Letterhead)
The Impact of Ethical Encounters Upon Midwives
Researcher Principal Supervisor Joanne Kinnane David Massey Centre for Nursing Research Centre for the Study of Ethics School of Nursing School of Humanities and Social Science Queensland University of Technology Queensland University of Technology Victoria Park Road Beams Road Kelvin Grove Q 4059 Carseldine Q 4034 Phone: provided Phone: provided Email: [email protected] Email: [email protected]
Statement of Consent
When you sign below you are indicating that → you have read and understood the information provided in the information sheets about this research project; → your questions have been answered to your satisfaction; → you understand that you may contact the research team if you have any other questions about the research project and that you have information that enables you to do this (contact details); → you understand that you may withdraw from the research project at any time, without having to state any reason and without comment or penalty; → you understand that you may contact the Secretary of the University Human Research Ethics Committee on 3864 2902 if you have any concerns about the ethical conduct of the project; → you understand that interviews will be audio taped and later transcribed and that the audio tape recordings will be destroyed at the completion of the research project; and → you agree to participate in the project Name Signature Date
283
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