From MIDWIFERY MATTERS, Issue No.110, Autumn 2006
Over the last twenty-three years I have worked as a midwife in a variety of capacities; the last ten of these have been spent lecturing and researching in universities. For quite some time, my quest has been to gain understanding of the reasons why I myself and others are so obedient. Why do I adjust my dress to fit in with the group? Why, sometimes, will I not argue a position when certain others disagree. My quest for understanding begins with the following story.
Several years ago I was working on night duty on the delivery suite of a maternity
hospital. One particular night I was given an appealing and fearful fourteen-year-old
girl to look after. Her antenatal history was unproblematic; scan reports, observations
and blood reports were all within normal range. The fetus was of normal size,
lying in a right occipital anterior position and had a well-engaged head. The
fetal heart was satisfactory. In essence, this labour could not have been less
complicated. Contractions began spontaneously and progressed as would be expected.
My concern related to this woman's psychosocial care. This young girl expressed
a need for emotional support from both her mother and boyfriend, and I was more
than happy for the four of us to share this special night together. At the morning
shift change, an assertive sister entered the room and imposed the policy of
one visitor and asked the girl's mother to leave. The family gracefully accepted
this instruction and relocated to the waiting room. A short while later a healthy
baby girl was delivered. This was a positive outcome.
Nevertheless, I remained troubled....
You may well ask why I failed to fight for a grandmother to witness her granddaughter's birth. After all, she was going to be the main carer of this new family member. This incident preyed on my mind and motivated me to undertake the gargantuan task of undertaking a doctoral research project looking into the magnitude of influence a senior person can have upon decisions of juniors. I wanted to focus on decisions that are within the midwife's remit, that pertain to normal midwifery and which, according to social policy documents, (DoH, 1993; DoH, 2003; DoH, 2004) should in fact be the choice of the childbearing woman. Accordingly, an investigation was carried out to ascertain midwives' willingness to acquiesce with instructions from superiors that contravene their own established views of best practice.
Obedience and Conformity
The two particular aspects of social influence analysed in this study were obedience
and conformity. Conformity, in particular, has a very broad meaning, and refers
to the behaviour of a person who goes along with their peers, people of their
own status, who have no social right to direct behaviour (Milgram, 1974). Obedience
has a narrower application. Its scope is restricted to the action of a person
who complies with authority (Milgram, 1963, 1965, 1974). Consider a recruit
who enters midwifery service. She/he scrupulously carries out orders from superiors
- this is obedience, while at the same time she/he adopts the habits, routines
and language of peers - this is conformity.
Obedience and conformity both indicate abdication of initiative to an external
source.
Many experiments have found that the tendency to comply can be very strong (e.g.
Asch, 1951, 1952, 1955, 1956; Bickman, 1974; Pendry and Carrick, 2001). Acquiescence
with a prevailing group belief or behaviour may be determined by a number of
factors, for example, informational social influence, or the desire to know
what is right. Individuals may look to others to determine how to behave in
circumstances that are new or alien, or in some way ambiguous, or in times of
crisis, or when they feel another person has more expertise (Bickman, 1974;
Deutsch and Gerard, 1955; Pendry and Carrick, 2001).
Research on Obedience
Research on obedience to authority has been confined to the study of the direct
and immediate power relationship between the person in authority who is in charge
and the individual who carries out his or her requests. In the classic Milgram
studies, an experimenter in the role of teacher, successfully ordered 65% of
participants to administer electric shocks to an undeserving person. This parallels
the situation in many natural field settings, such as a hospital where a physician
may order a nurse to give 'unauthorised' medication to a patient (Hofling et
al, 1966) or a factory where a supervisor orders a subordinate to pass a defective
product (Kilham and Mann, 1974).
Obedience experiments highlight superordinate-subordinate relationships in which
people become agents of a legitimate authority to whom they relinquish responsibility
for their actions. Once they have done so, their actions are no longer guided
by their own values but by the desire to fulfill authority's wishes. Studying
obedience to authority is a complex issue since legitimacy, as defined by rules,
may come into conflict with a practitioner's view of what is or is not morally
appropriate. This makes obedience and its relationship to clinical decision-making
in midwifery an issue worthy of discussion.
Contradictions in Maternity Care
The rhetoric of 'woman-centred care', with its emphasis on giving women choice,
and requiring their informed consent before undertaking treatment, is at the
core of Changing Childbirth (DoH, 1993) and is spelled out in the Reference
Guide to Consent for Examination or Treatment (DoH, 2003). However, it is difficult
to translate such rhetoric into action when working within a hierarchy that
appoints people to positions of authority. Those in authority have the power
to redefine norms and objectives (see House and Shamir, 1993) and these may
conflict with what a woman wants from her birth experience. Obedience experiments
suggest that high status midwives (for instance ward sisters and managers) have
more power to influence obedience than junior midwives. This may have a profound
effect upon whether a woman is 'allowed' a waterbirth, a particular style of
pain relief, adoption of alternative positions in labour or, indeed, several
birth partners present at the birth. None of these 'choices' threaten maternal
or fetal outcome and therefore such options ought to be client led. However,
junior midwives may be presented with a moral conflict between a drive for obedience
to authority and their role as advocates for women. Obedience experiments show
that most people are likely to relinquish their cognitive and social moral competence
and thereby lose the capacity to decide in favour of 'the underdog'.
The route to this study was inseparable from my own biography. Much of my working
life has been spent as a midwife where I gradually became aware of authoritative/subordinate
relationships within the workplace. As a practitioner these were part of everyday
working life. Later, as a graduate in psychology, I began to see these practical
issues from a perspective influenced by social scientific literature. I asked
questions about my working life with the aid of this literature and posed critical
questions from the vantage point of my experience as a midwife. This process
was given a new significance when Changing Childbirth (DoH, 1993) provided clear
evidence that women's preferences were frequently frustrated by what I perceived
to be the same authority structures.
Method
I focused on how midwives responded to guidance from a lecturer in midwifery
(myself). I was particularly interested in how midwives would behave when I
attempted to influence them to respond to clinical decisions in a particular
way.
My research question was: "Are junior midwives' decisions socially influenced
by those who have higher status in the workplace?" The participants in
my study were all midwives.
I developed a 10-item self-report questionnaire, which I called the Social Influence
Scale for Midwifery (SIS-M). The 10 questions asked were:
(1) I believe that guidelines are unnecessary when labour is progressing normally.
(2) I would argue with the consultant if he refused to support a home confinement
when a mother with a healthy pregnancy is keen to have one.
(3) I would follow a senior member of staff's request to rupture a woman's membranes
if this was the decided course of action.
(4) I would administer oxytocin to a woman desiring a normal labour if it was
a requisite of the guidelines for routine labour.
(5) I believe that it is acceptable for a women to have more than one 'birth
partner' present during labour when the unit policy states only one person at
a time.
(6) I would automatically commence cardiotocography if it was requested by a
senior member of staff.
(7) In general I would challenge a senior member of staff if they decided to
override a decision I made regarding normal labour.
(8) I would conceal my opinion from a consultant obstetrician when my stance
about carrying out elective section for social reasons differs.
(9) I would allow a women to have her two friends and husband present during
labour and delivery if this is what she wanted.
(10) Informed choice for women is an idealised dream when the reality is that
we know what is best for women in labour.
The questionnaire uses a 5-point Likert scale based on level of agreement with
the question. The possible range of scores is 10-50 where a score of 10 is least
conformist and a score of 50 is most conformist, for example:
(9) I would allow a women to have her two friends and husband present during
labour and delivery if this is what she wanted.
Strongly Agree Neither Agree Disagree Strongly
Agree nor Disagree Disagree
1 2 3 4 5
The questionnaire was self completed by 209 midwives and returned in the post. Fifty of these midwives were then invited to participate in an interview in which I asked the same 10 questions again whilst making my preferred responses explicit.
Format of the Interviews
A case study was presented to the midwife before each question, for example,
question 9:
Karen Bell is a 21 year old primigravida at 40 weeks gestation and has arrived
at the delivery suite accompanied by her husband and two friends. Karen's husband
and two friends ask if they can stay in the room with her throughout her labour
and delivery. Karen agrees. The unit policy states one 'birth partner' at a
time. You are the midwife in charge of Karen's care.
I cited information intended to influence the midwife's responses in a conformist
direction. For example, I casually mentioned that research supports that one
good birth partner is often better than an unsure crowd. I pointed out that
too many people in the delivery room could be extremely distracting to both
the midwife and the childbearing woman. I suggested that there is a health and
safety component in that delivery rooms are small and that overcrowding may
inhibit Karen from adopting positions with associated indignities. Also, that
Karen is an average woman, one of the 95% who accepts the guidance offered by
professionals. I further emphasised that the policy of one birth partner is
designed to protect women from an unknown and overwhelming situation. The goal
was to make my preferred question responses explicit. In the above example,
I Strongly Disagreed with the question asked. Unequivocally, I would not allow
this woman to have her two friends and husband present during labour and delivery
for the aforementioned reasons (I must emphasise that this was not a reflection
of my true ideals).
A further postal questionnaire was sent to participants after the interview.
My intention was to test whether the physical presence of the senior midwife
during the interview was the key factor in promoting participants' acquiescent
responses.
The scores from the postal and two interview questionnaires were then compared.
Appropriate statistical analysis was conducted. Results showed that during the
interview midwives scored significantly higher on the measure of social influence.
That is, the interview succeeded in making responses more conformist. Much lower
scores were obtained in the two private postal measures, both of which differed
significantly from the interview (see Figure 1).
Fig 1: Mean scores in the pre-interview questionnaire (C1), interview (C2) and
post-interview questionnaire (C3) as a function of condition and midwife grade
The post interview questionnaire results show that the social influence manipulation
during the interview had no major lasting effect, which supports Milgram's (1974)
transient situational argument. A full report of these studies can be found
in Hollins Martin and Bull (2004, 2005, 2006), Hollins Martin, Bull and Martin
(2004).
Discussion
Clearly, these midwives were significantly influenced by what I had to say.
One possible explanation for this success was that they perceived the direction
I gave as requiring an obedient/conformist response.
As mentioned earlier, Milgram (1974) showed that an authority figure can produce
complete obedience in 65% of participants (Experiment 5, Milgram, 1974). In
comparison, a person of similar status achieved levels of obedience of only
20% (Experiment 13, Milgram, 1974). In fact, five participants took physical
action against an equal, which shows that people feel free to challenge those
of equal status. This attitude sharply contrasts with the respectful politeness
customarily shown to high status people.
Milgram's studies confirm that obedience occurs specifically in response to
authority. Action flows from the top of the hierarchy to the lower, with people
responsive to signals from a level above their own and not below. These midwives
clearly were influenced by my position and what I had to say.
Conclusion
This study shows that midwives are by and large influenced by senior people.
The levels of obedience shown are similar to that shown in laboratory experiments
(e.g. Milgram, 1974; Meeus and Raaijamakers, 1995; Shalala, 1974).
Needless to say, at times obedience and conformity are essential for effective
functioning of maternity hospitals. If not, women may fail to receive appropriate
management and treatment. Nevertheless, if a midwife acts on the principle that
a senior midwife can direct treatment and where this denies the childbearing
woman a safe option in care, she is violating her own standards of practice
(DoH, 1993; DoH, 2004; NMC, 2004).
My results highlight considerable differences between what midwives say they
will do in private and what actually happens when they are placed within a hierarchy
and exposed to social influence from a senior person. When face to face with
a senior midwife, most junior midwives comply with the recommendations that
are made. In some instances, the midwife simply abandons her principles. Instead
she acquires a radically different focus. Concern shifts from patient care to
a prudent consideration of how well she is living up to the expectations that
the senior person has of her.
If this is how midwives can react when faced with a midwifery lecturer, we can
only speculate over the magnitude of social influence that a consultant obstetrician
could have in similar circumstances.
A midwife who follows orders obediently even where this denies a childbearing
woman a safe option in care breaches rule 6 of the Midwives Rules and Standards
(NMC, 2004, p. 17). This rule states that the midwife:
o Must make sure the needs of the woman or baby are the primary focus of her
practice.
o Should work in partnership with the woman and her family.
o Should enable the woman to make decisions about her care based on individual
needs, by discussing matters fully with her.
The Midwife's Dilemma
The clear fact that hospital authority reinforces obedient/conformist behaviour
whilst simultaneously advocating woman-centred care, causes conflict for midwives.
The situation creates a contradiction between the midwife's concern to follow
Rule 6 of the Midwives Rules and Standards (NMC, 2004) and the pressure to follow
directions from a senior person. In essence, the midwife is a link in the hierarchical
chain of command which the organisation reinforces. Both senior and junior midwives
encounter constraints that vary within their localised authority structures.
One response to this finding is that midwifery officialdom should look squarely
and forthrightly at the midwife's dilemma. Those in charge must do for the midwife
what she cannot do for herself in terms of interpreting direction from authority.
Senior staff must incorporate the women-centred element into their direction.
They must unequivocally take responsibility for their dictates. Direction given
should incorporate the preferences of the childbearing woman it relates to,
so long as it does not present a serious threat to maternal or fetal mortality.
Clearly, the question arises as to how this may be done? The challenge is straightforward.
Direction that takes no account of the childbearing woman's preferences is a
daily occurrence. Prescriptions are written, supply requisitions are processed,
women are prepped for routine procedures that have not been discussed with them;
a significant number of procedures preclude the input of the childbearing woman.
If the senior midwife or obstetrician wants a task undertaken that excludes
the input of the woman, that person must have the character to tell the junior
midwife during the decision-making process that this is the case.
Such practice would have a number of effects. First, accountability would be
diffused rather than focused. Second, transfer of responsibility would become
futile since accountability for the decision rests with both the senior and
junior midwife. If the decision exempts the woman from process, the issuing
senior person should label it so, thus giving the junior midwife the facts before
obtaining her agreement. If the midwife then acquiesces, she too would also
clearly be accountable for the decision.
To ensure a fair hearing takes place, a schedule could be devised in which the
decision to be made is clearly identified and recorded, for example, Mrs X has
requested a home confinement. In this to-do list, the professionals involved
would be expected to record that they have provided the woman with evidence-based
information upon which to underpin an informed choice. Once this has been done,
the choice of the childbearing woman may be clearly written in black and white.
Any obstructions to the choice are then clearly outlined, such as cost implications,
lack of facilities or staff, risks to mother or fetus and so on. The actual
outcome decision is then unambiguously recorded. Lastly, all three parties sign
the schedule, that is, the childbearing woman, the junior midwife and the senior
member of staff. Without a doubt, such procedures would make it extremely difficult
for maternity care staff to ignore the woman's choice without providing significant
reasons for doing so. Clearer definition of roles would further reduce confusion
over the limits of midwives' responsibilities.
To dismantle the hierarchy and give midwives real accountability and effective
legal protection may also be a solution.
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Caroline J Hollins Martin RN RM BSc. MPhil,
Department of Nursing, Midwifery and Social Work, University of Manchester,
UK
*Address for correspondence: Caroline Hollins Martin, Room 528, Gateway House,
Piccadilly, Manchester; E-mail:
Caroline.Hollins-martin@manchester.ac.uk
Updated November 29, 2006 LW