Dying for the Cause

Also by Carolyn Hastie Article : Horizontal violence in the workplace On the same subject Midwifery

About 5pm on a Monday evening in June 1995, a twenty five year old midwife, Jodie Wright, ended her life. Jodie gassed herself in her car. Her suicide note clearly stated her disillusionment, her frustration and her profound sense of hopelessness. Her words implicated the way our profession treats women; women as midwives and women as mothers as the basis for her decision to end her life.

Jodie was one of those 'bright young things' that older, cynical midwives knowingly smile at each other about and comment how they were like that once. Enthusiastic, passionate about her work, talented and committed to learning as much as she could about her chosen profession, Jodie was equally committed to improving the situation for the women and babies in her care. Jodie went to every conference and workshop possible within the limitations imposed by shiftwork and rosters. Those of us who knew Jodie were aware of the difficulties she experienced as she sought to influence practices and improve care for women and their babies in the institution in which she worked. Instead of support, interest and encouragement from the institution and its' management, Jodie met hostility, criticism and intimidation. Comments such as 'what would you know, you are only a new graduate, I've been doing it this way for 'x' amount of years' were common responses to her suggestions and ideas based on her rapidly accruing knowledge. Jodie developed a deep sense of isolation and despair. Gradually her confidence was shattered. Continued criticism and disparagement led her to doubt her value and abilities.

A report in the Sydney Morning Herald, Thursday 14th of September 1995, quoted a study done by Griffith University on office bullying and listed the effects of such behaviour on workers as 'withdrawal, fatigue, nervousness, self blame, depression and absenteeism' and suggested that the cost to the Australian workforce to be in 'excess of $100 million annually, not just in terms of sick leave and worker's compensation, but also productivity losses due to a lack of enthusiasm for the workplace'. Jodie never lost her enthusiasm for her work but the cognitive dissonance generated by the disparity between what she knew to be right, what the reality was and her inability to change the situation was intolerable to her.

Jodie's treatment is, sadly, not new or unusual within the nursing and midwifery professions. All of us within these professions have experienced similar behaviour to some degree. Leaving the profession is also not unusual. A lot of us who become disillusioned and distressed about the 'status quo' leave to do other things because of an inability to endure what we perceive as the inherent abysmal lack of true consultative change and commitment to excellence of care for women and their babies. What is unusual about Jodie and her experience is that she chose to kill herself.

Questions can be asked about whether she felt she did have a choice. Was the disparity between her love for her work and her experience at work too great to allow her to see any options? It has been an interesting and enlightening experience to discuss the issues Jodie's suicide has raised. Several staff members at the institution where Jodie worked referred to her as 'our bright shining star'. One staff member suggested that Jodie's suicide was a last resort to affect change, like a martyr perhaps? This contention is almost too horrible to contemplate, but, it may be true!! Certainly her suicide note was damming of the resistance to change and lack of willingness to embrace new ideas she experienced within the midwifery unit. Another person spoke about the use of canaries in mines to detect the presence of carbon monoxide and wondered if Jodie's suicide heralded the presence of a noxious atmosphere in midwifery.

Others have dismissed the possibility of Jodie's death resulting from political influences saying 'there most have been something wrong with her!!' Of course there was something wrong with her. She was totally without hope. Jodie had survived anorexia in her teens, various difficult life events with which, if we examined all of our life herstories, we would find similarities and congruencies. The refusal to examine the meanings behind and woven into Jodie's suicide is fascinating and compelling evidence of the compulsion for some midwives to maintain the status quo. Is this compulsion to be adhered to no matter what the cost? Perhaps to do otherwise is too painful and disturbing.

The behaviour experienced by Jodie and others has been attributed to oppressed groups and described as horizontal violence. (Friere 1970 in Hedlin 1986; Roberts 1994) Also well recognised is the fact that the hostility and violence increases with the level of enthusiasm and challenging of existing practices that occurs by the innovative/questing practitioner.

Oppression has been defined as the imposition of the choice of one person's or group's on that of another. Freire also describes oppression as any situation in which one person hinders another's pursuit of self affirmation as a responsible person (Freire 1970 in Hedin 1986:55)

Manifestations of subtle forms of self hatred such as divisiveness, lack of cohesion, lack of participation in professional groups, back biting, destructive gossiping, fault finding and other forms of violence and contradictory behaviour characterise oppressed groups. Freire (1970) explains that oppressed groups internalise the view of themselves held by the oppressor and imitate patterns of oppressor behaviour. There is a tendency to house the oppressor within. The dominant group struggles to maintain the status quo; change generated from those outside the dominant group is perceived as inherently threatening and potentially damaging to their power base, therefore fear of freedom is promoted using myths and positions of influence. The health system is a classic manifestation of a hegemonic institution.

Hegemony is the ability of the dominant class or culture to exercise social and political control. Power, technology and ideology combine to produce forms of knowledge and social relations. Knowledge is defined by the political, social and historical context in which it is developed and reflects the world view of the dominant group (Doering 1992:26) Foucault(Doering 1992:28) describes the 'normalising the view' of the dominant group as 'common sense' as one of the means of maintaining the status quo. Autonomy is curtailed by rules and social structures that allow those at the top of the hierarchy to view activities in every direction, thus having a total picture. Dominant groups present reality in parts, whilst keeping the total picture to themselves, therefore restricting complete knowledge and therefore ensuring compliance. Foucault likened the 'birds eye view' of patriarchal management, as the use of the Panopticon of earlier times. The Panopticon was a tall tower in the middle of the prison where war prisoners were held. The tower allowed the NCO's (none commissioned officers drawn from the ranks of the rank and file) to observe everything and therefore keep control in the absence of the leaders.

The position of midwives in the health care system reflects and parallels the submissive position of women in society generally. Caring is viewed as a female attribute and is the pivotal theme of nursing and midwifery. Curing is seen as the province of medicine and involves valued male attributes such as analytical thinking and a scientific approach. Recent developments have refuted the supremacy of curing versus caring, recognising that caring is fundamental to health and wellness and a precursor to curing. However, medicine is, like war, an extension of politics. It is not so much the story of science and advances, it is a 'story of control and access' (Mary Chamberlain 1989). The caring versus curing dichotomy, which fragments health care at the moment, creates moral dilemmas for health workers. Gilligan (1977) states that moral and ethical dilemmas are contextual and are viewed from a caring and/or a justice perspective. The caring perspective deals with relationships and connections and the justice perspective has rules, rights and an impartial balancing of competing claims at its' base.

Moral and ethical dilemmas are vulnerable to competing forces and to be a client advocate requires a high level of moral development and institutional congruence. Murphy (1979 in Millette 1986) describes three models of advocacy. Bureaucratic, which demands allegiance to the institution; Physician, wherein the doctor is given primary consideration and client advocacy, wherein the client is the primary focus and all the health providers work cooperatively.

Who of us has not known the pain of an ethical or moral dilemma when the institutional congruence is absent and there is no support for client advocacy? Each of us needs to ask ourselves some difficult questions, What is my vision for midwifery? What is my vision for maternity services? Am I satisfied with the status quo in maternity care in this country? How do I support/ encourage/ nurture my midwifery colleagues, especially the up and coming midwives? Am I part of the solution or am I part of the problem? What is the culture in my organisation? Is conflict and change seen as an opportunity or a threat. Are problems and differences of ideology dealt with openly or smoothed over and ignored. Is the emphasis on individual or shared action and responsibility? Do we recognise that change is an ongoing process, that it has circularity and is not an event that just happens?

Social justice is a necessity. Equity, access, co operation and participation in decision making are vital. We need to focus on outcomes and work together to create meaningful, rich rewarding lives. Ruth Lubic, a midwife and author visited Australia lasts November 1994 and spoke about instituting change and innovation in maternity services. Ms Lubic spoke about the barriers and conflicts she faced in establishing an Independent freestanding birth centre in New York City.

Ms Lubic was truly inspirational as she outlined her steps for professional success. These are:

• begin with the needs of the people you serve
• take care of all the people of the nation
• trust your caring instincts
• learn to tolerate uncertainty
• choose your professional colleagues for their caring philosophy
• be aware of the limits of the medical model
• avoid anger (consumes energy)
• avoid bitterness against professional adversaries
• base design for change on the best science possible
• overcome the fear of leadership

Jodie was at the conference in November. I spoke to her and we discussed the concepts Ms Lubic espoused. I last saw Jodie in May at a Educators workshop. We were to meet again at the follow up workshop the week of her death. I feel very sad that Jodie has died and it is tragic that our profession has lost one of its' talented and caring daughters. We must all ensure by our actions and our behaviour that Jodie's death was not in vain. Farewell Jodie, we will remember and miss you.

References

1. Chamberlain, M. 1984, 'The making of a male medical monopoly' in The New Our bodies, Ourselves, eds. Phillips, A. Rakusen, J. Penguin Books, London.
2. Lubic, R. 1994, Barriers and Conflicts in Maternity Care Innovation. Conference proceedings Birth Issues --- Choice, control and decision making CAPERS 1994
3. Pitt, H. 1995 'Bullying bosses: cost to business starts to mount.' The Sydney Morning Herald September 14th 1995.
4. Ashley, J. 1980 Power in Structured Misogyny Aspen Systems Corp.
5. Clare, J. 1993, 'A challenge to the rhetoric of emancipation:recreating a professional culture', Journal of Advanced Nursing, No.18 pages 1033-1038
6. Doering, L. 1992, 'Power and knowledge in nursing: A feminist poststructuralist view, Advances Nursing Science, No.14 pages 24-33
7. Millette, B. 1993, 'Client Advocacy and the Moral Orientation of Nurses' Western Journal of Nursing Research, 15 (5) pages 607-618
8. Roberts, S. 1994, 'Oppressed group behaviour: implications for nursing', Revolution the Journal of Nurse Empowerment, Fall, pages 29-35
9. Hedin, B. 1986, 'A case study of oppressed group behaviour in Nurses', Image: Journal of Nursing Scholarship, Vol.18, No. 2. pages 53-57
10. Roberts, J. 1986, 'Games Nurses Play', American Journal of Nursing, July, pages 848-849.

Carolyn Hastie is a midwife with considerable community and hospital experience and is based outside Sydney, Australia. She welcomes responses to this article and can be contacted at: heartlgc@bigpond.net.au.