News Briefs: Midwifery/Obstetrical Issues and Practice

Bullying/Mean Girls in Practice and Life : A Message Worth Repeating

Bullying and incivility in midwifery, nursing, and obstetrical practice have been the subject of several articles in the past few years. In 2008, JCAH published a sentinel event alert requiring all hospitals with their accreditation to have a policy in place for the confidential reporting of bullying without fear of repercussions. The American Nurses Association has also recognized the profound impact of bullying within healthcare environments. While helpful, research, recommendations, and position statements have not significantly contributed to mitigating the problem, likely due to the persistence of unhealthy care cultures that have been allowed to persist, especially in hospital obstetrics units.2

Obstetrical care provided by midwives, obstetricians, and labor and delivery nurses is particularly demanding and associated with significant levels of stress. Working together compatibly in the care of mothers and infants involves more insight, courtesy, and collaboration among providers than many of them are willing to consider. Often, in the L&D environment, the individuals who work very hard for the safety and well-being of women and infants somehow refuse to treat one another with respect and dignity. This dynamic has come to be known as "bullying." the term encompasses physical and psychological abuse, harassment, mockery, exclusion, criticism, and negativity, among several negative behaviors.

According to a position statement by the American College of Nurse-Midwives in 2019, bullying is a problem among various groups of healthcare professionals, not just midwives and nurses.3 Bullying is described as deliberate, aggressive behavior done to harm, intimidate, or coerce another person. Under the umbrella of bullying, aggressive behavior can be verbal, such as name-calling, harmful rumors, and ridicule. It can be physical, as in situations where there is a refusal to assist, shoving or physical assault, or relational, as in social exclusion or undermining the authority of the victim to others. Incivility describes rude and discourteous behavior.4

The ACNM describes the victims of bullying as those with less experience or familiarity with the practice environment. Midwives themselves can be the bullies. It has been suggested that bullying behavior can be motivated by a provider's desire to improve the performance of a student or novice midwife; however, this tends to have the opposite effect, causing a novice to feel humiliated, undermined, and less willing to ask questions or request help.5. Naturally, these behaviors may also compromise patient safety.

The mean girls' phenomenon can not only affect patient care and provider well-being but also nurture an unhealthy culture of care, diminish supervisory support, and provoke conflicts among providers who should be operating as colleagues (e.g., midwives, nurses, and doctors). Non-respectful care can spread to the patient, and having to witness this in the workplace can negatively impact both work and personal life. In addition to a chaotic and disrespectful care culture, a significant and legitimate concern is the potential for legal repercussions. Consistently safe care will not thrive in angry and dysfunctional specialty units.

Unfortunately, the behaviors described above are predominantly exhibited by females. We're referring to female midwives, nurses, and physicians. The dynamic does not necessarily change according to the scope of practice. This type of environment creates a healthy amount of psychological stress. Managers may not step in to help in these miserable care cultures. As a provider, if there is no reasonable means of escape, the best you can do is to maintain your composure, exhibit calm and confidence, and refrain from reacting to negative behaviors.

Additionally, it may be wise to personally document unpleasant or abusive incidents, including the date, time, location, and individuals involved. It is not information that you will enter into the medical record. However, a log of unpleasant encounters or situations may be helpful if the situation ever becomes truly unbearable or dangerous and you are forced to leave.

I have written other articles about unhealthy care cultures and warned of potential legal implications. Hospital corporations will circle the wagons in the event of a legal notice to sue. While you are still employed at a hospital that has received legal notice, it is unlikely that you will be allowed to testify to any issues that may imply negligence or dangerous practice. It is easy to recognize that dysfunctional care cultures are the breeding grounds for malpractice. Having experienced an unpleasant workplace, you will have left, if feasible. If not, medical malpractice litigation in this type of environment will be relatively straightforward for plaintiffs' attorneys.

Mean Girls Phenomenon in Health Care and Ordinary Life

Having already experienced or witnessed bullying in medical practice, you may have the skills to deal with mean girl behaviors in your personal life more effectively. Due to the pervasiveness of the problem and its effect on the happiness and peace of ordinary citizens, I offer the following information on the issue:

The first essential skill for addressing this phenomenon is always to try to take the high road. It is tempting to confront mean behavior, but your best choice is to distance yourself, either delicately or firmly, whichever your peace of mind requires. In employment and life, learn to sustain yourself and build connections with people who lift you up. Retaliation with meanness is a waste of time. Your best choice may be to resign from work or, figuratively, run from the perpetrator(s). I agree that passive-aggressive personalities are the most difficult to deal with. They are subtle, but you know it when you feel it, e.g., subtle exclusion.

Bullies operate from a position of low self-esteem. Many adult mean girls possess a powerful, psychological need for validation. Their lack of self-esteem may be the result of practically anything, such as perceived decreased intellect, little formal education, lack of success, mental decline, or, generally, personality issues.

Regarding friend groups, remember that social exclusion isn't just for kids; adult mean girls can be hurtful to friends. Online communications can often amplify meanness because the mean girl is removed from face-to-face interactions, which may embolden her. When a friend's behavior shifts from being supportive to manipulative, subtle meanness, it's time to go.

Trust your instincts when something feels off. Aging can bring about an increase in vulnerability and a decrease in self-worth; for instance, seeking validation from others: "I'm not as dumb as I thought I was?"

Mockery is a form of bullying where teasing can cross the line. Mocking can be verbal or non-verbal. It includes sarcastic comments, thinly veiled insults, and comments about body parts. The intent is to put you down, insult you, or dismiss your ideas and opinions, which can cause insecurity, a need for control, a lack of empathy, or emotional immaturity. Mocking can provide a very good reason for ending a relationship immediately.

Mean behavior is in a class all its own; when a person intentionally says or does something to hurt another person, it is often driven by a desire to harm or put someone down. Jealous and mean behavior usually stems from insecurity and manifests as attempts to demean others. These efforts are deliberate and aim to cause harm or make someone feel bad. Finally, mental health issues can affect emotional regulation and contribute to mean behavior.

These insights may help you tolerate (or leave) an unhealthy work environment or avoid specific personal interactions. In the hospital and the world, communicate what behavior is unacceptable. Taking little jabs at you may validate that you are, indeed, being picked on.

Remember: everyone can exhibit rude behavior, but it does not necessarily mean that we excuse them.

The intention of a person who behaved meanly: if they didn't mean to hurt your feelings, they were being rude, not mean. If they were intending to hurt feelings, they are being mean. If they consistently mistreat the same person, that constitutes bullying behavior. Bullying is willful, repeated, and harmful. It isn't very nice and repeated over time.6

Once again, unhealthy cultures of care encourage inappropriate behaviors and stressed, unhappy providers. Stress in the workplace from a mean girl culture or mistreatment from disturbed care providers is closely associated with provider error and patient harm, leading to malpractice litigation. When interviewing for a job in healthcare, it may be essential to ask whether bullying has ever been a problem on the unit. You may experience gaslighting from hiring personnel but always ask for the institution's documents regarding their policies and procedures for addressing bullying, such as those from the JCAH, American College of Nurse-Midwives, American Nurses Association, ACOG, etc.

1. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/ July 22, 2015

2. The whole Culture of Nursing Needs to Change; A Descriptive Phenomenology of Nurses Being Bullied.

3. Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40. 2008 The Joint Commission Website.

4. American College of Nurse-Midwives Position Statement. Bullying and Incivility in Midwifery, March 2019.

5. Ibid.

6. Dawn R. White, Patrick Palmieri, Eric Hickey; Sage Journals/Qualitative Nursing Research.

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News Briefs: Midwifery/Obstetrical Issues and Practice

Responsible Documentation of Patient Care IV