Connection as a Lifeline

Celeste: 00:17
Welcome to the Nursing and Midwifery Health Program for Victoria's podcast series, where we will be diving into issues that impact the way nurses and midwives navigate today's changing world. I'm Celeste Pinney, a registered midwife and senior clinician at the Nursing and Midwifery Health Program Victoria and host of this podcast series. The Nursing and Midwifery Health Program is a support service which provides care and assistance to nurses, midwives, and students by experienced nurses and midwives. Our service provides a space where you can bring with you any sensitive health issue impacting your well-being. The program is voluntary and importantly, it is free to access, confidential, and independent. Joining me today is Registered Midwife Lynelle Moran, who is going to talk to us about some amazing research she is doing about professional connections and relationships and how they impact midwives' well-being and career sustainability. Welcome, Lynelle.

Lynelle: 01:13
Thanks so much, Celeste. Thanks so much for having me.

Celeste: 01:15
Great to have you here. Could you tell us a little bit first off about your role in the profession and where you're currently working? Yeah, sure.

Lynelle: 01:23
So as a midwife, I've worked across multiple sort of models of care and various services in both clinical and research capacities. Most recently I was working at Joan Kerner Women's and Children's in the publicly funded hospital and home birth program, Midwifery Continuity of Care program. So that was a phenomenal career highlight, really. And then more recently, I've become a midwifery lecturer at ACU in NAM Melbourne, where I now work to support students on their journey towards midwifery. So feel very honoured to be doing that. And I'm also undertaking my PhD in the topic that you just shared. Fantastic, thank you. So very passionate about midwifery advocacy for the profession and for midwives themselves.

Celeste: 02:15
Yeah, it really comes through. That's so great to hear. And we'll get into now just hearing a little bit more about your research because it is a very important topic. And apparently, according to the Midwifery Futures report, which was published last year, the midwifery profession is in somewhat of a crisis for several complex reasons. There isn't enough midwives currently working in coming into the profession to meet the community's future needs, which is a great concern. And we also know midwives have high rates of burnout and other mental health issues such as depression and anxiety. In the report, it lays out some practical solutions such as increasing the number of students, but doesn't focus as much on the importance of positive workplace cultures for the retention of midwives. And we know you have explored this in your research. Could you tell us a little bit about your research and what prompted you to explore this aspect of midwifery?

Lynelle: 03:11
Yeah, so I agree, Celeste, just stepping back to the Midwifery Futures report, it's really identified some very tangible and vital solutions to addressing the workforce issues and also encouraging or looking at ways for midwives to increase their EFT because we're looking at maximising the existing workforce as well as looking at the future provision and expansion of the workforce. But looking at the current workplace cultural issues is so important as well, and looking at what the drivers for midwives are to sustain currently, and that's something that I was experiencing myself or observing within the workforce when I was working clinically, I could see that there was a massive exodus from the workforce around me, from people who were leaving with wisdom and skills and experience, and it was just really concerning to me personally. I was also noticing that there was a real prevalence of isolation amongst midwives, and there was a yearning for connection in the workforce, but there was no capacity to connect with each other given the adversity and the pressures that the workforce and the midwives were experiencing within that. So I guess this is how I came to the topic myself. So in 2016 I was working in a busy tertiary service, and I was really seeing that exodus from amongst my colleagues, and I really wanted to stay. You know, I'd worked really hard to have a career change. I was deeply passionate about midway free, and I knew that I had a lot more to give to the profession, but I also was feeling isolated, so I was looking at ways that I could create those connections with my colleagues, and so I reached out via social media to see if other people were feeling the same way in terms of feeling isolated and disconnected, and through that I got a large response from the community and from midwives who were feeling the very same as me. So from that I established what is the Vajurnal Club, and so in 2016 I created this basically a midwifery community that was a place for midwives to come together in person to meet every four to six weeks and discuss emerging and current midwifery literature and research and look at ways that we could incorporate that into our midwifery care and into our advocacy. And initially that was the sort of idea around it, but the journal club became so much more like it became a place that midwives from all different models of practice, from private public settings, from education, from academia, all these different sort of dimensions of midwifery, midwives were coming together to connect and to help, you know, share stories, share experiences, look at really tangible ways we could find solutions and try and help to mobilize our community to create system change and identify ways that it could be better for us. So it really forge this community that unearthed a lot of protections within it, you know, and that wasn't the initial intention, but it just became this beautiful thing that's still going today, nine years on, and it's different. Every meeting of the Virginal Club is different in terms of who's there, but it just has continued to provide this strength to the community, and from that I just really wanted to understand that more deeply and to see if that translated to the midwifery profession more broadly, and so that's why I proposed this topic, and I wanted to look at really better understand whether how protective midwifery connections and relationships were to midwives, and what it revealed was the protections that exist when there is the presence of connection, but also the vulnerabilities that occur and present when there is the absence of connection and professional relationships. Well, that was a long-winded answer, Celeste. I hope I answered your question.

Celeste: 07:25
Yeah, absolutely. You know, so great to hear that you created that space for midwives to come together and give them that connection and experience of belonging, which sounds like has been really lacking for people. And hopefully that's helped midwives want to stay in the profession even longer. So a great introduction to your research and to hear about how that came about. One of the causational factors you found in your research that influences connection and professional relationship building is something called toxic tribalism and interprofessional othering. And a quote that you had in your research from one of the participants, which I found really illustrates this challenge. And what she said was midwives face, we have this stuff about like how we identify midwifery. And I think that's what separates us. It's only when we're not together that we start to think about each other differently. There's too much separation within midwifery, which means we lose power. Could you tell us a little bit more about toxic tribalism, Linnelle, and intra-professional othering and how that impacts midwives?

Lynelle: 08:28
So I should just say that in the research I looked at, I grouped the midwives I spoke with into three categories. And so the first category was early career midwives, those who've been practicing from zero to five years. Then there was mid-career, those who've practicing from five to ten, and those late career midwives who've been practicing for ten or more years. Because I was also interested in how the connections and relationships may influence across the different career points. I would say that this category of toxic tribalism and interprofessional othering was resonant across all of the cohorts who spoke frequently about the siloed nature of work teams and how they felt that this contributed to a divisive workplace culture with poor understanding and appreciation and respect for each other's roles. So this the actual term toxic tribalism was used by one of the participants who just said they thought that it was such a really destructive force within their experience of midwifery. So I guess going into it, I was anticipating that there would be a medical and midwifery dissonance that came through around professional work teams, but I didn't expect it to be so palpable intra-professionally. So this came out between midwives working in continuity models compared to those working in core models, private midwives talking about their relationship with hospital midwives. It talked about very pervasive amidst birth suite midwives and postnatal midwives. So every sort of work team that had become siloed expressed this dissonance. And they said that it really impacted, it was expressed in many different ways, like through exclusion, through bullying, through vexatious reporting, through the presence of clicks and othering behaviors, and it really impeded the delivery of care and the experiences of care and definitely impacted feelings of belonging and cohesiveness from the midwives. So it was really fascinating to me that this intraprofessional toxicity came through so palpably.

Celeste: 10:46
And when you were speaking to the people about their experiences, did they express how they felt? It came about how this interprofessional othering came about. You said it was, you know, the people working in a sort of silo type way. What did you make of why this is happening in midwifery?

Lynelle: 11:03
I think, and in so many of these categories that emerged, it was that they were allowed to manifest within the culture, the workplace culture. They were left unchallenged. And maybe that was because of the pressures that exist within midwifery leadership or maybe the lack of support within the team. But I mean, I think it was just unchallenged. And some of the other quotes you shared, that one which I which I love, that quote that you shared, but one of the other participants said there was a real sense of us and them between birthing and postnatal, and it just really felt like a fight most days. So these sort of battle, the language of battle was used so frequently in this research. And also another midwife said, there's the ward midwives, and then there's MGP. It was like, ah, okay, you're not one of us, you're one of them. And so people who moved from one model of care to the other immediately felt that change in their belonging or acceptance, or that they were no longer part of the team that they had once been part of. So these very sort of binary and borderlines that once you were crossed, you were treated differently. And that really impacted people's experience.

Celeste: 12:18
So, like a territorial kind of experience where people again, an us versus them mentality, we're working in this area, you're working in another area, so we're not as friendly or open, and there's somehow maybe people feeling threatened in a particular way.

Lynelle: 12:33
Mm-hmm.

Celeste: 12:34
Yeah, absolutely. Very interesting. We hear quite often from participants who use our service about their experience of being bullied, and it does seem to be quite common in the nursing and midwifery professions. And you mentioned that the midwives in your research had experienced that. Did you find out how common that was at all? Or perhaps it might not have been something that you specifically looked at?

Lynelle: 12:56
Yeah, I mean, I wasn't it not statistically, because this was a qualitative study, a grounded theory study. So just going deep, in-depth conversations with midwives, I mean, bullying was very prominent in the discussions, and it was certainly a thing that drove people to absenteeism. It drove participants to leave teams or to seek other um workplaces, and it took a detrimental toll on those um participants. One of the categories that emerged was entitled It Takes a Toll, and it spoke about, you know, people's feelings of dread, of fear, and you know, the psychological and physical symptoms and impacts that that bullying took on to their experience. And so you you you know, I spoke to participants who shared stories about, you know, they'd work a week on and a week off, and in their week off, they'd start to recover and normalize, you know, and regulate their nervous systems. And then the two days leading up to their return to shift, they'd start to experience, you know, their inability to sleep, their anxiety levels would heighten, they'd start to either get full body aches or nausea, you know, just so these really pervasive symptoms that were impacting them, and they'd just have absolute dread, you know, going back into their workplace.

Celeste: 14:23
We really can't underestimate the effects of bullying. It takes a huge toll, and it's quite a shame that it's happening, that it's still occurring in this day and age, despite the laws and the government trying to affect positive changes in this way.

Lynelle: 14:35
Yeah, and I think with, you know, there is certainly people I spoke to, and I'd like to come to this a bit later, about things that were, you know, the dynamics within teams that are effective and that promote cohesive and, you know, very positive workplace cultures, but unfortunately the majority I spoke to were those people that were talking about this perfect storm or imperfect storm of factors that allowed bullying cultures to exist and to thrive really. And that was really around, you know, support systems that were non-existent. And so even though those midwives escalated their concerns through the appropriate channels, there was a level of inaction or no response that was meaningful to help mitigate and manage those poor behaviors in the workplace.

Celeste: 15:26
And just looking at some other factors that impacted the midwives and their ability to form connections, you mentioned that lack of time, busyness, demands, and stress in your research all interfere with that ability to foster relationships. What did you discover in relation to that?

Lynelle: 15:41
Well, one of the categories that emerged was entitled Systems, Structures, Pressures and Processes Prevent Connection and Relationship Building. So in this category, again, participants across the three cohorts consistently spoke of deeply embedded ways of working that inhibited connection and relationship building within the work environment. But this was particularly prominent within the early career midwives, and they spoke of the system itself as a barrier. So they spoke of conditions that were exacerbated by unchallenged ways of working, that worked to restrict the formation of their critical relationships, and that those barriers evoke feelings of powerlessness and isolation. So here I'll just share one of the early career midwives said one of their quotes. So hard to just choose one quote because there is so much better that, you know, the stories that were shared were just so pertinent in support of these categories. But this one participant said, because of how the hospital is structured and how the rostering works, the relationships between midwives stay quite shallow. You can feel people wanting to connect, but there's no time for small talk or even a quick debrief. And then someone from the late career midwife said, Sometimes I feel like I'm just another cog in the wheel, just a slot on the roster. But I think if those professional relationships were strengthened, then midwives could be empowered to be midwives. And it's just true. I mean, I know you'd know it as well, Celeste, having, you know, anyone who's worked in the system knows that can feel and connect to those comments, I feel.

Celeste: 17:17
Yes, absolutely. And I think, you know, depending on where you work and in what capacity. For example, I've worked a lot casually as a midwife, and when you're moving around different places a lot and you're not always working with the same people, it is hard to form those bonds and connections on top of the demands of the time pressures and just generally a lot of stress. And when people are stressed, they're not always at their best, and it can be hard to relax into and have those nice connecting conversations. So there certainly is a lot of complexity in that space in terms of how it impacts connection.

Lynelle: 17:51
And another category was too much too soon. So what we're seeing so often with the early career midwife workforce is that they are being elevated out of systemic deficits, staffing deficits. They're being asked to step into positions of leadership without the appropriate support and modeling and skills and training to enact the leadership role. And so again, I'm talking about this imperfect storm where midwives who are in their early career are in leadership positions and managing teams in busy and complex work environments such as birth suite or post-natal ward with very complex demands. And it's really not setting up people for success in those roles when we're responding in a knee-jerk way to system and workforce deficits.

Celeste: 18:47
Were the midwives who went into those roles encouraged to apply for those roles? I guess it's different depending on each workplace, or did they feel ready to move into that type of role themselves? And then once they were in that role, did they feel that perhaps they moved into it a little prematurely? Maybe they needed more experience, perhaps it was all a bit too much?

Lynelle: 19:07
No, I think no, these were midwives who arrived on shift and there was an absence or someone a sick call, so they were position out of a deficit. And then it just becomes, you know, maybe they did well on that one night and they get asked to do it again, and it becomes learned, but not in a, you know, not in a strategic way that can probably prepare and skill that person. It's reactionary filling of gaps.

Celeste: 19:39
Yeah, just kind of shoved into the room, really out of necessity, but not really given the right support tool and the ropes in that role, so that they can feel adequate and like they're fulfilling the job, you know, in a way that they'd like to. Yeah, that's right. Very interesting. And were there any other findings that stood out to you in terms of the impact on midwives' ability to maintain professional relationships?

Lynelle: 19:59
Oh, absolutely. One of the positives was those the midwives who worked in smaller services really reported much better interprofessional and intra-professional relationships. So those working in smaller services had very expansive and meaningful relationships with their teammates. They spoke about there being time and space to connect, that they had a better understanding of the interconnectedness and vitality of cohesive teams. There was more role and respect for scope between midwives and obstetricians. And they enjoyed more support and positive workplace cultures. So I thought that was a really interesting emergence from the data. So one of the categories became size matters.

Celeste: 20:52
So the bigger the team, the more likelihood there was a lack of connection and perhaps a divisiveness and maybe not as much respect for each other. Yeah, absolutely. And was your research done Australia-wide?

Lynelle: 21:04
Yeah, it was I called for participants throughout Australia. So I did get good representation from models of care and geographical locations as well. But it wasn't specifically what I was looking for. So that was an unexpected emergence from the data.

Celeste: 21:21
I can remember myself as a student working at some very big facilities and feeling like a bit of a fish in a big sea. You don't feel like you get to know other people or see other people and you feel a little bit more anonymous. Whereas in a smaller service, you're running into people, you're building relationships, aren't you? So it anchors you more.

Lynelle: 21:37
But you know, other categories, things like, oh, where is this one? I just want to read this for you because it's so pertinent to your organization and the service. It is debriefing with someone who understands. So this was an important theme that came through in one of the categories, which wasn't about just debriefing itself, but debriefing with whom is the most important factor. So often the midwives were talking about the fact that they'd been referred to the employee assistance program, and they felt that that was a very unsatisfactory experience. So, you know, that basically debriefs were only offered if there was a catastrophic outcome or something that was quite in the extreme, that there was no or very limited opportunity for appropriate debriefing. And so that type of debriefing had to be sourced and self-initiated and sometimes at great cost to employees and to midwives. But when they were referred to the employee assistance program, they just felt that they didn't understand the professional nuanced context of midwifery, and so that it it was unsatisfactory or even unsafe or tokenistic. They described it as. Yeah. And Celeste, if I can just say thank you to the participants. So the people who signed on to be part of the research and And you know, also my supervisors who are just so phenomenal in their support and commitment to this topic. It's it's just an honor to do that. I feel like it has helped legitimise the conversation.

Celeste: 40:12
Sounds like lots of people have been involved in making this happen.

Lynelle: 40:15
Yeah.

Celeste: 40:16
Well, thank you so much for joining us today, Lynelle. It's been a pleasure and a really amazing discussion, and we really hope that going forward you continue to do good work. For any nurse or midwife in need of support, after today's conversation, you can reach us on 9415-7551. Thank you so much for listening in.

Lynelle: 40:35
Thank you so much.