Journal of Obstetric, Gynecologic & Neonatal Nursing
ResearchSocial and Environmental Conditions Creating Fluctuating Agency for Safety in Two Urban Academic Birth Centers
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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