ࡱ> _ ^bjbjzz .B\B\)% x  8d>2=(""<<<<<<<$>A<m*m*m*<DD<666m*tDD<6m*<66:!;,;D r]/BM; <=02=W;R4B#4~4B;4B;'!86_$&z<<5v2=m*m*m*m*4B > >: Hollins Martin, C. J., Bull, P. (2006). What features of the maternity unit promote obedient behaviour from midwives? Clinical Effectiveness in Nursing. 952, e221-e231. Caroline J. Hollins Martin RN RM BSc MPhil1 Peter Bull MA PhD C.Psychol. F.B.Ps.S2 1 Department of Nursing, Midwifery and Social Work, University of Manchester, UK 2Department of Psychology, University of York, UK *Address for correspondence: Caroline Hollins Martin, Room 528, Gateway House, Piccadilly, Manchester; E-mail: Caroline.Hollins-martin@manchester.ac.uk What features of the maternity unit promote obedient behaviour from midwives? Summary The aim of this paper was to present a comprehensive picture of characteristics within a maternity hospital which promote obedient behaviour from midwives. The overall objective was to assess midwives views about their own acquiescent behaviour. A sensitive qualitative analysis appraised midwives views gained from semi-structured interviews conducted within the seven maternity units of North Yorkshire in the UK. Participants included a stratified sample of 20 (7 E, 7F, 6G grade) practicing midwives aged between 21-60 years. Taking a post-positivist approach, inductive thematic analysis was used to interpret the data. Two themes of situational factors that promote obedient behaviour were derived; an obligation to follow hospital policies and fear of consequences from challenging senior staff. The key conclusion is that midwives are frequently placed in unenviable positions of relative powerlessness. It was clear that some actions and strategies that midwives use serve to reinforce the fundamental power structures and status quo. Quite clearly, midwives are sometimes presented with conflict between a drive to agree with authority and supporting the safe, evidence-based choices of childbearing women in their care. Raising awareness of the processes involved in obedient behaviour and exercising sharing of power may be helpful to midwives in asserting not only their own professional capacity to influence, but also the autonomy of the women they seek to empower. What features of the maternity unit promote obedient behaviour from midwives? Keywords: Social influence, obedience, power, midwives, choice, evidence-based Introduction This paper reports a study that aimed to identify features of the maternity unit that promote obedient behaviour from midwives. The theoretical underpinning was the identified conflict for midwives between government directives to work as woman-centered practitioners (DoH, 1993; 2004) and a demand for obedience to authority (Hollins Martin & Bull, 2005). In brief, we sought to construct how midwives understand and account for obedient behaviour within their work environment. Hollins Martin and Bull (2005) demonstrated the powerful social influence that a senior member of staff can have upon midwives decisions, with scant evidence regarding factors as to why. The clinical significance is that midwives may face difficulties in working as woman-centered and evidence-based practitioners, when high levels of obedience are expected from authority. That some people readily follow direction from their superiors, even when this challenges what they see as right action, has been a source of puzzlement for half a century. Obedience literature emphasises that legitimate authority is a powerful and compelling force (Hollins Martin & Bull, 2005; Milgram, 1974; Meeus & Raaijmakers, 1995). This is particularly evident in the classic Milgram (1974) experiments in which a university professor gave direct orders to a participant to administer electric shocks to a confederate, with results showing that individuals have a propensity towards obedience (65% depending on experimental variation). To date there has been a dearth of obedience studies conducted within the arena of nursing and midwifery practice. A search of PsychInfo and PUbMed databases of obedience and nursing or midwifery yielded five studies that specifically focus on obedience. Only four of these addressed psychological studies of obedience of nurses (Hofling et al., 1966; Krackow & Blass, 1995; Nursing Editors Survey, 1974; Rank & Jacobson, 1977), and only one focused on midwives (Hollins Martin & Bull, 2005). Three of these references are from the 1970s or earlier, which emphasises a pressing need to investigate obedience within the contemporary culture of midwifery practice. The Hofling et al. (1966) study was a hypothetical replication of Milgrams (1974) seminal obedience studies. In the Hofling et al. (1966) study, a doctor ordered a nurse to administer an excessive dose of medicine to a patient in her ward. The medication order was transmitted over the telephone by an unfamiliar person and in violation of hospital policy. Of the 22 nurses, 21 would have given the medication as ordered, had the experimenter not intercepted them. The main findings are relevant given that they show the sizable obedience that a doctor could obtain from nurses at that time. The importance of the experiment does not lie in the issue of drug administration, or that participants were nurses and not midwives. Rather, the importance lies in the propensity of individuals, regardless of the organisation they work for and the job that they do, to show obedience towards an individual they perceive to be a trustworthy expert. This is consistent with the findings of Hurwitz et al. (1992). Obedience experiments have shown that situational factors dictate the level of obedience an individual will yield to a person in authority (e.g., Milgram, 1974; Kilham & Mann, 1974; Meeus & Raaijamakers, 1995); (1) simultaneous dissent of a peer reduces levels of obedience (Meeus & Raaijamakers, 1995; Milgram, 1974); (2) close proximity of an authority figure increases obedience (Meeus & Raaijamakers, 1995; Milgram, 1974), and (3) status of the initiator increases obedience, with superior ranking staff raising the level secured (Milgram, 1974). Over the years a working environment can change, with emphasis shifting in relation to factors that promote obedient behaviour. In 1977, Rank and Jacobson replicated the Hofling et al. (1966) study with two significant amendments. Nurses were requested to administer 30 milligrams of valium in an intramuscular injection and were freely allowed to interact with other nurses on the ward about the medication order. Rank and Jacobson (1977) reported results that differed markedly from those of Hofling et al. (1966). Of the 18 nurses who participated in the study, only 2 were rated as fully compliant. The non-compliant nurses attempted to check the dosage or the order in some way: 3 attempted to contact their supervisor, 1 attempted to call the pharmacy, and 12 attempted to recontact the physician who had given the order. Rank and Jacobson (1977) cited that interaction of the target nurse with other nurses was the critical determinant of ultimate non-compliance, consistent with Milgram (1974, Experiment 17). There remain considerable pressures on midwives to conform (Kirkham, 1999). Stapleton et al. (2002) and Stapleton, Kirkham and Thomas (2002) agree that there are demands for midwives to acquiesce. Ahern and McDonald (2002) report that nurses feel obliged to follow direction from senior people at all times. A survey by Krackow and Blass (1995) identified that obedient nurses more often relinquish responsibility to the person prescribing the action, while those who are defiant accept accountability for their own conduct. This finding is consistent with the attribution style of some of Milgrams (1974) obedient participants, who instead of taking responsibility for their behaviour blamed the experimenter for ordering them to give the electric shocks. Hollins-Martin, Bull and Martin (2004) developed a simple, valid and reliable scale - the Social Influence Scale for Midwifery (SIS-M) - devised to measure and score midwives private anonymous responses to 10 clinical decisions. Change in scores between a postal and interview condition measured the success that a senior midwife had at socially influencing junior midwives replies. Hollins-Martin and Bull (2005) found large disparities between the postal and interview measures, with overall findings informing that a senior midwife was capable of profoundly influencing participants responses, even when this influence challenged what the midwife saw as the appropriate action. The significance of this finding is that midwives may be presented with conflict between a drive to agree with authority and supporting a safe, evidence-based request from a childbearing woman. This makes obedience and its relationship to midwives clinical decision-making an issue worthy of address. Since the Hollins-Martin and Bull (2005) study presupposed a cause and effect model of understanding human behaviour and did not focus on the reasons why the midwives acquiesced, the present study aimed to do this. Rationale for the design and qualitative analysis of the interview data Triangulation combines research strategies for the purpose of achieving a multidimensional view of the phenomenon of interest (Foster, 1997). Postpositivists have argued for a set of criteria unique to qualitative research (Denzin & Lincoln, 1998). However, there is a great deal of disagreement about what these should be. Some that have been developed are simply an adaptation of positivist criteria to the qualitative paradigm (e.g., Mays & Pope, 1996), with positivism using the criteria of experimental research (Denzin & Lincoln, 1998). They argue that qualitative research should be able to generate formal theory, be scientifically credible, produce findings that can be generalised and take into account the effects of the researcher on the findings (Denzin & Lincoln, 1998). The Hollins Martin and Bull (2005) study took a positivist approach, with the quantitative paradigm afforded a dominant position in the hierarchy of approaches to knowledge production (Bowker, 2001). Obedience of midwives was assessed and understood through specifically designed measures, which provided independent numerical scores that represented an objective reflection of material reality. This approach led to a cause and effect model for understanding the behaviour of the obedient midwives. In contrast, this study takes a qualitative approach. It is primarily concerned with validating, explaining, interpreting and understanding how these midwives saw their working world. It provided information about the process of obedient behaviour depicted in the Hollins Martin and Bull (2005) study. In essence, the aim of the present study, was to discover characteristics within the organizational structure of a maternity hospital that promote obedient behaviour from midwives. This aim is more narrow than is usual in qualitative research, with emphasis on precise aspects, and as such falls into the postpositivist paradigm. The method was qualitative, since aspects of the social structure that promote obedience were derived from interviews rather than being found in response to a predetermined coding framework. From the literature review it appeared that situational factors could play a large part in promoting obedient behaviour from midwives. Hence, the following research question was asked: What situational aspects of a maternity hospital promote obedient behaviour from midwives? What follows, is the experiences of midwives as evidenced from comments they provided during an interview. Two themes and three sub-themes were identified (see Table 1): TABLE ONE ABOUT HERE Method The study assessed a representative sample of 20 midwives from an original cohort of 60 who had previously participated in a study regarding obedience of midwives in clinical practice (Hollins Martin & Bull, 2005). This number was selected since Kuzel (1992) suggests that 12 to 20 informants are needed when attempting to achieve maximum variation from a population. Maximum variation, as the label suggests, means that there is a breadth of different experiences within the sample. Participants The participants were recruited from the 7 maternity units of North Yorkshire in the UK. The serial sample included, 7 E, 7 F and 6 G grade midwives. All were female. The inclusion criterion was that the participant had to be currently practising midwifery. The age range was 21-60 years. Participants were randomly selected to represent the midwifery team at large. The hierarchical system in the profession is pyramidal. E grades have least responsibility, earn less money and function as part of a team led by senior midwives. G grades have more status and are ward managers or community team leaders (sisters). F grades are intermediate in status; they take charge when the G grade is absent and function as a team member when present. Procedure Approval for the study was gained from the local managers in each of the maternity units of North Yorkshire in the UK. The participants were volunteers and had signed a written informed consent statement prior to involvement in the study. The interviews took place in the midwives clinical area of employment. The interviews were semi-structured with the participant responding to 10 statements (see Table 2). TABLE TWO ABOUT HERE After each statement the interviewer encouraged the participant to clarify her response. Open and closed ended questions were asked and prompts were given. For example, after the midwife had answered the question the interviewer would ask: Would you argue? How would you go about this? Could you elaborate on that? Do you strongly agree or do you just agree with the statement placed? The participant could make as many (or as few) comments as she liked. Each interview lasted approximately one hour. The interviews were transcribed verbatim. The scripts were analysed using inductive thematic analysis (Boyatzis, 1998). As the researcher did not know what situational factors were involved in participants obedience, the coding was derived from the interviews using an iterative process. Short descriptive labels were allocated to sections of the text, (each section could have more than one label attached), following which labels expressing similar concepts were grouped together to form themes. Labels and themes were compared across scripts. As a reliability check (Flicke, 2002), a second rater (a research assistant) coded the first 7 interviews independently for characteristics implicated in producing obedient behaviour from midwives. The author and the second rater met to discuss these themes, comparing and contrasting interpretations until agreement was reached. Once this had been done for all of the transcripts, the themes and sub-themes were reviewed individually until agreement was reached. As the researcher had both knowledge of the literature and experience of causes that promote obedient behaviour, the reliability check was to ensure that expectations of particular reasons did not introduce a bias into the analysis, either by causing the text to be labeled inappropriately or by causing unreported reasons to be missed. Reflexivity The author has background and experience that assisted in the analysis and interpretation of the data. First, the author has been a registered practising midwife for 20 years. Second, the author has both basic and masters degrees in psychology. This variety of experiences afforded advantages in understandings and negotiations of the interview data. Measurements and findings Using an inductive thematic approach to interpret the data, two themes of situational factors that promote obedience were derived; an obligation to follow hospital policies and fear of consequences from challenging senior staff. The participating midwives were a diverse group in terms of the reports they gave of situational factors that encouraged them to acquiesce or resist direction given. Reported experiences spanned the full range from senior staff being libertarian to oppressive. Situational factors that promote obedience Interviewees gave multiple explanations of factors within their working environment that promoted their obedient behaviour. Two main categories were apparent: (1) the imposition of hospital policies, and (2) fear of consequences from challenging senior staff. The following excerpts show that when trying to facilitate childbearing women with making an informed choice or an evidence-based practice approach, midwives try to balance the expressed needs of the woman, the procedures and policies of the organisation they work for, and their own personal and professional needs. In order to achieve this balance midwives often feel they have to pick their line. In other words, midwives have to consider carefully how to achieve their goals without displeasing senior staff. An obligation to follow hospital policies Eight (40%) excerpts supported the idea that participants felt duty-bound to follow hospital policies. Three participants cited that they felt obligated to follow guidelines and policies: For the reasons that you have saidYou would just have to go with it (guidelines), wouldnt you (P6)? If the unit policy states one birth partner. I would have to go along with that (P8). Id have to if shes under his care cause you know, Ive got my own professional practice but I am employed and Im under the auspices of the hospital policies (P7). The following participant articulated feelings of overwhelming subordination, expressed in phraseology like, I would feel a bit narked that I would be having to. In such circumstances, the hospital policy seemed to act as an agent of domination that permitted piecemeal autonomy to the midwife. With this view, a midwifes obedience could be perceived as a forced choice: I would say that I disagree. It is sort of one of those situations where I would feel a bit narked that I would be having to rupture this womans membranes, but its there and it is in black and white. That is the issue, you have to work within these guidelines (P17). One participants use of the expression war crimes court suggested that she associated deviation from the guidelines with severe and overwhelming consequences: I mean before we get to here, its the same situation, its the same every time. I cant say I am having to follow orders because that doesnt stand up in a war crimes court I will have to get back into the reality check. I would, I would, I agree (to administer the oxytocin (P16). One participant cited that policies stand in the way of providing women with choice. This finding is consistent with Magill-Cuerden (2005) who affirms that policies frame the way a midwife works and as a consequence this inhibits the provision of care that is tailor made to the individual: I would probably say, if thats the policy, you know. Yeah you are not making that decision for that lady, you are making that decision for the senior midwifes breathing down your neck and saying this is the policy and I am not happy with more than one partner in the room. I would in reality of the situation, I would go along with the system and I would say all right then someone is going to have to leave (P18). One participant articulated the view that policies repress those who are lowest in the chain of command. It would appear that dominant groups make the rules that junior staff are expected to follow. This finding is consistent with Scamblers (1987) viewpoint that the term non-compliant is reserved exclusively for less powerful groups who are expected to comply with directions from more powerful groups: I think, I might well be obliged to follow the guidelines if I was junior (P19). Fear of consequences from challenging senior staff Fifteen (75%) participants gave examples of fears that prevented them from resisting direction from senior staff. The following excerpts show that the participants were obedient, not because they agreed with what was proposed, but instead to avoid some form of retribution that might result from their resistance. Obedience of this form could be interpreted as necessary agreement. This was also a finding of Wickland and Brehm (1976), who discuss how public compliance without private acceptance can be forced when there is a threat of punishment for non-compliance. Three aspects of feared consequences were identified. These included the participants fear of (1) an abnormal obstetric outcome, (2) litigation, and (3) conflict and intimidation. Abnormal obstetric outcome Five participants remarked that they feared an abnormal obstetric outcome would result from a decision that they had defended. As a result, many promoted the technological interventions suggested by senior staff, even when they contradicted the evidence-base. One participant coped with clinical uncertainty by asking the senior person to perform the prescribed action: I would ask the consultant to discuss it with the woman and for him to do it (amniotomy). I would not be happy (P8). One participant managed clinical uncertainty by simply not opposing the direction given. Her strategy for coping was to relinquish responsibility to the senior person: I think I would rather be safe than sorry. I am quite happy to go along with what he said. I dont think I would challenge him (P11). Two participants believed that use of technology (cardiotocography & amniotomy) would be viewed positively in the event of an abnormal obstetric outcome. This opinion reinforces notions of right and wrong choices rather than informed choices that are evidence based: I would be thinking if I dont do it (cardiotocography) and as you said if anything goes wrong (P12). Yeah (I would do the amniotomy). When you think about the sort of death rate (P13). One participant considered that she held only nominal power to influence clinical decisions. Stapleton, Kirkham and Thomas (2002) observed that midwives generally exercise little clinical influence compared to doctors. This midwife was clearly concerned about possible penalties from recommending options that contradicted obstetrically defined clinical norms: Again if Mr R has written this down (that he wants cardiotocography), if anything did go pear shaped then I would have a lot of questions to answer (P17). Litigation Eight participants expressed that they feared litigation might result from decisions they fought to support. This is a very real concern for midwives (Warren, 2001), since there has been an alarming increase in lawsuits against the NHS over the last few years with 70% of all litigation involving obstetric cases (Johanson, Newburn & Mcfarlane, 2002). Consequently, fear of litigation will inevitably shape midwifery practice: Four participants commented that fear of litigation made it difficult for them to instigate independent and autonomous decision-making. This worry promoted notions of right choices that clinicians felt secure with and which they thought would afford them protection from litigation: I think that there is a one good reason here and its not maternal age, its the fiscal body (P1). In the eyes of the court if I dont do it and something happens, then hes going to say I didnt follow his instructions or whatever (P5). I just think there is so much litigation. You dont practice just how you would like because of the fear of litigation, I think (P11). They are open to litigation, when working as an independent midwife (P16). One participant commented that she would not trust the senior person to stand by her in the event of an abnormal obstetric outcome. Such lack of trust will inevitably effect decisions that midwives make. A portrayal of trust was only present when the midwife was doing what the senior person wanted. I argued about something in the guidelines before. It was actually about labour and how long to leave women and she said, I value your judgment and its not cast in stone. I am happy for you to use your professional judgment, and thats because she trusts me and she knows I would ask and how I make my decisions. But then I could cross her and that would change, so you cant rely on that. If it came to a court case I wouldnt trust her still. Do you know what I mean? As long as you play the game and play the game by their rules (P14). Two participants cited that fear of litigation caused them to devolve responsibility to the senior person. This illustrates the ability of the dominant group to control the agenda by implicitly encouraging various sets of values and beliefs that regulate and control subordinates actions: And if there was litigation from it, then it would be the consultant that is sued and not me (P15). Like litigation and things, that someone higher up asked you to do it. Yeah, so I would agree that I would do it (cardiotocography) (P20). Two participants commented that the best way to avoid litigation was to follow protocol. Over time, what starts out as non-routine direction may become subsumed into scheduled investigations and interventions. Even though, with clinical governance there is a requirement for these to be evidence based, eventually these are less likely to be questioned or refused. Thus the routine package of care, written by senior people, by virtue of its routine character may come to be regarded as the only possible or reasonable way of giving and receiving maternity care. In turn, these patterns of expected behaviour will seriously reduce opportunities for genuine informed choice to be given to childbearing women: Emmm, I feel quite strongly and I think that for litigation reasonsthats in your best interests (to follow guidelines) (P20). If you are looking at it as a protection mechanism (from litigation), then yes I would strongly disagree, sorry I would want them in place (guidelines) (P7). Conflict and intimidation Twelve participants cited fear of conflict and intimidation as inhibitions to challenging authority. This is a very real concern for midwives (Dimond, 2002; RCM, 1996), since nurses and health care employees account for around 12% of over 10,000 cases of bullying reported to the UK National Workplace Bullying Advice Line between 1996 and 2002. Surveys by Unison and the Royal College of Midwives show that 33% of employees in nursing and healthcare experience bullying (Bully on Line, 2005). Rappaport (1984) proposes that disempowerment is characterised by powerlessness, helplessness, alienation, victimisation, subordination and oppression - terms Farmer (1993) noted have been used by some nurses to describe their position. Three participants articulated that challenging a senior person could result in some form of (undesirable) confrontation: Discuss not argue, argue is a bit dangerous, grey area, Miss M. would not take kindly to it (P7). Even the scariest onesbecause not many (midwives) do challenge them (senior staff) because they are frightening (P5). Well it depends, but on that particular personality here (sister), it probably would because I know what she would be like if I didnt agree (P11). Would you change that (question response) if that person came into the room (I)? Probably (P11)! One participant articulated frustration when imperatives, rather than evidence-based information or client choice determined the options available: I would challenge but it can often be quite intimidating to do so. I do though remember the feelings of helplessness, anger and frustration felt (when a senior person decided to override a decision I made regarding normal labour)(P10). Two participants cited that they would actively seek to avoid confrontation: But I dont like the confrontationYes. I am not a confrontational, not an aggressive confrontational person (P15). I would never be looking for an argument anyway (P16). One participant cited that she would acquiesce, not because she agreed with what was suggested, but instead to avoid the risk of losing her relationship with the dominant individual: I wouldnt argue with the consultant, but I would agree, I wouldnt have any problem with this mum wanting a home confinement. But I think you could cause more friction by arguing in front of the consultant. I think you could lose that relationship (P9). Three participants saddled the dominant individual with a reputation for intimidating junior members of staff: It was a long time ago and it seemed to be all right (to let her two sisters and husband in with her in labour), but the dragon (sister) wasnt on the ward (P12). Miss Truled with a rod of iron (P15). I used to know this consultant who went beserk when they had more than one (birth partner) (P13). Three participants cited that failure to comply would in all probability result in penalties. This was also a finding of Levy (1999): Id give her a channel to go tobut I wouldnt hurt myself personally (by arguing) (P13). I used to dread nights if he was on. I used to feel physically sick cause I knew if anything came in he would be so awfuland the bullying part of him didnt like to give other people a break (P14). The costs of being direct with some of these individuals is, one that they tend to go a shade of puce and they and you know that they are going to make your life a misery for the next goodness knows how long (P17). One participant cited that her failure to acquiesce had resulted in attempts to block her promotion: I have actually had this with Mr M, he tried to block my promotion, he didnt succeedBecause I used my professional judgmentHe doesnt like anyone to make a decision but him (P14). One participant expressed that she feared a disciplinary hearing would result from her failure to cooperate: Yes, but bit by bit people like this chip away at you. They do chip away at you. They makes you feel that you are to follow a disciplinary and this absolutely mortified me. It staggered me (P20). Discussion This study raises some caveats and reservations. First, the results could be criticised for being unrepresentative of the population from which they are drawn. That is, the sample size was small and cannot be generalised to all maternity units within the UK. Further, midwives within other regions may be subject to differences in the way legitimacy is constructed, behaviour is reinforced and directives are prescribed. Additionally, a midwifery lecturer conducting the interviews might have constituted a limitation of the study, quite simply because some of the participants may have feared consequences from revealing such information to a midwife in this position. It is also possible that this may have caused participants to under represent factors that promoted their acquiescence. Yet, the analysis has shown that situational factors play a critical part in promoting obedient behaviour. What emerged from the data was an image of organisational structures that empower senior staff to socially influence decisions of juniors, whilst simultaneously disempowering subordinates and reinforcing order. The analysis indicates that order is maintained through the hierarchy, with a chain of command implementing hospital policies to produce desired behavior. Adherence to procedures and discipline is sustained by an elaborate array of sanctions, which was also shown by Trevino (1992). Two inevitable consequences of such organisational structures are that educated, creative, capable, junior practitioners may have (1) their eagerness for initiating a new evidence-based practice obstructed and (2) their enthusiasm for providing choice and control to childbearing women stifled. Within such a regime, it is probable that established normative practice will be presented as the only reasonable way. Cleland (1971) wrote that, dominance is most complete when it is not even recognised. An obvious example of this is the medicalisation of childbirth, whereby senior staff assume control purportedly in the interests of women (Turner, 1987). For example, hospital confinements came to be regarded by childbearing women and professionals as safer than home births, even when childbirth was normal (DoH, 1970). This myth has only recently been challenged, and the safety and popularity of home births is (very slowly) reasserting itself in the UK (Office of Population Censuses and Surveys, 2003). In the World Health Organisation (WHO) (1996) summary of research on place of birth - Subsection on Place of Birth, it is stated that it has never been scientifically proven that the hospital is a safer place than home for a woman, who has an uncomplicated pregnancy, to have her baby. Studies of planned home births in developed countries have shown sickness and death rates for mother and baby are equal to or better than hospital birth statistics for women with uncomplicated pregnancies. The evidence states that selective planned home birth is a safe option (American Public Health Association, 2002; Goer, 1995; The Mother-Friendly Childbirth Initiative, 1996). Examples of other obstetric myths concern specific policies in childbirth, for instance; unnecessary inductions of labour, invasive methods of fetal monitoring, high incidences of operative deliveries and episiotomies, all of which have been largely discredited in recent years (Tew, 1990). The excerpts cited illustrate how less dominant groups of people may be manoeuvred into following courses of action that do not necessarily gain their approval. They explain the participants obedient behaviour in terms of powerful situational forces. Many of the midwives acquiesced because they perceived a requirement to do so, consistent with obedience literature (e.g., Hofling et al., 1966; Meeus & Raaijamakers, 1995; Milgram, 1974). The selected excerpts have shown that the working environment can make it difficult for midwives to be innovative and assertive. Also, at times there is conflict between personal views and what authority and protocol directs. Results of the qualitative analysis illustrate a paradox. Clearly, many of the participants wanted to practice in a specific way, yet their control of the situation did not necessarily lead to empowerment - rather the opposite. Many of the midwives experienced constraints imposed by dominant people and thus were unable to practice with autonomy. Responses have been articulated. First, midwives should take action, speak out, participate in decision-making and develop skills. These actions are reflected within organisations such as the Association of Radical Midwives. Midwives are becoming increasingly vocal in their views about childbirth, and the fruits of this action are visible in initiatives that relate to Changing Childbirth (DoH, 1993) and the more recent National Service Framework for children, young people and maternity services (DoH, 2004). Second, a sense of connectedness has been developed between those who share a social identity and between midwives and other health care professionals. By team working members collaborate to stimulate many initiatives to improve the working experience of midwives. The work of midwives is highly complex and often difficult. Data from this study has shown that midwives are frequently placed in unenviable positions of relative powerlessness. It is also apparent that some actions and strategies that midwives use reinforce the fundamental power structures and status quo. A raised awareness of the processes that relate to obedience and the exercising and sharing of power may be helpful to midwives in asserting not only their own professional capacity to influence, but also the autonomy of the women they seek to empower. Further consideration is needed of the issues surrounding giving and taking of power in relation to the clinical, educational, managerial and supervisory roles of midwives. Ample criteria have been established that specify the conditions under which a midwife can be an autonomous practitioner. Roles are clearly outlined by the Nursing and Midwifery Council in the Midwives Rules and Standards (NMC, 2004). Further research may also be useful. In particular, there is a need for a study that explores in more detail situational aspects of the maternity hospital that exerts influence upon midwives decisions. With greater insight, hospital managers could be helped to understand why particular demands of practice are not being met. Without such research, the work of a growing number of maternity care professionals now concentrating on improving choice and control for childbearing women may fail to yield the desired results. If hierarchical position and its associated power to influence decisions and situational constraints are shown to be durable and effective in obstructing midwives from supporting womens choice, then special efforts may be warranted to counteract this effect. Conclusion The qualitative analysis of participants interview transcripts has shown that there is a strong authority relationship that subverts what many midwives believe should happen. The excerpts have shown that much of this is embedded in hospital culture. That is, the explanation is in terms of a specific culture and hierarchy. The combination requires radical responses in order to meet practice directives (i.e., DoH, 1993; DoH, 2004). What is apparent is that the midwifes role blends rules with disciplinary sanctions and autonomy. There is a need for the midwife to think creatively and rapidly at critical moments in order to avoid sanctions, at the same time as accommodating the unpopular choices of childbearing women. Midwives are bound by regulations and at the same time they are required to respond to womens requests and the evidence-base. In the present institutional culture, this means that they have to bend the rules sometimes and face the risk of reprisal. This state of affaires is unsatisfactory. REFERENCES Ahern K, McDonald S 2002 The beliefs of nurses who were involved in a whistle blowing event. Journal of Advanced Nursing 38 (3): 303-309 American Public Health Association (APHA) 2002 Increasing access to out- of-hospital maternity care services through state regulated and nationally certified direct entry midwives (Policy Statement). American Journal of Public Health 92 (3): 125-129 Bowker N I 2000 Understanding online communities through multiple methodologies combined under a postmodern research endeavor. Accessed on the 12th December 2001:  HYPERLINK "http://qualitative-research.net/fqs/fqs-eng.htm" http://qualitative-research.net/fqs/fqs-eng.htm Boyatzis RE 1998 Transforming qualitative information: thematic analysis and code development. Thousand Oaks, Sage Bully on line 2005 Those who can, do. Those who cant bully. Accessed on the 9th October 2005.  HYPERLINK "http://www.bullyonline.org/workbully/nurses.htm" http://www.bullyonline.org/workbully/nurses.htm Cleland V 1971 Sex discrimination: nursings most pervasive problem American Journal Nursing 71 (1): 54-57 Denzin NK, Lincoln YS 1998 Part II: The art of interpretation, evaluation and presentation: In NK. Denzin & YS Lincoln (Eds) Collecting and interpreting qualitative materials (pp 275 - 281) Thousand Oaks, CA, Sage Department of Health (DoH) 1970) Domiciliary midwifery and maternity bed needs (Peel report). London, HMSO Department of Health (DoH) 1993 Expert maternity group, changing childbirth document. London, HMSO Department of Health (DoH) 2004 Maternity standard, national service framework for children, young people and maternity services. London HMSO Dimond B 2002 Staffing, stress, bullying and the midwife. British Journal of Midwifery 10 (11), 710-713 Farmer B 1993 The use and abuse of power in nursing. Nursing Standard 7 (23), 33-36 Flick E 2002 An introduction to qualitative research (2nd ed) London, Sage Publications Foster R L 1997 Addressing epistemologic and practical issues in multimethod research: a procedure of conceptual triangulation. Advances in Nursing Science 20 (2), 1-12 Goer H 1995 Obstetric myths versus research realities: a guide to medical literature. New York, Bergin & Harvey Hofling CK, Brotzman E, Dalrymple S, Graves N, Pierce CM 1966 An experimental study in nurse-physician relationship. Journal of Nervous and Mental Disease 143: 171-180 Hollins Martin CJ, Bull P 2005 Measuring social influence of a senior midwife on decision making in maternity care: an experimental study. Journal of Community and Applied Social Psychology 15: 120-126 Hollins Martin CJ, Bull P, Martin CR 2004 The social influence scale for midwifery (SIS-M): factor structure and clinical research applications. Clinical Effectiveness in Nursing 8, 118-121 Hurwitz SD, Miron MS, Johnson BT 1992 Source credibility about the language of expert testimony. Journal of Applied Social Psychology 24: 125-128 Johanson R, Newburn M, Macfarlane A 2002 Has medicalisation of childbirth gone to far. British Medical Journal 324: 892-895 Kilham W, Mann L 1974 Levels of destructive obedience as a function of transmitter and executant roles in the Milgram obedience paradigm. Journal of Personal and Social Psychology 29: 696-702 Kirkham MJ 1999 The culture of midwifery in the NHS in England. Journal of Advanced Nursing 30 (3): 732-9 Krackow A, Blass T 1995 When nurses obey or defy inappropriate physician orders: attributional differences. Journal of Social Behavior and Personality 10 (3): 585-594 Kuzel AJ 1992 Sampling in qualitative inquiry. In BJ Crabtree & WL Miller (Eds) Doing qualitative research. London, Sage Levy V 1999 Midwives, informed choice and power: part 1. British Journal of Midwifery 7 (9): 583-586 Magill-Cuerden J 2005 How do maternity services provide individualised care? British Journal of Midwifery 13 (8): 480 Mays N, Pope C 1996 Rigour and qualitative research. In N Mays & C Pope (Eds) Qualitative research in health care (pp 20 - 27). London, BMJ Publishing Group Meeus, W. H. J., Raaijmakers, Q. A. W., 1995. Obedience in modern society: the Utrecht studies. Journal of Social Issues 51, 155-176. Milgram S 1974 Obedience to authority. London, Tavistock Publications Morriss P 1987 Power: a philosophical analysis. Manchester, Manchester University Press Nursing Editors 1974 Nursing ethics: what are your personal and professional standards? Nursing 4: 34-44 Nursing & Midwifery Council (NMC) 2004 Midwives rules and standards. London: NMC Office of Population Censuses and Surveys 2003 Birth statistics: a review of the registrar general on births and patterns of family building in England and Wales (1993) (pp 39 - 42). London, OPCS Rank SG, Jacobson CK 1977 Hospital nurses compliance with medicalisation overdose orders: a failure to replicate. Journal of Health and Social Behavior 18, 188-193 Rappaport J 1984 Studies in empowerment: introduction to the issues. Prevention in Human Sciences 3:1-7 Royal College of Midwives (RCM) 1996 In place of fear: recognising and confronting the problem of bullying. London, Royal College of Midwives Scambler G 1987 Habermas and the power of medical expertise. In G Scambler (Ed) Sociology theory and medical sociology (pp 165 -193) London, Tavistock Publications Stapleton H, Kirkham M, Thomas G 2002 Qualitative study of evidence based leaflets in maternity care. British Medical Journal 324 (7338): 639-44 Stapleton H, Kirkham M, Curtis P, Thomas G 2002 Framing information in antenatal care. British Journal of Midwifery 10 (4): 197-201 Tew M 1990 Safer childbirth? London, Chapman Hall The Mother-Friendly Childbirth Initiative 1996 Coalition for improving maternity services. Marlborough, The Mother-Friendly Childbirth Initiative Trevino LK 1992 The social effect of punishment in organizations: a justice perspective. Academy of Management Review 17: 647-676 Turner BS 1987 Medical power and social knowledge. California: Sage Publications Warren C (2001) Safety in numbers: how many midwives at the birth. Midwifery Matters (Association of Radical Midwives). Autumn, Issue No. 90 Wickland R, Brehm J 1976 Perspectives on cognitive dissonance. New York, Halsted Press World Health Organization (WHO) 1996 Maternal and newborn health/safe motherhood unit of the world health organiation. Care in normal birth: a practical guide. Geneva, Switzerland, World Health Organisation Table 1. Themes and sub-themes generated from the qualitative analysis __________________________________________________________________________ Research Question Themes Sub-Themes __________________________________________________________________________ What situational An obligation to follow aspects of a hospital policies maternity hospital promote obedient Fear of consequences from Abnormal obstetric outcome behaviour from challenging senior staff midwives? Litigation Conflict and intimidation ____________________________________________________________________________ Table 2. Statements by the interviewer _________________________________________________________________________________ (1) I believe that guidelines are unnecessary when labour is progressing normally. (2) I would argue with the consultant if he refused to support a home confinement when a mother with a healthy pregnancy is keen to have one. (3) I would follow a senior member of staffs request to rupture a womans membranes if this was the decided course of action. (4) I would administer oxytocin to a woman desiring a normal labour if it was a requisite of the guidelines for routine labour. (5) I believe that it is acceptable for a women to have more than one birth partner present during labour when the unit policy states only one person at a time. (6) I would automatically commence cardiotocography if it was requested by a senior member of staff. (7) In general I would challenge a senior member of staff if they decided to override a decision I made regarding normal labour. (8) I would conceal my opinion from a consultant obstetrician when my stance about carrying out elective section for social reasons differs. (9) I would allow a women to have her two friends and husband present during labour and delivery if this is what she wanted. 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