Social and Environmental Conditions Creating Fluctuating Agency for Safety in Two Urban Academic Birth Centers

doi:10.1111/j.1552-6909.2007.00204.x

Journal of Obstetric, Gynecologic & Neonatal Nursing

Volume 37, Issue 1, January–February 2008, Pages 13-23

https://doi.org/10.1111/j.1552-6909.2007.00204.x Get rights and content

ABSTRACT

Objective

To identify processes affecting agency for safety among perinatal nurses, physicians, and certified nurse-midwives.

Design

Grounded theory, as informed by Strauss and Schatzman.

Setting

Two academic perinatal units in the western United States.

Participants

Purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives.

Findings

Agency for safety (the willingness to take a stand on an issue of concern) fluctuated for all types of providers depending on situational context and was strongly influenced by interpersonal relationships. While physicians and certified nurse-midwives believed that they valued nurses’ contributions to care, their units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Nurses’ confidence was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor interpersonal relationships, resulting in a process of redefining the situation as a problem of self.

Conclusions

Women and babies should not be dependent on the interpersonal relationships of providers for their safety. Clinicians should be aware of the complex social pressures that can affect clinical decision making. Continued research is needed to fully articulate facilitators and barriers to perinatal safety.

Section snippets

Background

Inpatient perinatal environments may be considered high-hazard domains. Although adverse events are extremely rare, they can have catastrophic consequences (Gaba, 2000, Knox, 2003, Rochlin, 1999). Safety in the high-hazard domain of health care has been conceptualized as a dynamic state of collective agency for identifying emerging threats and deflecting them from reaching the patient (Henneman & Gawlinski, 2004; Knox; Lyndon, 2006). An organizational culture that fosters collective agency

Design/methodology

Data for this grounded theory study were collected between September 2005 and January 2007 using individual semistructured, open-ended interviews and participant observation with a purposive sample of registered nurses (RNs), physicians (MDs), and CNMs from two teaching hospitals. Interviews were recorded and professionally transcribed verbatim. Transcripts were cross-checked against recordings for accuracy (Kvale, 1996). Fifty-two hours of participant observations were conducted across day,

Study settings

Participants were recruited from the birth centers of two urban teaching hospitals in the western United States. The centers had 1,200 to 1,800 annual births. Both were integrated perinatal units with antepartum, laboring, and postpartum women cared for in one location with one set of staff. They offered a full range of perinatal services from midwifery through maternal-fetal medicine and had in-house obstetric and anesthesia services and an intensive care nursery. Nurses were employed through

Context: The situation in which the phenomenon is embedded

The clinical practice environment was characterized by inconsistency in availability of resources for basic patient needs, strong segregation of professional activities by discipline, hierarchical social structures within and between disciplines, and a tendency for safety to be defined (especially by physicians and CNMs) as the absence of adverse outcomes.

Availability of resources Working under a shortage of resources was a common concern. The subtle and pervasive influence of working with

Conditions facilitating, blocking, or shaping agency

Confidence was a strong driver of agency for safety. This dimension was particularly salient for RNs in the study. Their confidencein themselves and in their clinical grasp of the situation was very important in their judgments about when and how to intervene and a key driver for asserting concerns. Confidence was not a fixed property of an individual; it was fluid and dynamic, highly variable both within and across individuals.

I might have—on my time on the night shift, been able to explore

Processes: Actions set in motion by conditions

Processes that were problematic for the development and maintenance of collective and individual agency for safety included avoiding conflictand its subdimension working the hierarchy,and redefining the situation.

Avoiding conflict The high perceived importance of interpersonal relationships for effective team function created an environment where participants described actively avoiding conflict with colleagues in order to preserve relationships. Conflict avoidance was safety threatening when

Redefining the situation

Nurses were often able to take these difficulties in stride by simply ignoring power behaviors, requesting providers’ attention for important conversations, or insisting on getting the rationale from the provider and having a discussion about the plan. However, novel situations and the responses of others to concerns threatened RN agency by undermining confidence in their assessment of the situation, sometimes causing them to question their own judgment. Thus, the RNs sometimes began redefining

Consequences

The context, conditions, and processes described above created a degree of variability in interactions and responses that undermined the reliability of the safety net for childbearing women in these settings. The use of assertive communication strategies and the persistence with which clinicians pursued their concerns were variable. The specifics of clinical situations (such as the clarity of the problem, the quality of interpersonal relationships, and the responses of others to expressions of

Discussion

The differences between the physicians and CNMs and the nurses regarding perceptions of openness to RN input into the plan of care in this study are consistent with reported differences in perception of teamwork climate between types of clinicians in labor and delivery and other settings (Sexton et al., 2006, Thomas et al., 2003). Physicians in those studies had higher perceptions of the level of teamwork and RN participation in decision making than did nurses. These findings are also

Acknowledgments

Funded by the Association of Women’s Health, Obstetric, and Neonatal Nursing 2006 Novice Research Grant and the Nursing Initiative of the Gordon and Betty Moore Foundation.

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ResearchSocial and Environmental Conditions Creating Fluctuating Agency for Safety in Two Urban Academic Birth Centers

ABSTRACT

Objective

Design

Setting

Participants

Findings

Conclusions

Section snippets

Background

Design/methodology

Study settings

Context: The situation in which the phenomenon is embedded

Conditions facilitating, blocking, or shaping agency

Processes: Actions set in motion by conditions

Redefining the situation

Consequences

Discussion

Acknowledgments

Journal of the American College of Surgeons

Journal of Professional Nursing

Journal of Obstetric, Gynecologic, and Neonatal Nursing

Journal of Obstetric, Gynecologic, and Neonatal Nursing

Lifelines

Joint Commission Journal on Quality and Patient Safety

Evaluating interpretive inquiry: Reviewing the validity debate and opening the dialogue

Qualitative Health Research

A sensemaking lens on reliability

Journal of Organizational Behavior

Fieldwork in nursing research: Positionality, practicalities, and predicaments

Journal of Advanced Nursing

Ethical dilemmas in healthcare

Key themes in healthcare safety dilemmas

Constructing grounded theory

Situational analysis: Grounded theory after the postmodern turn

An error by any other name

American Journal of Nursing

The field guide to human error investigations

Structural and organizational issues in patient safety: A comparison of health care to other high-hazard industries

California Management Review

Difference in safety climate between hospital personnel and naval aviators

Human Factors

The discovery of grounded theory: Strategies for qualitative research

Enhancing the rigor of grounded theory: Incorporating reflexivity and relationality

Qualitative Health Research

Ethnography: Principles in practice

On error management: Lessons from aviation

British Medical Journal

Cockpit resource management: Exploring the attitude-performance linkage

Aviation, Space, and Environmental Medicine

Overnight and postcall errors in medication orders

Academy of Emergency Medicine

Organizational silence and hidden threats to patient safety

Health Services Research

Tensions and teamwork: A study of midwives and nurses

Beyond high reliability: Moving to ultrasafe systems

Research
Social and Environmental Conditions Creating Fluctuating Agency for Safety in Two Urban Academic Birth Centers