Chocolates mean nothing

Grumpy Midwife has been extraordinarily busy for the last three months; hence her silence. But she would like to take a few moments to share a recent Damascene conversion experience.

GM is of the generation that attended Sunday School and confirmation classes so she knows all about Saul travelling to Damascus in Syria (in more peaceful times, around 2000 years ago, give or take) and experiencing en route an event that so upset his life that he changed his name and stopped prosecuting Christians and starting preaching. According to an article in New Scientist (April 25, 2015), the bright light and thunderous noise (and temporary blindness) experienced by Saul/Paul may have been caused by a meteorite – which is really interesting but the means need not distract from the outcome.

No meteorites involved in Grumpy Midwife’s conversion – just a couple of conversations with a wise woman and a lightbulb moment so mundane (in retrospect) that it is almost embarrassing to devote calories or kilobytes to the sharing. But here goes.

Midwives must listen to women. And not just listen: midwives must embrace what women are saying. Which actually sounds terribly dated, doesn’t it? As dated as Changing Childbirth (1993) in fact.

As she types this, Grumpy Midwife can sense the protestations: “But we have Family and Friends! We have birth afterthoughts and birth reflections! And MSLCs and PAT and CQC and LWFs! And complaints and debriefs and cards and chocolates! Lots of chocolates!”

Okay, so we are asking (closed questions, tidy tick boxes) but we are only asking because we are told to do so, by Cameron, by the CQC, by our commissioners. And, yes, we do listen, but only to a select group of women – and (again) because we have to, because they have complained or we think they may complain. So we listen – but with arms folded and minds closed, composing our replies, defending our practice, limiting the damage.

Buying anything online nowadays – a book, a pair of knickers, a holiday – invites an onslaught of pop-up surveys, requests for feedback, suggestions to share the experience. Because sellers know that if we don’t like what we buy, or the experience of buying it, we will look elsewhere. Yet when it comes to having a baby (arguably an experience marginally more life-changing than a couple of cinema tickets), consumer engagement is an add-on, begrudgingly and half-heartedly requested, if we have time. Satisfaction and due gratitude are, arrogantly, assumed.

It’s as if the maternity services operate in a 50s time-warp, harking back to a generation of users grateful for the largess of a public health service. Amongst midwives there seems to linger the notion that we all work jolly hard and modern mums are jolly lucky, let me tell you, epidurals blah blah, nappies blah blah, in my day blah blah. Grumpy Midwife is aware that midwives are an ageing workforce but this is ridiculous. Get with it, ladies!

The context for GM’s personal conversion was a gentle debate over the involvement of lay reviewers in the auditing of statutory supervision of midwives. Many midwives (including GM pre-Damascus) are aggrieved by the concept of a lay reviewer listening to a handful of new mothers and then having the audacity to contribute to an official report on that service. Grumpy Midwife would like to charitably assume that this antipathy is reflective of a lack of understanding of the validity of qualitative research sampling techniques but, sadly, having witnessed the response of midwives (often very senior midwives) to proposals to engage with women, she knows this is not the case.

Chatting to new mums in Children’s Centres; setting up a Facebook page to gather opinions; shadowing women and partners through clinics; sitting on beds to listen to birth stories; asking mothers for feedback on their midwives for annual reviews. So simple, so cheap, so normal – but such suggestions are met in too many maternity units with apathy and arguments and (sometimes) downright antagonism.

Of what are we afraid? Releasing an unstoppable genie of ingratitude and discontent? Learning stuff about ourselves and our service we would rather not know? Opening the gate to complexity and change and real-life messiness?

Chocolates, incidentally, don’t mean a thing. Women give midwives chocolates for the same reason we tip mediocre service in restaurants; because we are nice, polite people, who want to be liked. And may make a return visit. Especially if there is nowhere else to go.

The B Word

Sadly and shamefully, allegations of bullying rumble intermittently throughout Grumpy Midwife’s workplace like distant thunder on an otherwise pleasant summer’s day. The fact that her particular corner of the maternity services is not unique in this experience and that bullying permeates the NHS (see, for example, NHS Staff Surveys and the Francis Report) is no comfort nor justification; GM is just terminally fed-up with comforting tearful juniors belittled in front of patients, care assistants alternately excluded and unappreciated, and doctors feeling bamboozled by bossy midwives.
A busy labour ward is possibly one of the most challenging places to work within the NHS: pace of work and interface with the public akin to A&E on a Saturday night, skills and technology to match that of HDU, inter-agency working reflective of an inner-city health centre, personalities that make the Bolshoi Ballet look boring. And senior labour ward midwives are necessarily a tough breed, juggling the demands of the services (limited beds, limited staff, limited time) with the needs of patents promised “choice” throughout childbirth. Back in the day, Grumpy Midwife tried to be tough, but wasn’t very good at it.
On the other hand, labour wards are also surely the happiest of places to work! Midwives are well-trained and motivated – and queuing up for jobs. Management is tight and professional supervision excellent. So what is the problem?
One of the most exciting, most innovative, most sensible papers on leadership Grumpy Midwife has read recently (and, believe me, she’s read a lot) is Followership in the NHS by Keith Grint and Clare Holt (available on The King’s Fund website). To cut 22 pages short, there are three types of problems: tame, wicked, and critical.
Tame problems have arisen before and are likely to do so again. They require a management solution; implementation of standard procedures and routine actions (although this is not to diminish the skill required); covering for unexpected staff sickness, for example, or getting the labour rooms cleaned quickly for women waiting for admission.
Wicked problems are more complex; they are deeply rooted in context, and there is no clear relationship between cause and effect. Wicked problems are often intractable; drug errors in spite of endless training, poor team working in spite of communications sessions, unhappiness at work in spite of (let’s be honest) fairly good pay. 
Critical problems are self-evident; fire, haemorrhage, collapse of mother or baby. Midwives are good at critical problems; the emergency bell goes and everybody runs and generally mills around shouting until the crisis is resolved. Critical problems require a command response from an decisive, authoritative figure. Senior midwives are judged by their command abilities and technical competence in a crisis. “Good in an emergency” is the ultimate accolade; “flakey” and “not robust” the ultimate put-downs.
Grumpy Midwife reckons that a busy labour ward probably has just one or two genuinely critical problems a day – and lots and lots of tame ones. She thinks therein lies the issue of bullying: such is our love affair with crisis that every problem is treated as critical and handled thus; brusquely, briskly, with little time for civility, compassion, or questioning of self or others. 
The result is a pervading sense of crisis, a nagging undertone of anxiety, vague unease – or downright misery if you’re one of the less “robust”. All rather exhausting. And unnecessary.