The effect of professional socialisation on midwives’ practice

Women and Birth (2007) 20, 31—34

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

journal homepage: www.elsevier.com/locate/wombi

DISCUSSION

The effect of professional socialisation on midwives’ practice Myra Parsons a,*, Rhonda Griffiths b,c,a a

Midwife in private practice, University of Western Sydney, NSW, Australia South West Sydney Centre for Applied Nursing Research, Australia c NSW Centre for Evidence Based Health Care, South Western Sydney Area Health Service, Australia b

Received 10 April 2006; received in revised form 23 September 2006; accepted 25 September 2006

KEYWORDS Professional socialisation; Midwifery; Practice; Policy; Guideline

Summary This article discusses the influence that professional socialisation can have on midwifery practice. Differences in beliefs and practices regarding the oral intake of labouring women were the basis for this paper’s discussion. Midwives should be aware of the problems that may be caused by the socialisation processes experienced during the training and subsequent working life of a midwife which aim to procure obedience and unquestioning conformity. These attributes diminish the ability of midwives to challenge traditional practices and to make decisions based on the available research evidence and the preferences of women in their care. Basing practice on tradition or practice conventions rather than a formal guideline or an evidence-based policy may expose a midwife to potential litigation should there be an adverse event. # 2006 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

Introduction Research has made a significant contribution to health care, particularly in technology-based areas such as pharmacology and pathology. The focus on evidence-based practice has resulted in a profusion of evidence-based guidelines that clinicians can adopt or adapt as a basis for best practice interventions, however, at the bedside management continues to be based on tradition and convention.1 The reasoning behind the introduction of various models of midwifery-led care in Australia over the last three decades (e.g., birth centres, team and caseload midwifery) has been to change midwifery practice from a medicalised approach to * Corresponding author. E-mail address: [email protected] (M. Parsons).

more of a naturalistic approach which allows women and their support people to play a central role in their pregnancy and birth.2,3 Medical interventions are discouraged in these models of care except where the wellbeing of the woman and or her baby are at risk.3 Regardless of where care is provided, contemporary midwifery practice needs to reflect guidelines and procedures developed from the best available evidence for all aspects of care. However, research suggests that even in large midwifery units practice is not always supported by formal policies and guidelines to ensure consistent and evidence-based care for pregnant women.4 The labouring woman’s oral intake is one aspect of labour management which is often reliant on the practice convention of the midwifery unit.4,5 In fact, 80% of maternity units in New South Wales were found not to have a formal policy to direct this aspect of labour,4 a situation which has created inter-hospital and intra-professional inconsistency.5

1871-5192/$ — see front matter # 2006 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

doi:10.1016/j.wombi.2006.09.003

32 This article will discuss the effect professional socialisation can have on the decision-making ability of midwives when practice is controlled by the unit’s convention instead of a formal guideline or policy. To demonstrate this phenomenon the findings of a survey, performed by the first author, will be used.5 This survey examined the beliefs and practices of midwives (N = 147) working in birthing/delivery suites from four Sydney metropolitan hospitals (Levels 4 and 5) regarding the oral intake of labouring women. The findings demonstrated that, despite there being no written policy, two-third of these midwives followed their unit’s practice convention for this aspect of labour care while one-third did not. The reasons why these midwives chose to follow or disobey their unit’s convention is the focus of this discussion paper.

M. Parsons, R. Griffiths and rituals without questioning their basis. The surveyed midwives mentioned above, as an accountable, professional group,14 should have requested to cite practice policy, and in the absence of a current, endorsed document, initiated and contributed to the development of a guideline for the oral intake of labouring women based on the available information and evidence. It is possible for a midwife to be held legally responsible for an adverse outcome attributed to a practice unsupported by a formal policy or guideline.15 The fact that health professionals willingly comply with a practice that has not been ratified formally by their hospital or who deliberately practice contrary to their hospital’s practice convention is believed to be associated with their socialisation through the profession of nursing and midwifery.

Professional socialisation in midwifery Practice conventions, policies and guidelines None of the four hospitals in which the surveyed midwives were employed had a written policy for the management of oral intake during labour that had been endorsed by the organisation.5 Therefore, a convention had evolved in each unit, and that informal policy had been represented to the midwives working there as ‘the way to do it here’. Two of the hospitals permitted light foods and fluids during labour and two allowed clear fluids only. The practice reported by individual midwives within each of these maternity units was relatively consistent with the informal policy developed by their unit, that is, if the unit’s practice convention was to allow only clear fluids then this is what most midwives did. This finding demonstrates an interesting phenomenon inherent in professional practice; namely obedience and compliance to authority. Practice conventions are not written but communicated via word-of-mouth. The problem with this method of communication is that it has a tendency to be misinterpreted and may change over time.6 When there is no documentation for staff to consult, practices change, new staff have no guidance and monitoring of practice is difficult; situations that could compromise women’s safety7 and expose the practitioner to potential litigation should there be an adverse event.8 The reason that the management of labouring women’s oral intake has not been documented in many hospitals4 may be related to the paucity of reliable research evidence. A policy should be based on the best available evidence to promote safety and best practice and to standardise midwifery practice.7,9 When reliable research evidence is not available, a guideline should be developed in lieu of a policy.10 A guideline presents the available information and evidence11 and provides recommendations for clinical decision-making based on a critique of the information.10 An advantage of a guideline over a policy is that it allows for the autonomy of midwives by permitting the use of professional judgement based on the quality of evidence provided within the guideline along with the individual woman’s preferences.12,13 The absence of practice policies and guidelines endorsed by the organisation is unlikely to be confined to midwifery units. It is a concern that, despite the contemporary focus on evidence-based practice and procedures such as accreditation of hospitals, professionals continue to follow traditions

The process of socialisation occurs in all cultures and groups and begins within the family unit whereby one adopts the practices and beliefs of those around them.16 The term professional socialisation refers to the process by which one acquires specific knowledge, attitudes, beliefs and skills in order to be accepted as a member of a professional group.17 The midwifery profession is no exception.9 Preparation to practice in a profession is a complex process that requires students to learn the skills and knowledge required to perform their role, and to take on the norms and mores of their chosen profession that are required to function within the social context of the group. Until recently, most Australian midwives had been socialised first to the nursing profession and then to the specialisation of midwifery. It has been proposed by Carpenter (p. 27) that the prior influence of nursing socialisation with ‘its traditional Victorian virtues of obedience, efficiency and submission . . . and its emphasis on caring for the sick’, has had an effect on the attitudes, beliefs and views of midwives.18 Some researchers believe that standards of ‘obedience’ and ‘conformity’ set in place during the nursing socialisation process have filtered through and are maintained in the midwifery profession.9,12,19 Consequently midwives have been expected to obey those in authority without challenge in order to be accepted by their peers.20—22 It is suggested that the socialisation process has led to a lack of autonomy, selfreflection and authority to question practice.9,12,20,21 For a midwife to question or choose not to follow the ‘practice convention’ of their maternity unit not only alienates the midwife from those in authority but also from peers.9,12,23,24 Those who oppose the ‘practice convention’ may be subject to verbal abuse, intimidation, humiliation and exclusion by their peers in an attempt to preserve the status quo.13,25—27 Some midwives may adopt the ‘usual practice’ of the unit without knowledge of the literature. They may do so because they believed it is correct.16,28 Chamberlain found that some midwives never question hospital policies, preferring to adhere to the values of their organisation (hospital) at the expense of their professional values in order to maintain the status quo; a remnant and expectation of nursing socialisation.9 This situation should be of concern to midwifery leaders as these findings undermine the principles of professional practice that include the ability to self-reflect, be accountable and to practise autonomously.14,20 Foregoing

33

The effect of professional socialisation on midwives’ practice these ‘privileges of professionalism’ in exchange for a comfortable, unstressed work environment, however, may seem a preferable option for many midwives.12,26 The reluctance to question the origins and justification of some practices has led to the perpetuation and reinforcement of the preferences of those with authority within a facility to the extent that clinicians cannot differentiate between formal organisational policy and practice convention. Of the 147 midwives surveyed it was found that twothird of the respondents conformed to their hospital’s practice convention for the oral intake of labouring women, although they had not seen any documentation to support the practice.5 This overwhelming compliance in the absence of evidence to support the various practices employed for the management of oral intake during labour was suggested to be attributed to aspects inherent in the nursing socialisation process: (a) obedience to authority and (b) conformity for acceptance. Not all the midwives in this survey were compliant however, and for the purpose of this paper will be referred to as the rule-bending midwives.

Rule-bending midwives The society or culture to which one belongs is governed by norms or rules which ensure the smooth, orderly functioning of the group.28,29 What is considered normal in one group may be seen as deviant in another.16,28 Anecdotally, allowing labouring women to eat is seen as the norm in some maternity units yet deviant in others. It is not uncommon for midwives to deviate or disregard the rules of the group at one time or another, particularly if they disagree with the existing rule.29 This is despite there being enormous pressure from peers to ensure that each midwife conforms to the behavioural norms, practice conventions and policies of their maternity unit.24,28 One-third of the surveyed midwives did not follow the practice convention in their unit for the labouring woman’s oral intake, some unknowingly and some deliberately.5 The deliberate rule-bending midwives may have felt they had a certain amount of control over their practice decisions because of their previous experiences in midwifery or the number of years they had been practising as a midwife.29 In a study of ‘rule-bending’ behaviour Hutchinson found that midwives made an informed decision, based on their knowledge, ideology and experience, to ‘violate hospital policies’ for the benefit of the women, and they did so knowing the possible consequences for their actions if the practice was exposed.30 Christmas proposed that autonomy was associated with self-awareness and the ability to reflect.31 These qualities may have been the reason the midwives in Hutchinson’s study had the confidence to question a practice convention that did not support their own beliefs and experiences. By practising outside the usual practice convention of the unit the midwife is at risk of being considered negligent, dangerous or deviant by peers.13,16,28 Some midwives may resort to ‘horizontal violence’ to enforce conformity.24 Others may report the non-conformist to their administrators or managers so that formal punishment and disciplinary measures can be applied.20 Ideally, evidence should be available for each facet of midwifery practice in order to provide pregnant women with safe and effective care; however, that is not the case for the management of oral intake for labour. The paucity of reliable

evidence to support this aspect of labour management is the basis for the confusion and inconsistencies experienced by midwives when deciding on the ‘best’ practice. It is also an obstacle in the development of an evidence-based policy for this issue. Where differences in practice are influenced by a paucity of research evidence along with negative aspects of our professional socialisation, midwives must work together to: (a) develop a formal clinical guideline which provides a critique of all the available evidence and recommendations for practice and (b) participate in research to help lessen the research—practice gap.

Summary Although this paper has used the management of labouring women’s oral intake as an example, many midwifery practices are based on traditions or practice conventions rather than written guidelines or better still, evidence-based policies. Policies or guidelines based on the best available evidence are essential to ensure that each midwife is able to practise safely and confidently. While midwifery management is influenced by obedience and conformity our Victorian past will continue to deprive midwives of the ability to make decisions based on the available research evidence and prevent the professional status midwifery deserves within the health care system and the community.

Acknowledgements The first author of this paper was provided with financial assistance for her Ph.D. studies by the NSW Midwives Association and University of Western Sydney. This paper represents a section of her work.

References 1. Carr C, Schott A. Differences in evidence-based care in midwifery practice and education. J Nurs Scholarship 2002;34(2):153—8. 2. Homer C, Brodie P, Leap N. Establishing models of continuity of midwifery care in Australia. Sydney: Centre for Family Health & Midwifery, University Technology Sydney; 2000. 3. Newnman L. The midwife’s role: challenges and changes in the post-medical movement towards woman-centred midwifery care, vol. 14 (4). Australian College of Midwives Inc.; 2001. p. 12—5. 4. Parsons M. Policy or tradition: oral intake in labour. Aust J Midwifery 2001;14(3):6—12. 5. Parsons M. A midwifery practice dichotomy on oral intake in labour. Midwifery 2004;20(1):72—81. 6. Humphris D. Implementing research findings in practice. Nursing Standard 1997;11(33):49—56. 7. Cheek J, Gibson T. Policy matters: critical policy analysis and nursing. J Adv Nurs 1996;25(4):668—72. 8. Burgum M. Promoting EBP in midwifery. Aust Nurs J 1997;4(1): 22—4. 9. Chamberlain M. Factors affecting the acquisition of skills in midwifery students. Unpublished doctoral dissertation. United Kingdom: University of London; 1993. 10. Hayward RSA, Wilson MC, Tunis SR, Bass EB, Guyatt G. Users’ guides to the medical literature: VIII: how to use clinical practice guidelines: A. Are the recommendations valid? J Am Med Assoc 1995;274(7):570—4.

34 11. Rashidian A, Russell I. Towards better prescribing–—a model for implementing clinical guidelines in primary care organisations in the NHS. Clin Governance Int J 2003;8(1):26—32. 12. Currie SM. Aspects of the preparation of student midwives for autonomous practice. Midwifery 1999;15:283—92. 13. Stewart M. Whose evidence counts? An exploration of health professionals’ perceptions of evidence-based practice, focusing on the maternity services. Midwifery 2001;17: 279—88. 14. Etuk E. Professionals and accountability: what do they mean in midwifery practice? Practising Midwife 2001;4(7):28—30. 15. Mair J. An introduction to legal aspects of nursing practice. In: Daly J, Speedy S, Jackson D, editors. Contexts of nursing: an introduction. Sydney: Maclennan & Petty; 2000 . p. 117—34. 16. Giddens A. Sociology. Cambridge, UK: Polity Press; 1989. 17. Merton RK. Social theory and social structure. New York: Free Press; 1968. 18. Carpenter K. The subordination of nurses in health care: towards a social divisions approach. In: Riska E, Wegar K, editors. Gender, work and medicine. London: Sage; 1993. 19. Chamberlain M, The clinical education of student midwives.Robinson S, Thomson AM, editors. Midwives research and childbirth, vol. 4. London: Chapman & Hall; 1996. 20. Bosanquet A. ‘Stones can make people docile’: reflections of a student midwife on how the hospital environment makes ‘good girls’. MIDIRS Midwifery Digest 2002;12(3):301—5.

M. Parsons, R. Griffiths 21. Gray M, Smith L. The professional socialization of diploma of higher education in nursing students (Project 2000): a longitudinal qualitative study. J Adv Nurs 1999;29(3):639—47. 22. Mackay L. Nursing a problem. Milton Keynes: Open University Press; 1989. 23. Friedman M. Autonomy, social disruption, and women. In: Mackenzie C, Stoljar N, editors. Relational autonomy: feminist perspectives on autonomy, agency, and the social self. New York: Oxford University Press; 2000. p. 35—51. 24. Kirkham M. The culture of midwifery in the National Health Service in England. J Adv Nurs 1999;30:732—9. 25. Farrell GA. From tall poppies to squashed weeds: why don’t nurses pull together more? J Adv Nurs 2001;35(1):26—33. 26. Hastie C. Midwifery issues. Birth Issues 1999;8(3):91. 27. McKenna BG, Smith NA, Poole SJ, Coverdale JH. Horizontal violence: experiences of registered nurses in their first year of practice. J Adv Nurs 2003;42(1):90—6. 28. Downes D, Rock P. Understanding deviance. 4th ed. Oxford: Oxford University; 2003. 29. Roach-Auleu S. Deviance and social control. In: Jureidini R, Poole M, editors. Sociology: Australian connections. 3rd ed. Crows Nest: Allen & Unwin; 2003. p. 312—38. 30. Hutchinson SA. Responsible subversion: a study of rule-bending among nurses. Scholarly Inquiry Nurs Practice Int J 1990;4(1): 3—17. 31. Christmas J. Autonomy and personal history. Can J Philos 1991;21(1):1—24.