You are educated when you have the ability to listen to almost anything without losing your temper or self-confidence. - Robert Frost

Many of you are old enough (or savvy enough) to recognize the 3 "P"s commonly used in obstetrics: the powers, the passage, and the passenger. And, while I am an avid supporter of paying close attention to those particular "P"s during labor, those are not the "P"s I am referring to in the title for this column. I am going to speak to the importance of some other "P"s: patience, protest, and perseverance. These "P"s are crucial not just in our work settings but in our lives, and as we begin a new year together, they deserve some reflection.

The idea for this particular topic began at an airport, where I am spending much of my time these days. As many of you know, I travel with a great deal of equipment (computer, audience response system, videos, etc), which I will not put in checked luggage, as I cannot afford to lose it. This causes me to be a bit slower at the security lane, so I always try to arrive early so that I am not rushed or stressed, and, as a courtesy to fellow travelers, I often encourage them to pass me in line so that they are not frustrated. I usually can use the premium line, which also helps. Recently, I was preceded in line by a young woman who was clearly not from the United States (I saw her passport) and was also clearly not familiar with the myriad of airport security screening rules involving liquids, shoes, electronics, and metal items. I watched while she repeatedly had to remove items and return through the metal detector, and I will not deny I was growing impatient. But as I am trying to become a better person, I silently reminded myself to take a deep breath and practice patience and compassion rather than react with frustration. This was clearly not the approach the 6-ft, 200-plus lb, obviously important, time-is-money, gentleman was taking, who was behind me in the line. Beginning with a series of overly loud sighs, and quickly escalating to loud-enough-for-everyone-to-hear complaints and blasphemies, this guy was just being completely obnoxious. The young woman, clearly aware, began to grow increasingly nervous, and this only escalated her difficulties in following the instructions security agents were providing, slowing the process down to a molasses in January pace.

Now do not get me wrong, a minute or 2 earlier I had to remind myself to have patience and empathy, so I am not a saint in the tolerance department. But my heart went out to this girl, and I suddenly just could not stand by while this guy essentially bullied her. So I invoked the second "P"--protest. I turned around, stared him right in the eye and said (using, I admit, the Mommy tone), "Stop it, just stop it right now!! Does that really help? Do you really feel better? What on earth is wrong with you?" Well, he was surprised, but not more than me, because I felt like I was having an out-of-body experience!! It worked though, and while he now grumbled under his breath, no doubt about me, he at least left the poor girl alone and she finally made it through security.

How does this little tale apply to clinical practice? Well, I suggest that patience and protest are 2 things we need to cultivate daily in the perinatal setting. How about being more patient with labor for a start? Reexamining our need (or the need of others) to rush labor, to "get her delivered"? How about we have a bit more patience with our colleagues? Slow things down and establish open and respectful lines of communication, instead of assumptions and overreactions when conflicts, or what at first blush seem to be conflicts, arise? Patience includes the ability to sit quietly and listen and to give some time to seeing the viewpoints of others before responding with our own. It seems to me that this is a virtue we are sorely lacking in the workplace today, why not start the New Year with a reconnection to patience?

But patience does not mean standing mute in the face of bad behavior or inequity. That is where protest comes into play. Nurses, midwives, and physicians must speak up and step in when they see disruptive behaviors in colleagues, or when patient safety is being compromised. "Stop it right now" may not be the appropriate language to use in the clinical setting, I will admit that we need a bit more skill and diplomacy when addressing an issue, but to quote Elie Wiesel, "[t]here may be times when we are powerless to prevent injustice, but there must never be a time when we fail to protest." Or, if you prefer a hipper, musically oriented quote, how about Bob Marley, who encouraged us to "get up, stand up, stand up for your rights." Let us stand up for professionalism and respect in the workplace, for understanding and reverence for the birth process, for appropriate use versus overuse of technology and intervention, and for our patients' rights to compassionate and safe care, regardless of the ability to pay.

This rightly brings us to the third "P"--perseverance. Perseverance is defined as steady persistence in a course of action or purpose in spite of difficulties, obstacles, or discouragement. You can be patient, and you can protest when needed, but it is only through perseverance that significant change occurs. Many of the participants in my classes ask me the same question: How can we get others, or the system, to change? How do we address safety issues, improve communication, encourage, and teach critical thinking when there is so much resistance to change and so much misinformation out there? (Think about all those birth practices that no longer make sense but persist, such as closed-glottis pushing.) The answer is to persevere. Continue our own paths of education, serve as teachers and role models for our colleagues, be relentless as patient advocates, and be grateful for the progress we make, no matter how slowly it seems to unfold.

Patience, protest, and perseverance-the 3 "P"s I am going to make my mantra for 2010. I hope you will join me.

-Lisa A. Miller, JD, CNM

Perinatal Risk Management & Education Services