Hospital Agreements: An Opportunity For Engagement [Part II]
If a doula agreement is being waved in front of you, congratulations! It means that your doula community has gotten too large to ignore and is having enough of an impact that the hospital wants to exert some control. Now the real work begins, not with clients, but with the institutions where our clients are choosing to birth. You have an opportunity to create a collaborative atmosphere even if their actions seem hostile at the moment. This is politics, system change, and social change happening in your neighborhood, and I hope to give you concrete suggestions to co-create a synergistic relationship – even if it seems impossible now.
Keep the focus on your long term goal: an open channel of communication between this hospital and the doula community. Your goal is not to get the hospital to eradicate the agreement but to build understanding and strong reliable communication channels between two groups of people. You are using the proffered agreement as an opportunity for greater connection, understanding and dialogue between the people most affected by it. It’s imperative that the doulas who are approaching this conflict negotiation realize that attacking the hospital’s solution, the agreement, is counterproductive. Anytime you openly criticize something, you make that person defensive about it and more entrenched that they are right. Instead, you have to put the emphasis on the conflict and your mutual interest in resolving it. If you focus on the agreement and what’s ‘wrong’ with it, you will get into a power struggle and doulas will likely lose. If not this issue, how you handle this will set a precedent for communicating about any future conflicts. Sorry to increase the tension, but this is an influential time and needs to be recognized as such.
So what can doulas do?
- First, have a leadership committee of the people who have the best communication skills as well as doula experience. Prepare yourselves. Read simple books on negotiation and conflict resolution (see below), or see what community or internet resources are available for continuing education. Being prepared and having skills will give you more confidence – but don’t wait too long.
- Contact the people in charge and set up a meeting. Make it clear that your goal is to generate solutions to their problem, and not to deny that a problem exists. Explain your perspective is rooted in concern for the long term health of the hospital’s relationship with its future patients and future doulas, and an ongoing relationship with open communication can work to both of your benefits. Doulas are not going to disappear, and trying to exert power over the doula community without seeking to get to know them will not work in the hospital’s favor. Someone in that problem solving group knows that, but their voice may have been drowned out by others. Doulas, there are allies in that hospital, and you will need to find them. Hopefully, you will also cultivate new ones through your sincerity and focusing on the long term goals. This will be harder to do if the atmosphere is hostile or the agreement is written in a way that delegitimizes a doula’s contributions to maternal-infant health or seeks to restrict the doula’s access to a client. However it isn’t impossible. Remember, they don’t understand our values or our role and you can change this over time.
- Be gently persistent until you get a meeting. State that you don’t want to get rid of their agreement proposal, but seek to find additional ways for their needs to get met. Do they want someone to call and complain to? Often what people want the most, over and over again, is to feel that their concerns were heard and met with kindness and respect. If you push that aspect of the meeting – “we want to hear more about your concerns” – it will be more effective than “we have to do something about this agreement”.
- Use this handout Doula Information for Nurses Sheet (initially designed for a nurse and doula conflict resolution meeting in my city) or a similar one to explain why doulas do what they do and give background about the state of the profession. Make sure you are all on common ground about doula support and what doulas actually DO and don’t do. Issues may arise as you go through this sheet together. Listen. Listen. Listen. Even if the people at that meeting are not listening to you, listen to them. Reflect back their concerns in your own language. “What I heard you say is…”
- Emphasize common interests. “What we both value is…” Do this repeatedly as needed throughout the conversation.
- Ask, “What other possible ways to address this problem did you come up with besides an agreement?” This is where you’ll find out whether they fully explored the initial problem or took into account the concerns of other stakeholders. It’s possible they may not have and you can initiate it at this meeting. Ideally, you’ll be able to follow up with a small group made up of multiple stakeholders (see list in Part I) who are interested in a more complete problem solving process. Resist the urge to rely on one or two people from either group to do the negotiating or attend meetings – if one person leaves their position you’re back where you started from – without an ally.
- If the atmosphere is hostile or untrustworthy, it is critical that you do not allow emotions to cloud your judgment. Your communication needs to be intentional, not reactive. Don’t take bait – slurs on a doula’s past actions, a doula’s motivations, etc. Let it go for now. Frame it as “learning about the tactics of your negotiating partners”. Recognize that establishing trust takes time and repeated interactions where people behave reliably and do what they say they are going to do. Promise what you can deliver, not what you can’t. Set reasonable deadlines and meet them. People learn the value of a doula by experiencing you doing what you do, not from reading or talking about it.
- Be prepared for the presenting problem to not be the true problem. In one hospital I consulted with people were angry that doula clients kept insisting on special treatment for their newborns. Administrators discovered that while there were protocols for one hour of uninterrupted skin to skin contact in place, that was not what nurses were actually doing. Unless the doula reminded the parents and both parties actively advocated for it, usually repeatedly during that first hour, parents were not getting the care that the protocols were written to encourage. Nurses didn’t like the criticism and resistance they experienced from doula attended clients, and it was labeled as a ‘doula problem.’ However, once different stakeholders were interviewed, they discovered a deeper issue. It turned out the nurse’s workloads were so high that they felt pressured to do newborn procedures even when that interfered with the one hour skin to skin mandate. So what was initially perceived as a doula conflict, was instead a conflict between policy and workloads, with parents and babies being the losers and doulas as the scapegoat. This can also work the other way, so be prepared to listen to criticism of doula behaviors. Remember, listening is the most important thing you can do at this stage – there may be years worth of resentments pouring out if you’ve never had a meeting before.
- Focus on the possibility of a positive outcome. You can create collaborative relationships that don’t compromise the doula’s autonomy, ability to represent and serve her clients, and satisfy the hospital staff’s needs for predictability. In doing research for these blog posts, I found examples of several birth communities who had already created collaborative long term processes. (Please add yours in the blog comments.)
Susan Martensen, a doula and trainer in Ottawa, Ontario, Canada, states that her local doula group has worked hard to be recognized as part of “The Care Team” and not as a “visitor”. The instigating situation that brought doulas and nurses together was the SARS outbreak in 2003. Hospitals sought to limit access for anyone into the hospital. Doulas in the area formed a new group to develop a standard of practice and code of ethics based on ones from their different training organizations. All doulas in the area agreed to sign the document they had created. “Two hospitals in the area agreed to regular meetings to build bridges and establish doulas as part of the Care team (and not included in the usual visitor policy),” according to Ms. Martensen. “It took several in-services to introduce, or re-introduce, the role of the doula to the nursing staff, so that we all understood the collaborative model of care. The meeting was multi-disciplinary, so there were doctors, anesthetists, pediatricians, etc, there, but not everyone and not all at the same time.”
The next step was to establish nametags for the doulas that were created by the doula group and a book at the nurse’s station that listed photos, names and contact information for the doulas. “Over time we developed a complaint process as well as establishing a system for addressing any conflicts during a labor,” adds Ms. Martensen. “It is a collaborative model that has worked well for the most part, and it is not administered by the hospitals.” They continue to have regular meetings with key personnel and doulas to provide feedback and assess their collaboration with one another. Ms. Martensen feels that the emphasis on collaboration and being seen as a valued member of the care team is what has made all the difference.
Ana Paula Markel, of BiniBirth in Los Angeles, California, USA, initially worked with a small task force at Cedars Sinai Medical Center. A rising number of conflicts was leading to a tense atmosphere, and Ms. Markel was talking to a labor and delivery nurse about it. Out of that casual conversation, a small group of interested individuals got together and outlined several steps which they have been implementing in the last year. They created a Cedars-Doula Advisory Committee made up of labor and delivery nurses, midwives, the nurse manager, and six doulas from the community who each have a different level of experience. Ms. Markel feels that having new doulas involved is crucial, since they often present a different perspective. The CDAC meets monthly, and has its own email address where people can write with questions or complaints. It is used by both doulas and nurses. Based on this feedback, they created a teach-in day for doulas, which was also attended by much of the labor and delivery staff. They did several role plays of challenging scenarios and explored the point of view of both nurses and doulas and what each thought the other “should” be doing. It was very enlightening for everyone. After attending the teach-in day, doulas received a recognition badge to wear. In this way nurses were reassured about the doula’s perspective and background knowledge.
Both the Toronto and Los Angeles doula communities were able to turn potential conflicts into opportunities for collaboration and enrichment. So, take heart! It can be done – you can create a process that benefits many stakeholders long term. It is up to us, as doulas, to do the work and it is a task to be embraced. To have the ear of hospital leaders, even if it is coming in the guise of an untenable agreement, is what decades of doulas have been waiting for: an opportunity to create positive change in the system.
Here is a pdf copy of this blog post: Gilliland Hospital Agreements Engagement
 Fisher and Ury, Getting To Yes, p. 41 (first ed.)
 Fisher and Shapiro, Beyond Reason, p. 53
Other conflict resolution, negotiation, or mediation resources may be available through a community college, university extension, adult education, or state or provincial small business support organization.