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Fighting bad hospital policies

835 Views 10 Replies 9 Participants Last post by  mwherbs
I'm going to grad school to be a CNM in a couple of years. I know I'll see some bad hospital policies and I want to be able to fight them without either being seen as troublesome and causing a bad working relationship with my coworkers or getting fired. So, for anyone who has ever worked and/or birthed in a hospital:

-What are some of the bad policies you've seen?
-How did you try to fight them?
-Did you succeed?
-If you succeeded, was the change permanent, or was an exception made for you?

Thanks in advance!
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Hi minkajane!
I think we've pm'ed a few times?

I can't say I was ever revolutionary, and I don't know how useful my 2 cents will be, but here goes-
I didn't go about policy changes with the deliberate intention that you are. I also didn't "change policy", I just did things that were allowed by policy but never done. My most frequent was doing intermittent monitoring; closely following was putting IVs to heplocks and showering. Just doing anything/everything I could to get the mom mobile. I guess, overall, I did that Ghandi thing of "be the change you want to see". I didn't try to change policy, I just tried to take care of my patients the way I thought they should be. Since I worked nights, I had a lot of leeway.

I can't directly answer your questions, but here's what I'd suggest. Spend the first three months or so 1, learning your job (it's bigger than you think!) and 2, standing back and evaluating current practices at your site. Maybe they're great with breastfeeding support but lousy at intermittent monitoring. Maybe there's a long list of sadly out of date practices and you need to decide which one or two you'd like to focus on. Maybe you want to start with one small thing to boost your confidence before tackling something big.

During that time, pick out the major players and look at relationships. Maybe the unit manager wants to implement evidence based practices but the one nurse who's been there for 25 years sabotages all of her efforts. Also, and naturally, find your tribe-us natural birth types tend to gravitate together. Feed off of each other's energy.

Find who your doctor allies are-all hospitals I've been to, no matter how big or small, have at least one doctor who is a champion for nursing. Maybe his/her belief system isn't necessarily natural or holistic, but they tend to like and listen to the nurses who really know their stuff and will support you even if they don't understand your passion for it. Like the doctor who will support water birth as long as it's research based and even if they'd never do it themselves.

When you're armed with all of the preliminaries, pick out one item to start with. Look up all the research and use it to write a proposal, and present it to your nurse manager. Then do it! Prepare for resistance, but know who your allies are.

I guess I did accomplish one thing in my years. I took a doula class a few years after nursing school, mainly to remind myself of why I was doing this. When I finished I realized that working as a doula and an L & D nurse wasn't very practical. I ended up learning that a doula had been trying to start a volunteer doula program at my hospital (county hospital in Cleveland), and I called her. She had been trying for a year, and I was just the "in" that she needed. I did inservices for labor and delivery and all five of the hospital's satellite clinics, talked with my nurse manager about why should have a volunteer program, and coordinated meetings between nursing and the department of volunteer services.

Before too long the volunteer program was running itself. It wasn't terrifically accepted by the nurses, but last I heard, a few years ago, it was still going. It's been a great venue for newly certified doulas to get their births in.

I marvel at this because I was utterly clueless at the time. I was all of 25 and did everything based on passion and instinct. I wasn't paid for doing those inservices, because it didn't occur to me that I should ask. And I didn't set out to do anything revolutionary, I just did something that I thought was a good idea. I was puzzled when I met resistance, but for some reason it didn't bother me.

Hope this helps-you're going to be great at this!!

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Jennifer, what a wonderful response.

Thank you!
Wow, Jennifer, you rock!
Great ideas
I've just got a couple of thoughts from some MWs I love.

Put everything on the record thus making it possible for parents to complain if they want to. A MW I know and adore puts on her innocent face and then makes absolutely positive that everything the surgeons say gets put onto the woman's record.

Case in point:

3rd time mama (2 lovely vbs prior) told "Your baby's abdomen is measuring larger than it's head so you have to have a booked c-sec." My friend turns up at work on that day and ends up being the MW assigned to this woman.
Friend: Ok doctor, once the baby's out I'll make sure I do that abdo/head measurement for you.
Doc: Oh that won't be necessary. (Looks furtive)
Friend: Oh it's not a bother for me

Does measurement and records that the head is 2cm larger than the abdo, then makes sure she tells the parents "by way of interest" also making sure they're fully aware of the complaints process in the hospital. Also says to them, "WOuld you like Doc X to come discuss this discrepancy with you?" Then says to Doc X, "The parents of baby Y want to talk to you about the measurements of the head/abdo after you said it was too big to birth." Of course the doc isn't happy but the MW hasn't done anything other than firmly adhere to the guidelines around transparency and recording notes accurately

Another time she was present when a doc had SEVEN goes at a baby with the ventouse despite unit policy being nor more than 3 or it's a c-sec. So at the next unit meeting she says (big smile on face) "I note, Doc B, that you used SEVEN attempts with the ventouse to get that baby out and that our policy guidelines say no more than three. I realise that with your knowledge and experience you no doubt had an excellent reason therefore to go against those guidelines and I ask you to share your thoughts so we can all learn from your skills." (Big innocent smile on dial)

She also puts lots of research from ob journals up on the noticeboard in the staff room which directly contradict almost all of the CRAP the surgeons are imposing on the unit. She supports bfing strenuously and has thrown all the dummies out of the SCN several times while strongly advocating and supporting women to be in there bfing their babies. She isn't popular with the surgeons but she's saving lives so she's prepared to wear their anger.
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I've never had much luck with changing hospital policies, but I know of some professionals who did. One thing they had in common was that they had a lot of contacts and sources of information outside the hospital environment. People who work in a hospital maternity unit sometimes start to absorb the hospital world view and can no longer think outside the box. You can also start to get burnt out if all you see are invasive birth procedures. Keeping in touch with "alternative" birth professionals might be a good idea.
I was in a consumer group 27 years ago that put an ABC in the local medical center. We had sponsorship from Bank of America and many other community groups.

It was rarely used. It is closed now. This hospital has an extremely high caesarean rate, always had and always will.

The only other two hospitals in the area have closed.

The doctors hated the ABC and risked many patients out of it.

I would personally never try to change a hospital policy after that experience.

Furthermore, my own midwife told me that if I desired to become a midwife, I should not to try to change the system. I was able to have my children at home and I am glad. For me that is now all that matters.
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I think the "innocent, but exactly by the book" tactic works well sometimes.

I worked at a hospital where the residents (and some of the attendings) had trouble "remembering" that our policy said only three tries with a vacuum. So, we (the nurses) were complaining about this to the head of OB. She asked us how we thought that it should be handled, discreetly, cause this would be in front of patients. We came up with the idea of saying, "Dr. Weloveyouso, that was the 3rd try, is there anything else I can get for you?" to remind them that they needed to try forceps, go back to pushing without assistance, or call a c-section. Our lovely medical director (a huge champion of nursing) took that back to the OB dept meeting and it became exactly what happened, all of the time. Somehow, all the docs had no problem "remembering" after that.
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I agree that it is more productive to make sure the client you are there with is treated well rather than to take on policy overall. Your kindness and sensitivity toward one woman as an individual can speak volumes to anyone who is there to witness... I have requested less monitoring as well, and that nurses don't offer or even discuss meds b/c the client does not want them. I have also dismissed unkind nurses, demanding that we must have another. I too believe it pays to survey the surroundings a bit and find your allies. Many nurses come to the profession b/c of a similar love of birth, they will be the ones who openly enjoy working with you. Docs and MW's too, will often see you as making their job easier.
I don't have good answers- I have been on birthing room committees in the 80's and other consumer groups- change seems to take time and education consumer awareness and action as well as what providers are willing to do.
Locally a great loss was our county hospital birth unit- due to a terrible billing department they lost millions of dollars though negligent billing practices- any how when the unit was up and running it was run by CNMs basically and the nursing staff manager - hired well, nearly all the basic staff had had homebirths or atleast natural births and were experienced in caring for unmedicated women the epidural rate was very low they had 15% maybe --c section rate was when uneducated nursing staff or docs out of medical school came to work there they were all being trained to be better providers- that is how I have seen change be big and successful-
in the midwifery community what I have seen work is education- continuing ed- bring in outside knowledgeable teachers- I have seen this done with outlying hospitals where regional centers send out teachers so that staff is trained in newer techniques--
I also agree with PP about waiting to know your environment before you start shaking it up- many people who would be great allies loose the battle too quickly--
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