Becoming a Midwife in the 21st Century

Ian Peate, Cathy Hamilton, Professor Ian Peate, OBE, Professor Cathy Hamilton, Ian Peate, Cathy Hamilton

• Publisher: Wiley
• Year: 2013
• Print ISBN: 9780470065594
• eBook ISBN: 9781118690994
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

The NMC have produced standards of proficiency for pre registration midwifery education and those standards have been written in an "academic" language, for higher education institutions. Each student prior to being admitted to the profession must have achieved the proficiencies stated in the NMC publication.

The purpose of this book is to provide students with material related to the standards of midwifery education. The students will be able to use the contents of this text and relate it to their own approved programme of midwifery study, as their programme of study would have had to comply with NMC's requirements. It will help student midwives appreciate how their own programmes have been designed, and why they are required to study and understand some of the subjects they are, or will be studying.

1

Effective Communication

Tandy Deane-Gray

Introduction

The purpose of this chapter is to relate and understand how the development of communication from infancy can influence and inform your skills as adults in order to enhance your work-based experience to meet needs of the clients in your care. The chapter encourages you to draw from the lessons of optimal parent–infant relationships, including sensitive responsiveness, which underpins effective communication, as well as providing an outline of communication issues for practice. This is a condensed chapter on communication skills for midwives, and is designed to stimulate the reader to seek the original sources for expansion of the concepts.

Midwives are in a unique position to observe how humans learn to communicate. When time is taken to observe infants it is apparent that babies are ‘pre-programmed’ to interact with adults (Stern 1985). This is due to their preference for the sound, sight and movement of adults rather than other comparable stimuli. They are especially attracted to their mother. This is probably a biological instinct, as humans depend on their mother and other adults to care for them to ensure survival.

MacFarlane (1977) highlighted the ability of babies and dispelled many myths about infants, such as the belief that they cannot see. Not only can they see – and focus well at about 30 cm – but they like to look at the contrast and contours found in the human face. They turn to sound, particularly their mother’s voice; and will turn to the smell of their mother’s breast pad in preference to another woman’s. So they develop recognition of their mother very quickly through their senses, and communicate their needs through behaviours (RCM 1999).

Babies also mimic the behaviours of adults, most noticeably by facial expression. If you smile, open you mouth wide or stick out your tongue, the baby will watch carefully and then copy. This is quite remarkable – how do they know that they even have a mouth? This can be observed in the first hour after birth and it is this response to adults that makes the baby a social and communicative being, as they will demonstrate taking turns in their non-verbal responses and vocalisations (Murray and Andrews 2000), provided the adult is sensitive to them.

It is not surprising that adults are attracted to baby features. We find certain attributes of the human infant ‘cuddly’: a relatively large head with big eyes, a receding chin and large forehead, round body outline and relatively short limbs, small size and high-pitch vocalisation (Eibl-Eibesfeldt 1996). These features normally stimulate care-taking responses and are perceived as loveable.

Care-taking and our sensitivity to infants is normally based on how we were cared for as infants. If we formed a good enough attachment to our parents and they were in tune with our needs, if they were ‘baby-centred’, then we become secure adults (Steele 2002). Every time babies are changed in a loving way or sympathetically responded to when lonely, tired, hungry or frightened, they take in the experience of being loved in the quality of care received. For a baby, physical discomfort is the same as mental discomfort, and vice versa (Stern 1985).

How do mothers respond sensitively to the specific emotional needs of their infant? Sadly not all of them do. ‘Insensitive mothers’ base their responses on their own needs and wishes, or general ideas about infants’ needs. What is sensitive from an adult’s point of view may not be perceived as such by the infant.

As the WAVE (Worldwide Alternatives to Violence) report (Wave Trust 2005, section 3) summarises, it is the parental attunement to the needs of infants, which midwives have a role in fostering, that leads to loved individuals who do not become anti-social. Sinclair (2007) suggests that through our early relationships and communication from conception to 3 years of age, we develop our emotional brain and our capacity for forming relationships occurs. Fundamentally, human beings at any age respond and feel understood when an attuned sensitive other interacts with them. As a professional, if you respond to the client in your care as a sensitive parent would, your communication with her can be improved.

Sensitive responsiveness is one of the key constructs of attachment theory (Bowlby 1973). The early infant–mother relationship has far-reaching consequences for the developing child’s later social and mental health. It is the underpinning theory in national agendas and frameworks interventions (e.g. DH 2004; Wave Trust 2005; DfES 2006; Sinclair 2007), and recommended for effective practice in the promotion of family health and parenting skills, which are now a priority politically and professionally.

The concept of sensitive responsiveness includes the ability of parents to perceive and respond to infants’ signals accurately, because they are able to see things from the baby’s point of view (Paavola 2006). This has been refined by many researchers.

Mothers who are sensitively responsive demonstrate the following (the key concept is in italics):

• They are observers who listen and see their strengths and help them with their difficulties
• They have warm and responsive interactions with caretakers. The mother’s task is to respond empathically – to mind read. Babies have no control or bad intent, but they learn they can self-regulate through maternal containment. They then learn to self-soothe, for example, by sucking
• They offer structure and routine, which is flexible and age-appropriate, and set boundaries. They provide psychological and physical holding. Holding also relieves anxiety – they feel held together
• They maintain interest by providing things to look at and do through play and touch, but in tune, e.g. they recognise a yawn means ‘leave me to sleep’
• Vocalisation is reinforced by response-dialogue. Hearing and being heard – respond to parent’s voice, familiarity gives sense of security; and babies need to hear talking to develop speech

(Paavola 2006, drawn from DH 2004; Wave Trust 2005; DfES 2006; Ponsford 2006).

Sensitive responsiveness can be facilitated, and when mothers’ sensitivity and responsiveness are enhanced, this results in a dramatic increase in secure attachments with fussy infants (Steele 2002).

Our infant–parent attachment patterns are largely acquired, rather than determined by genetic or biological make-up (Steele 2002), so with support we can improve our ability to relate to others. For midwives this means relating to clients and colleagues, but also facilitating parent–infant relationships. This can be done by praising the sensitivity you observe in parents and helping them see and understand their baby. Using the questions in Table 1.1 might enable parents to realise that they can understand their baby.

Table 1.1 Helping parents know their baby

Ask them to tell you about their baby:

What does he/she like? What does he/she like to hear, look at, feel and smell in particular? How does he/she get your attention? How does he/she tell you they are content? What does he/she like when going to sleep? What do you notice about their sleep or their crying?

The basic method of improving our relationships are those that mothers ideally use with their infants. This is primarily non-verbal, which is not surprising as over 65 per cent of our communication is non-verbal (Pease 1987). Observe bodily and facial cues, and be in touch with what that person might be feeling. This is truly listening and being with another person, and because we are listening and empathising, we provide a safe environment. This is something midwives demonstrate by holding women physically, which seems to help contain the labouring women in their pain, and at birth by encouraging skin-to-skin contact giving the baby a safe framework after being contained in the womb. But we also provide holding psychologically, by being with women and trying to understand what the experience is like for them. This is demonstrating empathy. When we reflect back what the client says and feels by our actions, whether by touch or words, the client feels held and heard.

Humans become socialised and learn that they should not do certain things: they should not upset others; they should stop arguing. We learn to hide our feelings and disguise what we really mean, which in turn leads to a lack of communication.

Dissatisfaction with midwifery care and in family life is often due to lack of communication. Our early skills in relation to communication become set in patterns, and the stamped foot of a toddler’s temper tantrum can still be apparent in the adult. Nichols (1995) summarises the four early stages of development of self described by Stern (1985), which helps inform us of how we adopt patterns of acting and reacting which become unconscious responses in adult life. Interesting as these stages are between the ages of 0 and 18 months, this partly explains why, when we are anxious, we become inarticulate because we have reverted to a pre-verbal developmental stage.

Effective communication can be hard to achieve. Sometimes it seems that no matter how carefully we phrase what we say, the listener either does not understand or misunderstands us. In verbal communication we often add emphasis through body language or intonation. We may adopt a defensive or threatening posture to reinforce our message and, of course, we may raise or lower our voice. These techniques are used spontaneously, having developed through our socialisation in childhood.

Some common problems in communication

Bolton (1979) suggests there are six peculiarities or common problems in human communication. These are mainly to do with understanding and listening:

1. Lack of clarity as words can have different meanings

2. Failure to understand because a message is ‘coded’

3. Failure to receive the message as another agenda is clouding the issue

4. Being distracted and not hearing the message

5. Not understanding because the message is distorted by perception or other filters

6. Not handling emotions during a conversation

The first problem is poor understanding, often due to an unclear message or ambiguous words, because words may have different meanings for different people. As Ralston (1998) points out, terms such as incompetent cervix or inadequate pelvis are open to a very different interpretation to the non-professional listener. But even straightforward terms such as mayonnaise, when it is not differentiated into ‘home-made’ (using raw eggs, which should be avoided in pregnancy) and a commercial product, can lead to women misunderstanding the information they are given (Stapleton et al. 2002).

When the message is ‘coded’ the real meaning is masked; for example, when the client asks you to put her flowers in water, it could be a message to keep her company. It can also often be observed that clients present with one agenda, but really have a different problem – for example, they present with backache, but are really concerned that the pregnancy is normal. Midwives also miss conversational codes for more information from clients (Kirkham et al. 2002a). ‘I don’t know’ and ‘What would you do?’ are both tactics women use to elicit more information, tactics which unfortunately are not very successful.

The way a message is spoken can also conceal a message within the message. Most speech has both an obvious and a hidden meaning (Kagan et al. 1989). For example ‘What did you say?’ has the obvious meaning ‘Please say that again’, but the hidden meaning could be, ‘You’re so boring, I wasn’t really listening’. However, if we say what we really mean we can hurt another’s feelings. So we try to look and act professionally and this creates barriers to communication, because our message is not clear. Indeed, as professionals there are times when we are acutely aware of appropriate interactions and the need to adopt a professional face. For example, it is inappropriate to look cheerful or go into a long explanation of care during a life-threatening emergency (Mapp and Hudson 2005).

Clients also do not hear, or take in, what we say when they are distracted by the environment or physical symptoms. The disruption of a child needing attention during a conversation is an example. A client who is in pain or focused on their child, for example, may miss the information you are giving. However, midwives often miss non-verbal cues and carry on their own conversations neglecting the woman. The woman may interpret this as an ‘I’ve started so I’ll finish’ attitude, while the midwife thinks ‘I know I have given her the information’, even if the client ‘could not hear’. It is interesting to observe that mothers will say ‘Look at me when I am talking to you’ when addressing their children, thus ensuring the non-verbal feedback needed, which tells us we are being heard (Yearwood-Grazette 1978). Midwives should ensure that they respond to nonverbal cues with their clients, particularly eye contact.

Midwives and clients can filter information, because of perceptions, emotions or simple hearing what they wish to hear. For example, if you say ‘You can go home after the paediatrician has discharged the baby’, the client may hear only ‘You can go home’ and so phones her partner to collect her. Midwives too filter information by avoiding discussion. They emphasise physical tasks and this sends the message that discussion, particularly about how the woman feels, is less important. Indeed, discussions are often avoided by filling time asking for urine samples, ignoring possible anxiety even when the last pregnancy was a stillbirth, for example (Kirkham et al. 2002a). In essence, filters become blocks to communication.

Another block to communication is ‘don’t worry’, a term that is used to reassure (Stapleton et al. 2002). However, paradoxically it causes anxiety as the client is denied the opportunity to express how she is really feeling (Stapleton et al. 2002). The words ‘don’t worry’ should be avoided (Mapp and Hudson 2005). A smile or touch is more helpful and reassuring (Mapp and Hudson 2005).

It is not just what we say and do, it is also how we listen. It is rare for midwives to explore topics such as what foods a client eats to invite discussion (Stapleton et al. 2002), yet this would enable the client to say what she knows. However, the midwife would then need to listen for any relevant missing information. This is hard, so instead there is a tendency to tell clients what to do – things they often already know, such as the advantages and disadvantages of breastfeeding – but not what the client wants to know, e.g. ‘what does breastfeeding feel like?’ (Stapleton et al. 2002). Kirkham (1993) suggests:

‘Good care must involve sensitive communication. Good communication is concerned with the exchange of information, ideas or feelings so that both parties understand more and have appropriate expectations. Just to impart our instructions cannot be called good care.’

Finally, people who have difficulty with emotional issues may deny their emotions or become blinded by them (Bolton 1979) because anxiety and fear or any high levels of emotional arousal lock the brain into one-dimensional thinking (Griffin and Tyrrell 2004). Our emotions affect our physiology and hijack the brain’s capacity for rational thought. This inhibits our ability to rationalise or entertain different perspectives, because traumatic and distressing experiences – whether big or small – cause imbalances in the nervous system which create a block or incomplete information-processing. This is why it is difficult to take in medical or other information or advice when we are upset, frightened, angry or in pain. This dysfunctional information is then stored in its unprocessed state in both the mind (neural networks) and the body (cellular memory) (Pert 1997). During emergencies poor communication can compound stress, so careful, sensitive communication that is congruent (i.e. the non-verbal matches the verbal) is what is required (Mapp and Hudson 2005).

Non-emergency situations can also involve high emotional arousal. Emotional arousal as a consequence of a power struggle will evoke a defensive response. As the thinking part of the brain becomes inhibited when the client feels conflict or stress, learning and taking in information cannot be effective (Griffin and Tyrrell 2004). When a midwife says, ‘I want to tell you about breastfeeding’, the emotional arousal from the client may come from the unspoken – ‘Who are you to tell me how to bring up my family!’ It would be more useful to reduce the emotional arousal and reframe or present the information another way, for example, ‘It’s good you have decided on your method of feeding. I would like to hear more about how you are going to feed your baby.’ As Nichols (1995) points out, ‘It isn’t exuberance or any other emotion that conveys loving appreciation; it’s being noticed, understood and taken seriously.’

Midwives may find that employing open questions is time-consuming. However, when information becomes blocked, misunderstanding is increased and this eventually leads to spending more time sorting out the problem later. Midwives also limit their emotional effort and may stereotype in order to increase control over work situations (Kirkham et al. 2002b), although if they were to increase their sensitive responsiveness, clients would be able to get the information they need, understand and feel understood.

Midwives need to give their clients emotional care, particularly those in labour, but this is draining. Many midwives realise they do not have time for their own emotional feelings so they ‘pull down the shutters’ in order to appear calm. It is this that can give the impression of aloofness, whereas others are perceived as naturally friendly (John and Parsons 2006). As John and Parsons (2006) suggest, support mechanisms need to be developed and implemented in order to reduce stress in practice. According to Nichols (1995):

‘If you see a parent with blunted emotions ignoring a brig...

Table of contents

• Cover page
• Contents
• Title page
• Copyright page
• Dedication
• List of contributors
• Acknowledgements
• Introduction
• 1 Effective Communication
• 2 The Aims of Antenatal Care
• 3 Programmes of Care During Childbirth
• 4 Interdisciplinary Working: Seamless Working within Maternity Care
• 5 Intrapartum Care
• 6 Effective Emergency Care
• 7 Initial Assessment and Examination of the Newborn Baby
• 8 Effective Postnatal Care
• 9 Medication and the Midwife
• 10 Effective Documentation
• 11 Regulating the Midwifery Profession - Protecting Women or the Profession?
• 12 The Impact of Cultural Issues on the Practice of Midwifery
• 13 Legislation and the Midwife
• 14 Confidentiality
• 15 Clinical Decision-Making
• 16 Health, Safety and Environmental Issues
• 17 Evidence-Based Practice
• 18 Statutory Supervision of Midwives
• 19 Clinical Governance Framework and Quality Assurance in Relation to Midwifery Care
• Answers to the Cultural Awareness Quiz
• Glossary
• Index