Today, I am featuring a final project done by Tracy Cuneo on 4/26/2016 while she was a student at MCU, “The project was part of a qualitative research project for an Advanced Midwifery Studies class at Midwives College of Utah.”
Bullying in Midwifery:
An exploration of the power imbalance in the student/preceptor relationship
By Tracey Cuneo
Bullying from precepting midwives to student midwives is a problem globally. In the United States, it is a widespread problem affecting Certified Professional Midwives. This paper looks at the problem of power imbalances in the student preceptor relationship and the effects of bullying on student midwives physically, emotionally, and psychologically. It includes research conversations with student midwives, practicing midwives and national midwifery leaders. Lastly, it provides recommendations for changes to eliminate bullying in midwifery on the Certified Professional Midwife path.
Bullying in midwifery has become a wide spread problem in the United States in the Certified Professional Midwife model. While being under reported, bullying is clearly an issue that needs further action in the midwifery community.
Research occurring since 1996 struggles to define bullying in midwifery, and a true consensus on the definition has been yet to be made. The definitions describe intimidation; undervaluing of skills; humiliation; belittling of work; undervaluing effort; questioning of professional competence and excessive criticism. Case studies by Hadikin and O’Driscoll (2000) further illustrate the culture of bullying with midwives recalling occasions when they had been, “undermined, belittled, controlled, victimized, had work devalued and been passed over for promotion” (Gillen, Sinclair, & Kerhohan, 2008). While workplace bullying definitions apply to midwifery, there are distinctly unique problems in the midwifery model and there is an obvious need for a well-rounded, universal definition.
A good definition of bullying at work is provided by author and psychologist Gary Namie:
Bullying is repeated, health harming mistreatment of a person by one or more workers that takes the form of verbal abuse; conduct or behaviors that are threatening, intimidating, or humiliating; sabotage that prevents work from getting done; or some combination of the three. It is psychological violence—sublethal and nonphysical—a mix of verbal and strategic assaults to prevent the target (the victim) from performing work well (Namie, 2009).
Bullying in the workforce has been a significant global subject of research, discussion, education, and policy-making over the last twenty years. It’s gained more attention in the last ten years as bullying awareness campaigns have gathered momentum in the school atmosphere (Namie, 2011). Currently, there are no U.S. laws against workplace bullying but groups are beginning to lobby for legislation in many states (Namie, 2009). Many corporations have begun to design anti-bullying policies and grievance policies for employees dealing with bullying issues.
Bullying has a high price tag at the level of the individual and to the institution in which it occurs. Bullying affects worker’s health and productivity (Liddle, 2015; Stagg, Sheridan, Jones, & Speroni, 2013; Stutzer, 2014). The financial consequences of bullying behaviors manifest in a loss of profit for companies, high turnover rates, and employee burn out (Stagg et al., 2013).
In the nursing profession, in the United States, bullying is recognized as a significant problem, with anti-bullying education and task forces creating resources for both bullies and victims (Australian Nursing Federation, 2011; Craine et al., 2015; Nurse Uncut, 2014).
In midwifery, bullying is a pervasive problem that many students, new practicing midwives, and experienced midwives are familiar with (Farrell, 2006; Gillen, Sinclair, & Kernohan, 2009). In a recent survey of 119 student and practicing midwives in the United States, primarily Certified Professional Midwives, over 90% of respondents said they experienced bullying by another midwife.
Bullying can occur from preceptor to student or in the form of a group to an individual. “Another form of bullying in the workplace is known as ‘horizontal violence’ or ‘oppressed group behavior’ where there is bullying and aggression by an individual or by group members towards another individual or group of members within a larger group. There is evidence to show that student midwives routinely experience this during placements” (Curtis, Bowen, & Reed, 2007).
The Bullying in Midwifery Survey was an anonymous national survey that students and practicing midwives responded to in February of 2016. The project was part of a qualitative research project for an Advanced Midwifery Studies class at Midwives College of Utah. The survey consisted of 26 open response questions that 62 students and 57 practicing midwives responded to. Additionally, the research project involved interviews with national midwifery leaders and educators. Interviews were held with Marinah Farrell, President of the Midwives Alliance of North America (MANA), Treesa Mc Lean, Director of Public Affairs (MANA), Ellie Daniels, President of National Association of Certified Professional Midwives (NACPM), Kristi Ridd-Young, Vice President of the Midwifery Education Accreditation Council (MEAC) and President of Midwives College of Utah, and Sarah Carter, Clinical Dean at Midwives College of Utah.
Participants of the Bullying in Midwifery survey identified bullying behaviors they experienced as verbal assault, physical assault, behaviors with others, acts of power/abuse of authority, acts of non-support, and unclear/changing expectations. Respondents reported verbal attacks as being the most common, with name calling, threats, and verbal abuse. Physical assault consisted of being slapped, hit, or pushed; having objects thrown at them, or being forced to submit to internal exams and venipuncture.
Responses that were common to behaviors with others consisted of embarrassing or bullying behavior that was done in front of clients or other student midwives. The most common responses were gossip, rumors, negative comments about the student, and being black listed from midwifery groups/associations. Participants responded about acts of power and abuse of authority writing they were required to do non midwifery related things (childcare, clean preceptor’s home, wash preceptor’s personal laundry, personal shopping, clean her yard, etc.); manipulation; and a refusal to sign off on births or skills after performed that, “paperwork was held as hostage.” Intimidation and being denied clinical experience as punishment for personal disagreement was prominent.
Another common response was feeling that preceptors ignored personal boundaries and the student’s personal life. One participant reported that her preceptor, “Told me how to run my house, how to discipline my children, insisted on what birth control I use and what extracurricular activities my children could do— I was not allowed to move ahead unless I complied.”
Participants listed acts of non-support as being significant factors. “I was told if this bothers you or makes you cry, you should just give up now, because you can’t handle midwifery!” This included unclear expectations to move ahead and avoiding set times for evaluations. Some reported preceptors demanding money for sign offs that was not previously agreed to and one participant recalled her preceptor demanding $6,000 at the time of sign offs for births. Participants felt forced to choose midwifery over family emergencies/sick children. Several reported being told, “You must abandon family to be a real midwife!” and, “You don’t want it enough!” Discrimination due to religious beliefs, age, or motherhood status was also reported by participants.
The final category for multiple responses was unclear/changing expectations. This involved poor communications or no communication of what the preceptor wanted done to reach needed benchmarks on the CPM path.
One large difference in the Certified Professional Midwife route of training compared to the Certified Nurse midwifery route is that it requires students to spend two to four years in a daily apprenticeship, working for free or very little pay, with experienced midwives in exchange to learn essential skills, gain experience, and receive skills sign offs. Often the power imbalance in these relationships along with the limited accountability and oversight of preceptors makes these relationships vulnerable (Wiley, 2013). Additionally, the student’s collective financial burden (paying for tuition, expenses incurred with apprenticeship, and inability to maintain other full time employment), along with the limited selection of preceptors in some areas, and the private nature of the CPM work in homes and birth centers, can make the situation ripe for abuses of authority.
An expectation of bullying came up repeatedly in the survey. “This is just what midwives do to each other!” Several others shared the response of, “I just put my head down and tried to get through it.” It was a prevalent belief among students that some bullying behaviors would occur. Marinah Farrell, President of MANA, responded to this idea of cultural acceptance of bulling in midwifery, “We need to eliminate the student expectation that bullying will occur. The bullying culture needs to be unacceptable.” Even though this may have been acceptable practice in the past, eliminating bullying is essential for a healthy midwifery work force.
While hospital midwives do report bullying behaviors, the Bulling in Midwifery Survey of 2016 made it evident that these abuses are under-reported and rampant in the CPM community, with 97 of the 119 saying it was a, “huge, significant problem, happening often.” Student midwives are unlikely to report incidents of bullying, the survey found, due to fear of losing the clinical position or being shunned professionally in their community (Wiley, 2013).
National midwifery leaders who were interviewed responded with personal stories of how they were bullied, with one accounting a story about her preceptor who always demanded they do four-handed catches, and another responding that her local birth community became angry when she published an article about bullying in midwifery. Their stories were similar to what students report. “I wasn’t nurtured,” one leader said.
As to why they think this problem still exists today, Ellie Daniels, NACPM president explained, “Oppressed people oppress others around them. As midwives, we have been oppressed by the medical society around us, and we take that out by oppressing our students.” She continued to say, “As midwifery becomes less marginalized this issue will go away.”
Over time the move to professionalize midwifery will distinctly change with midwives feeling less oppressed by the medical community. It is doubtful though that those who choose to use their power and authority negatively in the preceptor relationship will recognize the disparity and change how they speak and interact with their students by their own initiative. Preceptors have no authority they must answer to, and they are left to formulate “how” they want their apprenticeships to go. While NARM supports the autonomy of preceptors, this privilege can, at times, lead to a crippling abuse of the student.
Another leader stated, “It’s the old-school mentality that says ‘this was hard for me and you will just have to suck it up and get through it.’ When the old-school finally retires, we will have a new generation of midwives who remember how unfairly they were treated and will not repeat these abuses.” Or will they? Our survey asked, “As a preceptor, do you ever find yourself justifying a behavior because, ‘that’s what was done to me?’” We found the overwhelming majority (74) felt that they would not repeat this behavior as a preceptor. Many stated that they actively evaluate their own behavior as a preceptor so as to not repeat the abusive behavior. One responded that she would not take students or ever precept because of what she had experienced, and two respondents replied that they felt their past negative experiences as a student made them “lenient” and “a pushover” as a preceptor, now.
Six participants did say they felt justification in their behavior as a preceptor, even though their experience as a student was negative, because, “that was done to me.” Marinah Farrell, president of MANA, said, “Trauma affects us all. Those who bully are usually those who have been traumatized and have not processed that trauma. Instead they return it to others.” The individuals who were subjected to the greatest amounts of abuse must take time after their student experience to heal from the ordeal and process their pain, lest they go on to become callous to the experience and later pass on those same behaviors to their students in the future.
Sarah Carter, Clinical Dean at Midwives College of Utah brought in another perspective. “Preceptors are dealing with their own problems. Maybe they have relationship or marriage stresses. Maybe they are dealing with practice stress and poor relationships with the medical community or other midwives. They have not had any training in how to be a preceptor and how to successfully teach a young student. They are dealing with a ton of stress and it comes out on their students.” Busy preceptors have very little available time to spend on additional training and meetings, and yet the need for support in their unique role is crucial.
Preceptors need training in how to precept. The North American Registry for Midwives (NARM), the certifying body for Certified Professional Midwives, does not require any specific training on how to precept a student. MEAC schools also do not require preceptor training and Sarah Carter expressed that it might further deplete the already limited pool of preceptors if mandatory training was required.
Can we expect preceptors to just know how to be good preceptors? If bullying is occurring at such a high degree, how will new midwives know how to be excellent preceptors later when they have no true model to recall? “By actively addressing this problem as a profession, we have the opportunity to stop this destructive cycle,” said Nicole Croft, Academic Dean at Midwives College of Utah. Organizations like the Association of Midwifery Educators (AME) are working to change this, but with no absolute requirement for preceptor training, it’s unclear if busy midwives will take the time to attend these trainings.
Several participants in the Bullying in Midwifery survey denied they were bullied, yet went on to describe bullying behaviors that occurred to them. These responses matched what has been found in previous studies on the effects of bullying in midwifery (Gillen, Sinclair, Kerhohan, 2008). One young midwife even became so enraged by the survey link for the Bullying in Midwifery survey being posted on social media she responded with, “What about the students who bully preceptors? This survey is a form of abuse and bullying!” Another very experienced midwife posted, “If you can’t deal with bullying midwives, then there’s no way you will be able to handle doctors! Stop being such wimps!” These statements serve as great examples of how women, who have internalized trauma within the profession, continue to perpetuate it.
When asked what training preceptors receive, most midwifery leaders recognized the lack of programs in this area. AME is trying to tackle this issue head on with training videos, webinars, and resources for preceptors. Accredited schools have taken multiple directions to try and entice preceptors to attend these trainings. Many have offered CEUs, free classes at their schools, and even rewarded preceptors financially but are still finding a very high rate of non-compliance by preceptors. “We just can’t force them to do it,” Sarah Carter remarked. Preceptors receive tangible assets by having students involved in their work; especially advanced students as they negate the need to pay a birth assistant fee, and the advanced student attracts clients to the practice. It seems unlikely that the greater majority of practicing midwives who choose to take on a precepting role would no longer take this position if they had training requirements
Preceptors must be recognized and valued for the skill they bring to training future midwives. Treesa Mclean, CPM and MANA board member, who has been a preceptor for four different midwifery schools, said that preceptors, in a large part, feel undervalued for their part in teaching. She reported that schools have very few, if any, optional trainings available and that personal connection and oversight with each school was very limited. Since MEAC views these preceptors as field faculty, training these preceptors on how to precept should be expected.
The Effects of Bullying
Previous research on bullying in midwifery (Clews, 2009; Gillen et al., 2008; Gillen et al., 2009), and the experiences of participants in the 2016 survey found almost identical health and emotional outcomes resulting from experiencing bullying behaviors. Targets are more likely to have nausea, digestive issues, panic attacks, crying spells, depression, and suicidal thoughts (Namie, 2015). The Bullying in Midwifery survey found participants having physical symptoms of sleep problems, nausea, adrenal stress, weight gain, heart palpitations, migraines/headaches, high blood pressure, miscarriage, low back/neck pain, menstrual periods altered or stopped, excessive crying, and panic attacks. Emotional symptoms included depression, feelings of excessive stress and worry, feelings of self-doubt, lack of confidence, disillusionment, disappointment, and embarrassment.
This left students feeling afraid to practice, having an inability to trust anyone, and with feelings of being worthless, inferior, “beaten down,” or a failure. Many responses included feelings of intense anger/hatred; feelings of isolation (i.e. trying to avoid preceptor, isolated from midwifery community); that the behaviors brought up feelings of past abuse (childhood/marriage); feelings of lack of control/desperation to finish/worry, and feeling of confusion and emotional numbness. Suicidal thoughts were recorded by several participants in the survey.
Family life was greatly impacted because of bullying with many (49 participants) responding their relationship with their husband or primary partner and children suffering. The greatest response was a changed sex life and that primary relationships were “put into survival mode.” Many women reported seeking professional counseling during their apprenticeships because of bullying victim experiences. Six participants wrote that their primary relationship was destroyed because of the bullying they were dealing with.
Many targets of bullying feel driven to leave their jobs (Green & Baird, 2009; Stagg & Sheridan, 2010; Stutzer, 2014; ). Along with the physical, emotional, psychological and social effects of bullying, targets often have felt an overwhelming desire to quit midwifery school or leave the profession as a new midwife because of the bullying they received (Gillen et al., 2009). The response in our survey was quite the same, with 45 participants responding that they considered quitting, nine of the participants quitting, and four returning a year or two later.
Bullying impacts the kind of care midwives offer their clients. Many students responded that clients witnessed the bullying behaviors and that senior midwives often corrected and belittled them in front of clients. Several described being blamed for the senior midwives mistakes. One even noted that she was told to lie to clients and was denied clinical experience if she refused. Students reported clients asking questions, clients being confused about the perceived tensions and feeling, “uncomfortable with how she treats you.” Many students recounted preceptors being angered when clients asked for the student’s phone number or arguing about minor issues in front of the client. One student told of her preceptor regularly yelling at her in client’s driveways before clinical visits while another reported being hit at a birth by an enraged preceptor. Clearly, pregnant women are noticing how students are being treated. Bullying not only impacts the student, but it affects the level of care the pregnant woman and her family receives, and also may cause women to have distrust in their care providers.
What can we do to diminish bullying? The Royal College of Midwifery in the U.K., and the Australian College of Midwives in Australia, has done extensive research in this area and has successfully put programs into place. Research points to naming the problem, educating and creating awareness about what bullying is, adopting anti-bullying policies and resources, offering support for the target, and training for the bully are essential first steps to eliminating bullying in midwifery (Clews, 2009; Craine et al., 2015; Farrell, 2007; Nurse Uncut, 2014; Gillen et al., 2008; Stagg et al., 2010; Stagg et al., 2013).
The U.K. successfully created a bullying tool kit which is available online to help both students dealing with bullying and midwives accused of bullying (Royal College of Midwives, 2014). In the U.K., written anti-bullying policies were adopted, but the real effectiveness was found with staff training (Georgiou, 2007).
In Australia, they have taken it a step further with adopting laws that make it illegal to participate in workplace bullying, along with national midwifery organizations taking an anti-bullying stance (Australian Nursing Federation, 2011). Australian nurses reported a larger impact by attending trainings that raised awareness about bullying (Nurse Uncut, 2014).
In the U.S., the nursing profession has created the Stop Bullying Toolkit (Pacers Committee, 2015; Nurse Uncut, 2014) and some professional direction from the Center for Disease Control (Craine et al., 2015). When U.S. midwifery leaders were asked what could be done to diminish bullying in the preceptor/student relationship, Ellie Daniels responded, “Students need to look for another opportunity. They need a guide to help them find good preceptors….and they need to complain to their schools when they experience bullying.” The majority of participants in the survey did not report their bullying incidents to their schools for fear of losing the only perceived opportunity for clinical work in their area. While leaders would like to be made more aware of these incidents there lacks an anonymous way for the student to make a report and get the help she most needs. Schools need to create safe avenues for students to get professional assessment and counsel if they feel they might be in a bullying situation.
A majority of participants in the survey did not report abusive behaviors to their schools or midwifery program but did discuss it with someone in their birth community. “Students are afraid of losing their only perceived option for a preceptor,” stated Sarah Carter. Kristi Ridd Young, MEAC Vice President described students’ vulnerability by saying, “So many people think that by entering a MEAC school you will avoid this issue, but the truth is, it still continues.”
Participants commented that fear of being black-balled in their birth community, of not being believed, and of just making the experience worse for themselves by speaking out were not unfounded. Thirty-nine participants reported that discussing the issue with their preceptor resulted in continued or worsening negative behavior, punishment, termination, or they received no sign-offs. However, for some, this did improve the apprenticeship.
Student midwives were asked if they tried to approach their preceptors about problems in the relationship, and many (46 participants) replied they did but were met with resistance and were mocked. “She said she is, ‘in the club, and if I would like to get in too I must comply and not complain or she will just drop me,” wrote one student. Thirty-seven reported they did not discuss the issues with their preceptor, with many who did attempt to discuss the issues reporting that it, “just made things worse”.
Ridd-Young told of how the Midwives College of Utah, has a grievance policy for students and preceptors. She stated that many students do not realize that preceptors are field faculty, and it is the responsibility of the College to respond to acts of bullying. In nine years, there have been two formal complaints filed at MCU involving preceptors. Informally, there are about “two to three a semester” that want to talk to administrators about their preceptor issues. We know from our survey that bullying is occurring at far greater numbers, but students are not coming forward.
The cycle of abuse in a bullying relationship disempowers the student to feel she has no voice, generates fear, and much like domestic abuse creates a sense of low self-worth that makes the woman feel she deserves the treatment on some level. The bullied student just feels if she can just endure it, then she can move on. Even students who recognize the repeated behavior as harming, find themselves paralyzed about how to change the situation.
Students who reached out to their schools did not find the support or advocacy they needed, with only a few stating they received support and listening from their school administrators. Students were met with a, “That’s just the way they are, put your head down and get through it!” response by faculty. Or, “Don’t tell me anything else or I may have to disqualify her!” Only six received communications skills or classes, three received counseling, and two were offered a book with coping techniques. Two did report having mediation. Many reported personally paying for professional counseling. One student midwife reported that she was told, in writing, from NARM, that they would, “always take the side of the experienced preceptor.” Another recalled NARM’s response, “They responded by saying it is up to the preceptor to define her/my role in the apprenticeship, and they will not get involved.” Many noted, that while NARM acknowledged their complaint, they offered no investigation or accountability.
Some PEP students had stories of years of work for one preceptor with no sign offs of skills and no available recourse when contacting NARM. Preceptors who choose not to follow through with their promised agreement have no consequences if they forgo their verbal or written contracts. One student wrote, “When I contacted NARM, they told me, in writing, that it is up to the preceptor to define the relationship. ‘We always take the side of the preceptor’.”
The power imbalance continues to exist even when the student pleas for intervention, often silencing the target for speaking out. This furthers the cycle of abuse and bullying. While there is a grievance policy in place with NARM, it appears to be met with resistance when students ask for help. Accountability for preceptors must take priority and rejecting of statements like, “We will always take the side of the preceptor,” must be discouraged. Accountability of preceptors must be a high priority.
The effect of bullying lasts long after the apprenticeship is over. One participant in practice wrote, “It made me wonder if I was even worthy of becoming a midwife. It caused me to doubt myself on every level of ability as she went from saying I was great to saying the most horrific things to me that no person has ever said to me. It takes a toll on your confidence, and it takes a while to recover from that.” While the close working relationship between an apprentice and a midwife can create a lifelong sisterly bond, it’s clear that student midwives carry, for years, their preceptor’s voice in their head, and often struggle to silence the negative aspects.
Certified Professional Midwives need to adopt a standardized definition of what bullying is. “Bullying diminishes another person’s needs, concerns, or contributions. Bullying is behavior that is repetitive and creates communication gaps. Bullying involves escalation, power disparity, and attributed intent” (AACN, 2016). Bullying is not legitimate performance feedback, holding a student to a workplace standard, demonstration of necessary control and authority, or a disagreement/difference in style between a student and preceptor (Lieber, 2012). Bullying is not two powerful women just not getting long (Farrell, 2006); its repeated destructive behavior.
The nature of homebirth is that most of the work is done in private. The tradition of apprenticeship is an essential element to learning not only the skill but the art of midwifery. Apprenticeships must evolve with professionalism, integrity, education, and high standards of practice. Preceptors ask for long commitments from their students, often lasting multiple years, along with most students sacrificing an income during those years and financing midwifery school tuition. Students are desperate to finish and preceptors rely heavily on their unpaid assistance. The lack of accountability for preceptors has created a power imbalance in the apprenticeship model that is ripe for abuse and exploitation.
As Certified Professional Midwives are overcoming obstacles and becoming professional peers in the maternal health care system, we must be honest and comprehensive in examining our training techniques. Abuses of power and authority are causing students, and new midwives, to leave the profession, thus reducing options for safe childbearing in many communities. The physical and emotional effects of bullying are not short-lived and do not cease when the student graduates; it impairs how these midwives later practice. It destroys their self-confidence and greatly affects personal relationships, leading to high burnout rates and midwives leaving the profession.
Midwives have created a survivor mentality; a false belief that, “if you want it enough, you will sacrifice everything or endure anything.” I would challenge that this surviving does not make better midwives; it just creates an impaired, fractionalized, damaged group. If we truly care about empowering women we will also care enough to look at the dysfunctional side of midwifery: bullying in apprenticeships and take steps to create a healthier, balanced process.
Based on what is identified as best practices in the literature and the experiences of students, midwives, and midwifery leaders, I am offering the following recommendations for CPMs to begin to address and end bullying in midwifery.
- Midwifery organizations need to name the behavior and adopt anti-bullying statements
- MEAC-accredited schools should adopt anti-bullying statements
- MEAC-accredited schools should develop a course of action for student and preceptor education (classes and/or webinars to raise awareness and help find solutions), complaints (ways for students to report without fear of losing placement), support, counseling, and resources that comprehensively address and mitigate bullying
- All preceptors need training. This can be in the form of webinars, classes, workshops, or forums. Preceptors should be trained in teaching techniques and have verbal check-in points with staff, preferably a mentoring, experienced teacher who will give individual oversight and written and verbal feedback to the preceptor
- NARM, as the professional certifying organization, needs to offer a clear, legitimate way for students to report bullying behaviors and offer clearly defined contracts that all preceptors sign
About the author:
Tracy has twelve children, and has been married for 26+ years. She had her first ten babies in hospital, and her last two babies were born at home using midwifery care. After having attended over 100 births as a doula, she began pursing midwifery. She enrolled at the Midwives College of Utah in 2012 and received a Bachelor of Science in Midwifery after four years of dedicated didactic and clinical work. She graduated in May of 2016, and holds the title of Certified Professional midwife with a Bachelor of Science in Midwifery. She is offering midwifery services in the Metro Atlanta, Georgia area. Her website can be accessed here.
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