Nurses as Advocates and Change Leaders #013

We are celebrating Nurses Week with two special guests on the show, Mandy Irby & Torie Pugh.  We are digging in to what it means to be a nurse advocate, the pressing issues facing birthing people right now, and empowering nurses to step up and into their roles as care leaders at the bedside and beyond.

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Maggie, RNC-OB:   0:05
Welcome to Your BIRTH Partners. We're here to break down barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you no matter what your background is and are so excited to learn together. Today we have two wonderful guests on the show, Mandy Irby and Torie Pugh, in honor of Nurses Week. These two nurses both have a strong history in labor and delivery and obstetrical nursing. You will learn more about their journey through nursing and how they have grown in their role as advocates for their patients. You'll gain a greater understanding about some of the pressing issues that are facing our patient population and the clear and actual steps you can take as a nurse to improve birth for all those in your care.  Onto the show!

Maggie, RNC-OB:   0:55
All right, so I am thrilled today to welcome Torie and Mandy to the podcast. These are two just rock star nurses who I look up to you immensely, and I'm really excited for them to share with us during Nurses Week a little bit more about what it means for them to be a nurse, how they have become a stronger advocate throughout their practice and what they can do to encourage other nurses to step forward and really be change agents and leaders within birth care and obstetrical nursing. So I would love it if you all want to just kind of introduce yourself, tell us a little bit more about who you are and you know your path through nursing

Torie, RNC-OB:   1:30
Hi everyone, my name is Torie Pugh. And I am a nurse and I've been a nurse since 2010. Most of my nursing has been or maternal child health, preferably L&D.  I started off as a staff nurse, then I went back to school and got my master's degree. I taught nursing students. I've also been a nurse educator for the actual unit. And as of right now, I'm the Perinatal Program Manager, which means that I'm looking at the entire program at my hospital as a whole, starting from the of obstetrical offices through inpatient through out-patient, so looking at the entire program.

Mandy, RNC-OB:   2:06
Wow.

Maggie, RNC-OB:   2:07
I know, right?

Mandy, RNC-OB:   2:10
That job is amazing and huge

Torie, RNC-OB:   2:13
Well thank you, Mandy.

Mandy, RNC-OB:   2:13
and I'm sure very difficult and challenging.

Torie, RNC-OB:   2:17
[laughter] Yeah, you know.

Mandy, RNC-OB:   2:19
Yeah. What an effect you may have.  That's awesome.

Torie, RNC-OB:   2:22
Thank you, Mandy.

Mandy, RNC-OB:   2:24
Well, Torie and I just met. My name is Mandy Irby. And so I'm like listening. And I'm like, "Oh, wait, I have to talk." I'm Mandy Irby.  I'm a labor and delivery nurse. I am a lamaze childbirth educator, peanut ball trainer, trauma informed nurse educator, Spinning Babies parent educator. Essentially, I am on the education side, instead of the bedside right now. I was a labor and delivery bedside nurse for 11 years, and I just left the bedside a few months ago, and it's new and different and exciting still. But I now work online mostly to educate families and nurses about trauma informed care and choice and voice at the bedside, mostly online now that we're in a pandemic, but people like online anyways.

Maggie, RNC-OB:   0:00
Yes, going with the times.  

Torie, RNC-OB:   3:20
[laughter]. Awesome, Mandy.

Mandy, RNC-OB:   3:25
That's wonderful, and I feel like most of our listeners are probably familiar with me already, but I'm Maggie Runyon. I am a labor and delivery nurse. I've been working within the maternal child health sphere for over a decade now, predominately as a labor and delivery nurse, and I worked also on, you know, Mother-Baby and Nursery.  I have mostly worked per diem since my babies came along a few years ago.  I had the opportunity to teach nursing students in clinical and in college settings, and I enjoy educating very much. I feel like that piece of be able to shape kind of the next generation of nurses means a lot to me because I had a couple of nursing instructors who really changed who I am today and really empowered me. And so I love providing education. I love doing parent education. I also do prenatal yoga right now, it's a really great way to kind of get a little bit more active with the women in my community, the people who are coming in to have babies and get to know them a little bit more, and then it's always a treat to actually see them when they're coming in to give birth to their babies. And then through through this work, I feel like part of my journey as a nurse has really been stepping into my role as an advocate. And that was what kind of led me to to found Your BIRTH Partners and to start doing this work a little bit more publicly. I think as nurses, I feel like when I was coming up as a nurse, there was a lot more emphasis, and we had courses about how do we kind of interact and collaborate with physicians and other colleagues within medical sphere and more emphasis on really kind of stepping into that role. I think, that being said, sometimes it still feels challenging as a nurse to really kind of like fully embody everything that we know all the different ways that we care for patients and effectively communicate with our colleagues and other staff and really get into that collaborative practice environment. And so I love that through this podcast, and the people I've come to know through kind of getting out there in the birth world a little bit more, I love seeing the connections that we make, the things we share across the disciplines. But I also I really wanted to focus, since this is coming out during Nurses Week and 2020 is, you know, the World Health Organization, "Year of the Nurse and Midwife." And, of course, with COVID-19 and the pandemic, there is even more attention on nurses and the really important role that we play in health care. And so I would love to just be able to focus a little bit more on, you know, what does it mean to you all to be a nurse?

Torie, RNC-OB:   5:54
Well for me, being a nurse is life changing. It's what I've literally always wanted to do. I think since I was a little girl playing with my little cabbage patch dolls and having a little doctor set. Ever since then, always wanted to be a nurse. And I knew that coming into nursing that I wanted to work in maternal child health field. I started off in the med-surg world. They say you should do first, but technically, I don't think that you should have to do that, but did that for about a year to and then migrated over towards Maternal Child Health, and L&D.  And I think for me being a nurse, it gives me that empowerment to feel like I'm making actual change. I think nothing is better than seeing someone come in one kind of condition and then seeing them leaving in a totally different one, and that you had a huge impact on that. And, you know, a lot of us don't get recognition for, but we don't do it for recognition. I mean, you don't because you honestly love it. And I remember in nursing school, one of my instructors telling our entire class as a freshman was, you know, "you guys hear that nurses make all these crazy amount of money. Yes, and probably could. But if you're coming into it just for the money, you should probably leave now, because there's gonna be times where you're not gonna make that much money and you're gonna walk away from your shift and like question yourself being a nurse so you have to really have a passion for it." And I love what I do. I absolutely love love what I do. And like I said, it's not just about the patients, it's about, you know, these nurses and these doctors and everyone that you work with her like your family, you're with them all the time, and, teamwork is really important. And again, I think nurses are awesome, and I think a lot of nurses, well, the nursing field, I think we don't get as much credit for a lot of things that we actually do that we should get credit for.  

Maggie, RNC-OB:   7:35
Mmm.

Mandy, RNC-OB:   7:37
Yeah. Isn't that true when a family says, "Where's the doctor?"

Torie, RNC-OB:   7:42
Oh, you gotta love it. [laughter]

Mandy, RNC-OB:   7:43
That's TV, guys, it's just me." [laughter]

Torie, RNC-OB:   0:00
Literally, literally.  

Mandy, RNC-OB:   7:50
They're like, "Whoa your job is so important." Best job ever. Yeah. I did not come into nursing, knowing I wanted to be a nurse. I wanted to probably work in a lab. Except I realized I really like people and I wouldn't be able to see very many that way. So I stumbled into nursing, stumbled into labor and delivery. Someone else had to tell me. "Oh, my gosh, you're really good at this." And I was like, "Really?" And of course, love it, and you don't, yeah, you can't do it unless you love it. But I think, I think the nurse is the liaison between the patient, their family, who is also your patient, their baby, who is also your patient, and the system that they're in. So I love that in birth, we don't have birth centers where I live, well, we don't have birth centers with RNs or CNMs. I love that RNs, nurses can work in all kinds of different locations, they can be outpatient, that can work in birth centers, they can work in hospitals around birth they can teach and all of that also, they can work online. And they're always the liaison between where they're at and the people that they're helping. And it makes it so incredibly difficult to do what we do because we have so many languages that we have to speak. And we feel like we're juggling all the plates sometimes.  But I think labor nurses have the best job ever. I think they have so many superpowers. I think truly it is the most important job in the entire world because   

Torie, RNC-OB:   9:35
Agreed.

Maggie, RNC-OB:   9:35
Absolutely.

Mandy, RNC-OB:   9:35
Because of the life changing things that happen during birth, I mean parents are reborn, people are reborn. Babies are born, humans are coming out, and all of their layers are open, they're vulnerable, they're learning, and people listen the nurses. So I think I think it's an incredible opportunity for helping people heal and move, move into that transformation that is parenthood.  

Maggie, RNC-OB:   10:02
Absolutely.  I always think just birth is it's such an honor. It really is, you know it sounds cliche, but it really is just an incredible like gift to be able to be a part of such a transformational experience, you know, for people. And I think especially, you know, like we said as the nurse, because of the way you know, staffing ratios work and everything, we get to be the ones who are there through so much of that time. And, you know, oftentimes we get to be there longer than you know the provider, the midwife, the OB, or whoever else is caring for them. And that really gives us this really intimate glimpse into a family into how people operate. And getting to see that is, it's an honor. There comes a lot of responsibility, you know, with that as well in terms of how, what role we actually get to play in how their story unfolds. You know, certainly no one else can make someone give birth, can you know, can make a baby come out if it's not, you know, working. There are limits, obviously, but we do have a big role in how the story plays out, in how people perceive their experience in, you know, in how the different measures that are necessary to help guide, you know, birth along. And so I would love if you all could speak to that kind of piece, how do we, how can we as nurses kind of step into that that role more? Be stronger advocates and really kind of own that place at the bedside.

Torie, RNC-OB:   11:36
I think for me, from what I've learned is that, you have a totally different experience when you graduate from a novice nurse to a seasoned nurse and all of us remembers being that brand new nurse, timid, didn't know anything, terrified to even talk to a patient, let alone touch them and then fast forward a year one, year five. All of a sudden you are charge, you are critically thinking, you're running stuff, you're making these calls, you're figuring out what's gonna happen before it even happens. And I think that kind of empowerment comes with time. And I think it comes with what kind of support that you actually get, even as a seasoned nurse, a few years in, when I, you know, totally, felt empowered totally felt as though I could see this patient, I know what's gonna happen, I can call the doctor.  I had to speak with physicians and, for example, if there was a new nurse on the unit or if I had a nurse that was shadowing me, a brand new nurse, that the doctor will listen losing to me, and only speak to me, and talk to me. And I would have to say, you know, "she's here too, this is her patient, you know?" And I've had doctors tell me "Well, I know you know what you're doing, but she doesn't." And yeah, but you don't give her the chance, you know? And so I try to be that advocate for newer nurses, for novice nurses, for new graduates that we really don't have a voice yet and really, you know, don't have that relationship with these doctors yet, and and other staff yet and try to speak up for them. We've all been there, we've all been there, as I think it's important as a nurse, as a seasoned nurse for us to not like you, said "eat are young" and stick up for them and guide them through this journey that we've all been through. You know, it shouldn't be a sink or swim. You know, it shouldn't be they're going to sink to the bottom or, you know, that's it.  It should be, let's help you peddle a little bit. And so again for me, I think empowerment a huge part of it comes from experience, and the other part of it comes from the kind of support that you have.

Mandy, RNC-OB:   13:51
Mmm. I love that.  Yeah, I think, uh, I struggled, still struggle. Not everyone, I think who looked at me. I hear people who I work with say, "Oh, what you can communicate and get your point across and have those discussions with the provider and you talk to him in the hallway sometimes," and I never felt very confident about that. I wish I was better at that, but to speak to so that takes even longer time and probably some really specific education, leadership, education, communication, education that we can we really have to find on our own. That's none offered often, but to feel confident in the space that you're in. I think it takes sitting with physiologic birth. It wasn't until I was many, many years in that I was forced to sit with physiologic birth for my own birth prep. And I fought it for probably seven years because physiologic birth, untouched birth, birth that's just watched and not messed with ,birth that you hear about in books that you don't see very often or it's those precipitous kind of drive byes that you're like, "Whoa, what just happened?" That was amazing. I didn't see it very much in the medical model. I didn't see it very much in the hospital. I had to go seek it out, and I so I read about it and tried to watch as much as I could try to be at the bedside as much as I could. And it was quickly a feeling of confidence in just birth itself, on the people that I was with the patients and the families because they were looking to me. Of course, they're looking to the nurse to be like "Is this normal" and in the back of my head for so long, I was like, "I don't know." I mean forever, we don't know, we don't know it's normal for each person or what's expected, right? We don't know what to expect, but learn, like feeling solid in one's ability to give birth, or at least most body's ability to give birth if untouched, and then allowed me to feel confident to just, you know, be with someone instead of feeling nervous about what if sounds came out, or what if someone came in and asked me if everything was okay? Because to me, that felt like maybe things weren't okay? But when I could sit with birth, I felt like I could really give space for someone's individual birth situation a little better. My eyes were a little more honest with them about like, yeah, all kinds of things happen, "this is fine; I hope." 

Maggie, RNC-OB:   16:40
Yeah.

Mandy, RNC-OB:   16:42
And finding that as a newer nurse, I think requires intention. So someone told me this, and I was exhausted for many, many years, doing it as a new nurse on night shift. But every birth that happens, that is appropriate, and you can find a job to do, you go into the room and you find a job to do and you do it and you experience birth with other people so that you experience that feeling of like "everything's cool, everything's cool" because you're not experiencing it with the patient, necessarily that whole time. So that nurse has a specific, you know, unique relationship with that patient. But to view birth over and over and over, you can get it in faster if you can help support the nurse, like doing all the little jobs if you're not adding, like extra eyes that are watching the patient. Of course, I don't advocate from people watching people give birth. But if you can find a job that is helpful and you can support the nurse, be at the bedside, then you'll see twice as many births maybe as you normally would, so that can speed up your experience factor. I think it's cool to see how other people support birth too, right? Go ahead. You kind of learn like "oh, I'm not gonna do that...that made me feel weird."

Mandy, RNC-OB:   17:57
Yeah, I think, you know, like you both touched on that idea of that support that you kind of find within your workplace and some, you know, some cultures are different in every unit. Every place you work has their own vibe, you know, and there's different, there's, you know, challenges in any situation and also really great things. And where have you found, do you feel like it's been more internal things that have kind of held you back? That feeling of just being being a novice, not having seen enough birth or other kind of extra factors that have made it feel hard for you to kind of step into that role? 

Mandy, RNC-OB:   18:37
I don't think we're taught how to advocate for someone, right? Right, ever.  Yeah. I was looking back it just now that I'm teaching nurses I'm looking back at, like, where did I miss this information? And AWHONN doesn't give us a very good definition of how to advocate, my like VNA doesn't give a very good definition in Virginia. My education from a prestigious university didn't give a lot of good information about what does it look like and sound like and feel like to advocate for someone inside a hospital. You're not speaking for them, but sometimes you're speaking for them from what they've told you. But then, for some reason, everyone needs to hear it from the patient again, right? It's not clear. That was a huge challenge for me to be like what is advocating for a patient? And I decided I can't go wrong if it's always the patient's decision. So then it became education, tons and tons of education with the patient every chance I got. And if they could make a decision from that, then I could stand solid in a decision that they made. And if it was up to the patient than I wasn't doing wrong by advocating for what the patient said in just repeating "No, this is what she told me. This is what she wanted" and trying to feel confident in that. But there's not a lot of education for the language to use for advocacy. What what does it mean? What does it look like? What it does it sound like, because a lot of times that feels uncomfortable, right?

Torie, RNC-OB:   23:39
I think Mandy made a really good point. I think that education is like everything to me. I feel like if you have education, you are empowered to make decisions and so I will say about 90% of my patients that I get a chance to sit down with them at some point. I have this thing where you know, I pull the stool next to them, a chair next to them and sit. And we have education session for good five or ten minutes, and I try to tell them quickly, but "here's what's gonna happen, here's what could happen, here's what could go wrong, here's what could go right, here's what you can say." And I can't tell you how many patients at the end of their journey after having a baby went back and said, I remember you told me that that could happen and that did happen. So they felt like they had that that empowerment to be able to speak up for themselves or if things didn't go the way that they wanted it to go, but it was necessary, they at least felt empowered to, you know, take some of that that being scared away a little bit. And, you know, she did tell me this, that this was a possibility. So now here we are, you know, and I'm I mean all about education. and even teaching nursing students. I usually make this like speech in the beginning, off their semester, which is "Listen, I'm not one of these instructors that does teaching by being meam. So breathe." And they're like, ok. "like breathe. It is okay, it's okay. I said I am about education. That's why we're here. And I was where you are. I was terrified. Sitting in that same exact seat that you were sitting in and let's get through this." And I teach them things with my students. I would teach them things that they wouldn't learn for another two or three months like EFM strips on day one we go through that, day one. And so by the time they got into it was like, "Oh, we've been going through over that for the past three months." Now, you know, with my patients, you know, if you get them from the beginning, I believe that education is probably one of the most strongest things that we have as a person that no one can take away from you.  I've always been told that, no matter what. No one can take away your graduation, no one can take away your MSN, like you've earned that. And so that's what I've always had that mindset that as long as they're educated that they have something that no one can ever take away from them and make actual decisions based off of the current predicament. And, they're empowered. So absolutely, I do, I definitely agree with being educated, and I don't think that we are educated. You don't get that piece, like you said, where is it found like, why do some people have it and some people don't, you know? 

Mandy, RNC-OB:   23:39
Yeah, it takes a lot of work. Yeah, practice. And when you have education, when parents know how a body gives birth, when parents know what it's like to be in the hospital, I think they have choice. I don't think they have a choice unless I don't know... That's what I hear afterward a lot is "Oh, my gosh, I had no idea that was gonna be a choice."

Maggie, RNC-OB:   23:40
Well you don't have a choice if you don't know what your options are, right?

Mandy, RNC-OB:   23:42
Right? 

Maggie, RNC-OB:   23:43
If you've never been told that there are different ways to to do anything, you know?

Mandy, RNC-OB:   23:48
Right. Because when we say, Do you want to get a gown on? That's only one of the choices. "Do you want to get this gown on?" and that's what we're taught. Just give them the gown. "Okay, here's the gown. Do you wanna put this on?" We don't also say, "Or do you want to wear sports for in a skirt? Or do you want to wear two gowns? Or do you want to wear nothing?" We don't give 16 choices, because who, you know we're in a system where there's no time for choices. Please come into this program with some education. And then when we reinforce choice, it's not overwhelming for either of us. It's not overwhelming for the nurse to go through every choice because we have other patients. We have the limitations of the work, of our job, of our numbers and things like that, responsibilities. But also it's not overwhelming for the patient.  When they're like "I'm crumbling under all the choices."  

Maggie, RNC-OB:   24:38
Right.

Mandy, RNC-OB:   24:38
It should be empowering to be like, "Oh my gosh, it didn't go the way I had envisioned, but I made decisions, every single decision along the way with the information that was given to me." 

Torie, RNC-OB:   24:50
Yup.

Mandy, RNC-OB:   24:50
I think that feels so good to really lay it out for your patient. And you don't have a horse in the race like I have no cares what you choose, right? "Wear a gown, be naked. Don't care."

Maggie, RNC-OB:   25:07
That does not impact my experience.

Mandy, RNC-OB:   25:08
Right? It does not impact my day. I have seen naked bodies, I have seen bodies covered from head to toe. It is totally, I don't know what your answer is, you have to come up with that answer and then practicing easy things helps them make other more challenging choices.

Maggie, RNC-OB:   25:27
Yeah, I  think I mean, you both raise such good points there. I feel like there. I think a lot of what holds us back from necessarily stepping into that advocacy role is that feeling that, like, the right thing to do, is to say yes, right? Like we go with the flow that's like everything just keeps going right, like no one likes a squeaky wheel. And I think sometimes we see that, like in certain, in certain practices, and it's certainly regional as well. Some health care systems, everyone's expected to just do this, right? There's the semblance of no choices, right? You're just, "yup. you do this, and then you get that, and then we do that, and then oh, okay. Great." It all kind of plays out on this, you know, pre recorded track that everyone's just plugging into. And...

Mandy, RNC-OB:   26:13
That's not birth.

Maggie, RNC-OB:   26:13
It's not, that that's just not real life, you know? Like, I think so many of us, obviously humans, I think a lot we crave control, right? We crave that idea of knowing that, like, "yes, I will do this, that will happen, it will all be this plan. Okay."But that is all in our head. There are very few things in life that we actually get to control. We get to control the way we respond to something, right? But I think when we as a system try to say that like, this is the role of the nurse, they're going to do all of these things in this order, and then that's gonna create this outcome; it sets everyone up for failure. You know, we're not able to respond dynamically to what our patient actually needs. What they're saying they want, if we think they were supposed to be going along with a party line for birth and what it's supposed to look like. And I think like you said, you know it, obviously, I have supported birth over, you know, several years I've supported births in several different hospital settings, at home, I feel like I've seen birth go a 1,000,000 different ways, and there are so many different great paths to having a baby. And everyone is on, you know, their journey. And I do feel like sometimes you said like, I don't, "I lovingly don't care what you choose about this" because it's not my birth. Like I have had my births and was able to make the choices that I wanted to for those because that was my experience. And I think sometimes there's this pressure on birthing people that they feel like they're supposed to do something. They're looking us as the nurse, they're looking to the provider or they want to do whatever like the right thing is, and it's very challenging as a nurse to help them to navigate that and to truly believe that, like no, there isn't one right decision, the right decision is the one that's right, you know, for you.  And I do, I definitely think that that pressure, that birthing people feel it plays into then how we're able to help them kind of navigate that winds with more or less ease. When I do think it comes with a price, it would be awesome to see more nursing instructors, you know, do what you're doing, Torie talking to, you know, having words, honest discussions and preparing students a little bit more. And I know there's a lot of discussion about kind of what nursing education could look like and things that we need to incorporate into, you know, curriculum. Like you said, at many nursing schools all over the country, there seem to be a lot of gaps with, you know, critical race theory, with advocacy, with how do we actually stand up with social determinants of health.  Like there are so many things that we do not address in our nursing education, sometimes not at all, and certainly not to, you know, the degree that they really need the emphasis that they need for how often nurses are gonna be in situations where that's relevant I think that's something that to change to advocate for, you know, as nurses on the other side as much as we can. But I also I would love to know, you know, from your perspective, what kind of the critical issues in you know, obstetrical nursing, in maternal child health nursing. You know, what are the torches that nurses could be picking up right now and really trying to help make change, you know, at their level in their units?

Torie, RNC-OB:   29:27
So there's been this huge topic that's been kind of hitting the headlines a little bit in the past few few years, predominately with the amounts of maternal deaths amongst African American women. And I remember being a staff nurse and feeling like beds. I had to advocate more for them, for the other, maybe people that didn't have as much money, maybe lower income people, or people from different cultures, people who didn't who didn't speak English. You know, people who you know, didn't have these top careers basically all of the, the latter, because you can see how they may have been treated a little bit different. A mom comes in that has history of drug use. Okay, so you automatically pass judgment for it, right? But you don't look back, you don't talk to her and find out well, what what like happened? And you'll find that when you sit and talk to her, it was the car accident that she had been in five years ago that caused her get on this medication, that now caused this...she had this huge job as the top director of this law firm company. And now she is living out on the streets. But you just judge her from living on the streets, not knowing that 3 or 4 years ago, she made three times as much money as you did. She had this huge mansion, she was, you know, this great person. And then this life happened, and we take life for granted and and not knowing that you're probably one car accident away from the same thing happening to you. I probably spent most of my nursing career being huge advocates for the latter. And then, like I was saying, beginning with African American women are more prone to dying during childbirth more than any other race. And why? Why was that? And I went to a seminar about that and they honestly from the studies they could not figure out why. Because they said that even it was determined that women that even had a doctorate degree were still...because the first thought was that maybe they were just weren't being as educated. Okay, but then they said that a lot of these women even have like doctorate degrees. But they were still more prone to dying more than any other culture that just had a high school diploma. So why was that? And looking back, as being a staff nurse. I do remember again, advocating more for those women, sometimes feeling like they that their concerns weren't taking as seriously, that maybe they were just being complainers and then me trying to, me advocating and then turns out that no, it actually was a serious thing that could have went way, way left, had not [I stepped in], you know, and again, just advocating for those type of people. Like I said earlier, low income, whatever the case is. Again, I don't think we have that education as far as using your best nursing judgement with, you know, like I said, with drug addicts and whatever the case is that as a nurse, you need to throw all that out of the window. They are your patient, they're here, they're having a baby. What we're doing now, don't just for anything else, just because she acts for some pain medicine with a history of drug use. Now you judge her and say no, she's probably not really in pain, she just wants medicine, those kinds of things. So that has been, I think the forefront of my thinking going into being a nurse is that I don't treat anyone different. I will have two different kinds of patients. I'll have a 30 year old mom who makes all this money, this great career who has done all of her research, went to all of the education classes and go right next door to a 16 year old who knows absolutely nothing, who was living out on the streets, who doesn't have any money. I'm treating them exact the same way, because that has nothing to do with the current situation that we're currently in. Which is that you're my patient,  you're important and let's get through this, and I think that's been like a huge, huge passion of mine since the very beginning. 

Mandy, RNC-OB:   33:29
Mic drop.  I mean that's it right there. Yeah, I love that. You say it and you said it first. The studies that you've learned about I mean, they found a cause, that was racism.  

Torie, RNC-OB:   33:46
Okay, Yeah. Okay.  

Mandy, RNC-OB:   33:47
So let's just to add to your discussion people that don't speak English, people from other cultures that maybe their care providers don't understand or they're not from the same culture, people who are not white, people that are African American ,people that are low income, low socioeconomic okay, all of that is true. They have worse outcomes in labor and all three of us have seen them treated markedly differently. It's whether we notice it or not. It's whether we talk about it or not. It does happen in everyone's unit. It does, because it's our whole country's numbers. It's not just one state, one hospital, the teaching hospitals, the community hospitals. It's not that. But then the studies specifically for African Americans took into account people who have immigrated and then have babies that are black, people who have come from other countries that are Africa, who are dark skin, people who have lived here and then beyond generations...and it is racism and it is systemic. It's generational trauma, stress. It's not just one thing for one person, it's generational it's in the history of how people are treated and then how we treat people. It's two sided, so just like laying that out there from that's a thing and that is...

Torie, RNC-OB:   0:00
Very well said.So from someone who has seen it, I have seen that happen. I have felt this deep, dark pain of helplessness. If we've had racism for ever, how do all of a sudden we have better outcomes in labor and delivery? Just because we know that is right, like it doesn't come with an answer. It is a lot of good information, but I was a missing like an answer, like what we do I've seen this happen and it angers me and it, you know, in rage and lights a fire and I talk about it and I'm like, "Okay, now everyone I know is gonna hear it because when you hear it, you can't unhear it." Now go prove me wrong. Go tell me that you work somewhere that doesn't treat people that are different than whoever treating, treats hem differently on.  Go tell me why your numbers are not universal, you know, in the country because they are, we all have the same numbers and it's staggering. It's frightening. It's so much fear. And I teach all you know when we teach parents we're like, "What are you afraid of? Get it out on the table. Let it out. Let's work it out. Don't bring it into labor because that will affect hormones in a no effect where your mind is, it will affect how your baby comes out." But that's terrifying to walk into a hospital and not know how you're gonna be treated and not know if famous rich pro athletes are sicker, then people that are not black or not African American, that's got to be terrifying. So along the same lines, but different, I think critical critical nurse attention is trauma informed care. I think that incorporates and kind of puts everyone at a even playing leve,l playing field. When you, when you learn trauma informed care, it's patient centered and focused on individual needs and reinforces that the patient is the expert on their own body, on their own choices, on their own baby and takes pressure off the nurse as well. So I find it to be at least a placeholder for an answer to well, if I know that African Americans are more at risk than I advocate differently. But then what about, what about that 16 year old, you know, homeless mother? Or what about the person who I feel, can't say no to anyone like that, they're vulnerable in a way that I don't have answers for, either. Not to minimize the racism aspect, but I'm hoping to incorporate it together with your latter idea instead of feeling like because I always felt like I was juggling the plates like I don't know what's right for this person, and this patient doesn't know what's right for this person, but they're definitely going to be told what to do unless, you know, I can help them come up with their own choice. I think trauma informed care. You can go in with an open slate and, like you said, like people guess people guess someone's history. If you see the numbers of mistreated or abused people, especially women in the US it's the majority, the majority of people taking care of people giving birth, it's the  majority of birthing people. So that's doesn't matter, how much money you make, doesn't matter what your partner looks like right now, it doesn't matter who's at your bedside like we can't ever guess those people on when we start to be open to it and hear stories, I think it's easier to be like, "oh so like I have no idea what might harm this person or trigger this person or hurt this person's potential to have a healing experience. So I think that it should be Trauma Informed. Foundation should be how nurses learn how to give care, how to do cervical exams, how to get consent, how to do education and at least as a placeholder until we figure out more answers for how to care for everyone the same. It helps me realize that everyone comes with their own experiences, whether you're 16 or 36 and that's going to affect how you make decisions, how you feel about me as your nurse. The fears that you bring in and also the like, strengthen and  triumphs that each birthing person has.

Torie, RNC-OB:   40:05
When I was a new nurse, I looked at everyone the same. At that point, I was  just so terrified just not to kill somebody at the end of the day.  I didn't care what race you were.  

Mandy, RNC-OB:   40:17
I'm looking at you like you have an amniotic embolism right now because you probably do [laughter].

Torie, RNC-OB:   40:22
[laughter] I didn't want to kill you. So that was it. That was my foresight, but I think what kind of woke me up to "oh maybe be this is maybe a problem" was I got a letter from a patient a few weeks later. She gave it to my manager and this letter she thanked me for being nice to her. She said, because some of the other staff, some of the nurses and doctors were not nice to her because she was a drug addict and this, and that she was like, "You were always very nice to me, and you never talk down on me. And you asked about my history, and I told you, you know, like you weren't scared to ask me, and we be talked about it and you looked like you were concerned. And you held my hand this and that." I'm like, I'm thinking isn't that what we're supposed to do? And that's when the little light bulb went off, this may be a problem, and then I was think, from that point forward, I was seeing how people were being judged.

Maggie, RNC-OB:   41:18
Exactly, you can't stop seeing it.  Like how many prenatal visits did that person have before she got you.

Torie, RNC-OB:   41:20
Right? And she was still being judged along the way, even as being a patient in the hospital. And because once you know, whoever saw in her chart history of you know IVDA, drug use, it was like, "Oh, well, that's it," you know. And so, yeah, I think it's a problem. I think, as humans, we can definitely be biased. And I think you know, that's a huge problem, particularly, in the medical community, because that's one time that you cannot be biased because someone's life is in your hands, literally. What do we do about that? You know, it's not taught how to be unbiased that, you know, they expect that as a good human being that you just won't be. But let's be real, all of us at some point have been. But how do we take that out, as we walk in those front doors of the hospital or birthing center or whatever care they were giving the patient? How do we check that at the door? And we stop that.

Mandy, RNC-OB:   42:15
I think labor nurses have an incredible potential to do that, but it takes so much time that we really need to be taught specifically and intentionally. But over time, like how many times were you shocked by what happens with your patient or with birth, or how resilient they are, or how brave they are, or how they're like stone cold, stoic and boom, they have a baby on you.  

Torie, RNC-OB:   42:38
Yup.

Mandy, RNC-OB:   42:39
Like, oh my God, you were like working, working, working And I had no idea. You're just always shocked by people's potential. You would think that labor nurses would be incredible at it, but I think the system just, you know, medicine is just so boxy and square and dare I say...patriarchal and racist forever and ever and ever. It's very difficult to change. I think it would take every nurse, I would think there's numbers in nurses...right?

Mandy, RNC-OB:   43:08
Yeah. Uggh, I appreciate it, you both speaking so openly about that because it is so pervasive and all of the "ism"s that kind of follow us around, it's really hard, and I agree wholeheartedly with you, I do feel like that's the most critical thing we can do as nurses is to become champions of our own education. And I think it's hard because we work long hours and you're exhausted and there is so much that we have to keep up with constantly, in terms of our certifications and knowing this and doing that on healthstream and keeping up with the new hospital policy. And I think it's something that, you know, we, as nursing management, absolutely have an opportunity to kind of step in and advocate for the trainings that we provide to our staff, to provide paid time to pursue these trainings, and not just a couple people who get to go to a conference here or there and learn something and come back and share with your friends, which is great and there's a there's a place for that. But for these, you know, these big issues that have to do with bias and racism and the way we think about other people and how we truly turn our humanity on as a nurse each and every day, even though it's the same thing again, even though we're tired, even though things could be hard for us, how do we leave that at the door? How do we leave those preconceived notions that are, you know, I think so mmuch of it, it really is...it's the subconscious piece of it. It's from growing up in a society that allows all of these to persist. All of these beliefs, all these feelings that you know, the systemic racism that exists in our country causes all of us to have racist beliefs, not because we are actively trying to be racist, but it's one of those things that you have to be actively anti it. You have to be anti racism, you can't just be passive about it and hope that you're not doing the wrong thing. You can't just be like casually, "I don't think I'm biased." You have to be anti bias and actively looking, checking yourself when you see something that triggers that like, whether it's drug use or it's a new immigrant or its whatever little things pop up in the chart that you see and you think like, it's her seventh baby, how many new partners is this? Like any of those little things that can pop up and make you start to have a sense of Oh, I understand what this patient is, I know their story, I know all the potential issues that can come from this, like you don't.

Torie, RNC-OB:   45:51
Mmmhmm.

Mandy, RNC-OB:   45:51
You don't You don't know that person's story unless you actually take the time to sit there and ask and actually get to know that individual. And I think that's hard. But I would love it if all of us as nurses were able to take on a little bit more of that and be really conscious of the way that we approach those who are in our care and really, it's hard to do it every single day. It's exhausting in some ways, but I think with training, and I'll put some things up in shownotes with different trainings available online, you know, for people who are doing work around trauma informed care, including our own Mandy, from people who are actively working to dismantle racism, within nursing, within medicine, particularly with obstetrical care. So people have, like some reliable resources to go to if you're ready to kind of take next steps along that.

Mandy, RNC-OB:   46:44
That's a good point to learn altogether because I never chose breakout sessions in conferences or things that I thought I already heard but didn't really see. I think it's, I think every nurse does it and I already said every labor nurse is incredible and we all are learning, so this isn't like you guys or them or us; we're all learning.  I think learning together is so crucial; when I teach peanut ball education, I'm like, "no I come and I do two classes and I get all this staff, all the stuff."  Because if you don't teach all the stuff, you're gonna have champions, which is great. But then you're gonna have 85% of the people who didn't want to learn anyway. Don't know it, haven't seen it work, and don't do it. When it's really probably improving care for everyone and really doesn't have anything to do with the nurse, has everything to do with outcomes and patients and their experience. And if they want it, and you don't know how to do it now you're limiting their experience when they came in because they've watched on YouTube about peanut balls like, "Don't be silly, just learn it." That has, that's everything. Like I wouldn't go to an LGBTQ+ breakout session. Well, what does that have to do with my patients? What does that have to do it like? You just don't know until you go and then you look for it and then you can't unsee it and you're like, "Oh, shoot! I'm like, 10 years behind."

Maggie, RNC-OB:   48:08
Yup.

Mandy, RNC-OB:   48:09
And then you can expand and then you can try to practice it, and then it's less exhausting the more you know, because there's a lot of really great information out there. A lot of smart people talking about how we can do better. We shouldn't just know because we're nurses, but C-section rate is still 30-33%, birth trauma rates about the same or more.  People leave hurt and then racism, and the fact that we have worse outcomes for certain populations is just apalling. It's not up to one nurse to just figure it out, though. If we can all learn together and peer pressure each other or have like drills. Come on, we have shoulder dystocia drills. Do you guys have drills? Oh, yeah. We need a drill for, like, what happens when you have a young mom, old mom.

Torie, RNC-OB:   0:00
We have one for everything.  

Maggie, RNC-OB:   49:06
Right, I'm loving your role for you to be able to step up some of that piece of it.  I think about, like program development and how you could bring some of that into play.

Torie, RNC-OB:   0:00
Oh yeah.  

Mandy, RNC-OB:   49:17
Like we're in our own bubbles. We are in our own rooms individually, separated from everyone else. Except when we do those drills and we're all looking around like "that's not how I would do it. That's what I would say." But for someone who doesn't identify his female, there's a drill.

Torie, RNC-OB:   49:33
Oh, yeah. There is so much resistance on that from people who might really like "What does that have anything to do with you? Like it has nothing to do with you. Why do you want care?"

Mandy, RNC-OB:   49:47
Why do you have an emotional response to this?  

Torie, RNC-OB:   49:50
I mean, you know, I have had quite a few lesbian moms and learning how to talk to that type of population where you know I'm including both of them in the in the conversation, I'm calling both of them Mom, you know, it's, you know, this is your baby too, you know, it's not just yours, and they really appreciate it. Like I'm like, "are you guys excited? like you guys had a baby." And, you know, they're like, yes. And I'm like, God, like why people are so resistant to change. We all know nurses are resistant to change, we know that. The slightest bit of change that we implement in the hospital, it is like, Oh, my God...

Mandy, RNC-OB:   50:30
Because we had to go to Epic. We haven't got over that [laughter] We had to go though that upgrade and now we can't even we can't even, we're like "don't change our script color, we can't handle it." [laughter]

Torie, RNC-OB:   50:38
[laughter] Don't change the color, please. I mean, you know we are resistant to every little bitty thing...

Mandy, RNC-OB:   50:49
There's so much change.

Torie, RNC-OB:   50:49
And so I make the point, some of the nurses kinda smoking me a little bit, but I'm like guys. You guys are so resistant to this change, right? I said, is it is the best outcome for the patient.? I mean, yeah...they'll say yeah. Okay. You know, guys, like 30 years ago, you weren't required to wash your hands. Look where we are; things change. It changes. 30 years ago, when a doctor walked into a room you have to stand up.  Back in the day, nurses could smoke like at the nurses station. Things change people, we are not living in the same times. And let's move on from it. Let's just move on, you know.

Mandy, RNC-OB:   51:27
We can do it.

Mandy, RNC-OB:   51:30
We can, you know, and I think that's what's encouraging. We can do this like we can. And just saying all of this feels like overwhelming. And there's so much to, you know, take it. And when will it happen? But think of the advocates back then who were saying, like I think we should really wash your hands all the time.  

Mandy, RNC-OB:   51:43
That was OB, right?

Maggie, RNC-OB:   51:45
Yeah, like, you know. So for those people who were and then finally like it caught on, I think we need to feel like, empowered about the fact that, like, yes, there are so many of us nurses.

Torie, RNC-OB:   51:57
Like maybe we shouldn't smoke at the nurses station. Maybe we shouldn't do that...

Mandy, RNC-OB:   52:01
Now it's like, we teach our patients not to smoke, so we shouldn't. Now it's, we teach our patients how to breastfeed....we should have some pump space, we should have some some time.  

Torie, RNC-OB:   52:11
Absolutely  

Maggie, RNC-OB:   52:12
The same kind of "duh" way.

Maggie, RNC-OB:   52:16
We need to feel, like, empowered to, like, take these issues and run and know that the change won't necessarily happen tomorrow, right? Because that's not how the human condition works, but it does incrementally change. And we can hope that, you know, when the next generation, our children go into healthcare, they look back and they say, "Huh? You guys had an issue with that? Oh, you didn't do that. Oh..." And we'll go, "yeah, what a wild time to be alive," you know, that would be amazing. You know, I would love to see such a 180 you know, in some of the issues that it really seems like. Oh, yeah, that was a whole different world that we lived in. And I do I feel like for all the nurses who are listening to this,. I hope they feel empowered by this to find the issue that they care about. What is the thing on their unit? What is that thing that they see constantly with their population, that they always have, like, had more questions about or haven't known how to address it, had that, like "OOH" feeling we are in a wonderful time in terms of education. There is so much that is available online all over the world, and especially now, because everything has to be online, but also all the time. You know, there's a lot more resources that are available to us beyond what's just on our unit. So if you're working somewhere, that doesn't have really supportive staff. If you're working somewhere that hasn't gotten on board with new wave obstetrical care that you know there are ways for you to reach out and find resources and I'll link those, some of those in the show notes that I found helpful and that I'm looking forward to doing myself as everyone is on their journey. Thank you both so much for being here.

Torie, RNC-OB:   53:50
Thank you so much.  So much fun.  Nice to meet you, Mandy. Really good. 

Mandy, RNC-OB:   53:57
Nice to meet you too.  This is really good.  We're all in different states, and we're all doing the same thing.

Torie, RNC-OB:   54:01
This is so awesome.  So call me back anytime!

Mandy, RNC-OB:   54:04
Repeat performance by Torie.

Maggie, RNC-OB:   54:10
Thanks for tuning in. We love to talk birth and would love to talk about it with you. Please join the conversation by finding us on Facebook, Instagram or Twitter, we're Your BIRTH Partners on all platforms.  Check out our show notes today for links to trainings, classes, and books that you can check out to gain greater understanding and comfort in your role as an advocate. Happy Nurses Week!  Till next time!