How do power and hierarchy influence staff safety in maternity services?

NHS Improvement consider patient safety as the ‘avoidance of unintended or unexpected harm to people during the provision of healthcare’ (NHS Improvement and NHS England, 2019), where safety is defined as ‘a state in which there is no danger or risk’ (University of Cambridge, 2020).

Numerous healthcare safety inquiries have revealed examples of poor care and highlighted systemic issues, with a deeply ingrained culture within healthcare services inhibiting progress in the quality improvement arena (Francis, 2013; Francis, 2015; Kirkup, 2015). It has been estimated that 1 in 20 patients are exposed to preventable harm in healthcare (Panagioti et al, 2019), and the Keogh (2013) review revealed that trust data often belied actual data, challenging opportunities for safety improvement initiatives.

As can be seen from Figure 1, there are considerable tensions for healthcare staff, divided between their employee allegiance and contracts, and their professional codes of conduct to speak out for safety (Nursing and Midwifery Council, 2018). Within the UK, nursing and midwifery staff have additional responsibilities to the NHS Constitution. The ‘Freedom to Speak Up’ report (Francis, 2015) exposed the reality of bullying within healthcare services, and despite the creation of ‘Freedom to Speak Up Guardians’ as a response to findings highlighted by this report, 45% of Freedom cases in 2017–2018 included an element of bullying (National Guardian's Office, 2020). MBRRACE (Draper et al, 2017) estimated that staffing capacity issues affected >20% of perinatal deaths reviewed, and the true figure is likely to be much higher as Trusts can choose what documents to submit. The Royal College of Midwives (RCM), and the Office of National Statistics (Bonar, 2019) noted that there is a shortage of 2 500 registered midwives and 80% of midwives who have left the profession have stated that they would consider returning if there was a change in the workplace culture. This >20% figure quoted from MBRRACE was derived from documentation evidencing staffing issues and as staff are not routinely encouraged to admit capacity complications within their daily records, it is likely this figure of capacity affecting safety is a conservative one.

Figure 1. The quality problem

Aims

The research aim was to identify how power and hierarchy influence staff safety in maternity services, and this was achieved by reviewing research papers concerned with personal narratives of staff experiences and perspectives of employment in their profession.

Methods

This systematic narrative review was based on the approach of a narrative synthesis, systematically analysing empirical studies which had researched similar topics. Nvivo research software was then used to code narrative content for key concepts for a contemporary summary. This led into a discussion on staff safety in healthcare. Alternative approaches such as an ethnography or a focused case study would have required research ethics approval, and the author was studying during a global pandemic with severe restrictions on access to healthcare facilities due to pressure on staffing and resources. Overall, this approach was considered the most suited and ethically rigorous given the unique healthcare circumstances.

Inclusion and exclusion criteria

The date range was initially limited to a post Freedom to Speak Up arena of 2015 (Francis, 2015) but due to a lack of relevant material, this time scale was then extended to 2000, the year that ‘To Err Is Human’ was published (Kohn et al, 2000). The publication of this document was pivotal for healthcare safety because it broke the silence on the consequences of medical errors and gave recommendations to build safer healthcare systems by design, formerly acknowledging that good people were working in flawed systems which impacted directly on patient care.

The author was interested in primary research which would provide direct staff experience narratives, and language was limited to publications written in English to avoid missing the nuances of works interpreted through poorly transcribed language applications. Snowballing of some, the literature identified through citation of articles already read produced a greater pool of literature to consider. Inclusion criteria involved searching for primary research collected globally because the researcher was interested to discover whether there were wider issues affecting maternity services safety culture rather than simply restricting this research solely to her own and colleagues' experiences within the UK. Removal of duplicates was necessary as search saturation was reached.

Dixon-Woods et al's (2005) five-point checklist was chosen for screening eligibility criteria because of the ease with which primary study identification, screening, eligibility, inclusion and synthesis could be drawn (Table 1).

Search strategy

The Spice acronym adaptation of the PICOS model was used in relation to the research question: ‘how do power and hierarchy influence staff safety in maternity services?’, with keywords and alternative words tabulated as possible search terms (Table 2).

Information sources included Cinahl Plus; Midirs; Scopus; Wiley online; Pro Quest; Web of Science; Science Direct; Open Athens; All4Maternity; handsearching through bibliographies, and snowballing.

Data analysis

Information was gathered through Nvivo one paper at a time and papers were analysed applying methodological guidance created by Dixon-Woods et al (2004), Seers (2012) and Snilstveit et al (2012). In these papers, small chunks of narrative are inductively coded as read, with nodes labelled as they inductively occur through the reading of the narrative. This process created ‘speaking out’, ‘avoidance’, ‘feeling powerless’ and ‘exhaustion’, for example. Figure 3 illustrates the flow of this process, developing descriptive themes from inductive coding and then from these generating analytical themes to answer the original question.

Figure 2. Search and review strategy (PRISMA flow diagram) Figure 3. Narrative synthesis of developing themes process

Constituent numbers of like-minded papers with coded references were then developed once saturation of groups of coded nodes were combined. Many nodes naturally interlinked into broader codes. For example, the subtheme ‘dangerous workloads’ included the nodes of exhaustion, inflexibility, lack of breaks, low morale, staff engagement, pay, poor management, poor communication, poor staffing levels and quality of care. Manageable workloads were not mentioned.

The ‘descriptive finding’ concept of dysfunctional relationships included subthemes of bullying, discrimination, feeling powerless, power to manipulate, feeling worthless, grief, learnt helplessness, relationships, the futility of speaking out, error reporting, subordination, feeling abused, gaslighting, the silence is deafening.

These descriptive themes were then used to answer the original research question, leading to the development of implications for intervention development (Snilstveit et al, 2012). Another approach which could have been applied to this topic of staff safety within maternity services is thematic analysis but this would have served to answer ‘what’ rather than ‘how’. The researcher was particularly keen to investigate new levels of meaning in how staff are affected relative to their role in promoting patient safety, really for a deeper dive into the nuances of staff experiences.

Quality appraisal

Having initially applied Dixon Woods et al's (2005) five-point criteria (Table 1) as a first-line, low-threshold screening tool for quality and inclusion, a quality score out of five was then awarded to each paper for relevance to this research. See Appendix 1 for the characteristics of the included studies and Appendix 2 for quality appraisal (both online).

Researcher characteristics and reflexivity

The researcher's professional history as a legitimate informal whistleblower concerning inadequate staffing within maternity services, and the personal fall out from this, influenced the choice of topic for this research paper. Such a deeply unique subjectivity to this topic of interest brought possible advantages in terms of personal history and professional competence as an enabler, positively supporting an emphasis on staff welfare for sustainability of services and process improvement, which another researcher without these personal experiences could not have accommodated in the same way (Bateman, 2006). In this way, the researcher did not seek to avoid research bias, rather actively embracing the credibility that was derived from discovering similar research papers across four countries, clearly evidencing that little has changed spanning two decades, and showing that this situation is far from unique to the UK maternity health service.

Findings

The views of 173 maternity staff across 10 qualitative research projects in four countries were involved in this narrative synthesis, with free text from 5 389 surveys also included as research data, giving a total of 5 562 participants. These papers were predominately small studies ranging from 10–33 participants and qualitative in nature. However, larger cohort papers such as the WHELM study (Hunter et al, 2019) with 1 997 participants, and ‘Why Midwives Leave’ (RCM, 2016), with 2 719 participants, were included as these were considered pivotal papers for understanding the underlying problem of acuity with the midwifery profession specifically within the UK. Both of these studies incorporated survey questions with free text which was subsequently themed for analysis, and whose excerpts contributed to the underlying findings of this narrative synthesis of like-minded papers.

Overall, 18 subthemes were iteratively created from smaller coded nodes. These were divided into five descriptive findings of related themes, separated into two overarching analytical findings or concepts of related descriptive findings: psychological vulnerability and working conditions, as seen in Table 3.

Findings 1: psychological vulnerability

All of the selected papers involved psychological vulnerability, which included anxiety about the job and cultural normalisation of dysfunctional relationships.

1.1 Anxiety about the job

Anxiety about the job could be seen in participants anecdotes surrounding fear of investigation, the futility of speaking out, feeling powerless and burnout/stress/anxiety’. This was seen in conversations about error reporting, and under reporting, where staff felt unsafe to raise concerns or change the system out of a fear of being labelled ‘troublemakers’ (Currie and Richens, 2009), or calling attention to themselves and therefore ‘ear marking’ themselves for more trouble:

Student: Would I go to matron if I had a problem? (sounds incredulous, eyebrows raised). She'd be the last person I'd go to, that's for sure! (laughing). No, I certainly wouldn't go to matron, no. I'd only be highlighting myself; I'd probably just be ear-marked for something else again. No, I wouldn't.

(Hospital 1) (Begley, 2002)

Burnout/stress/anxiety and fear of investigation appeared to be intrinsically linked in five of the papers reviewed, with staff emotionally drained by the risky nature and lack of support for the roles and responsibilities involved in midwifery: the complexity of care now means we are far more aware of risk, problems and clinical governance and of course the huge increase in paperwork and technology (Hunter and Warren, 2013).

1.2 Cultural normalisation of dysfunctional relationships

Cultural normalisation of dysfunctional relationships were at the crux of psychological vulnerability, with all analytical and descriptive themes spiralling back to this. Staff spoke of their own personal needs not being acknowledged or accommodated in a rigid organisation system by managers who manipulated their hierarchical power so that staff were not even able to swap shifts to ensure the smooth running of family life:

‘They talk about family friendly environment but it is not. We can't change or swap our shift with colleagues; we have to meet with the manager face-to-face. We are not even allowed to send them email request, even when we have discussed it with the other midwife’. Midwife, England

(RCM, 2017)

Currie and Richens (2009) brought a different dimension to this theme by considering that so much is done to support the clients, that clients then believe they have the right to abuse staff so that generally staff felt unsupported from both managers and patients in a workplace atmosphere, echoing the powerlessness staff experienced which linked to their ‘anxiety about the job’ discussed previously:

‘I think there's a lot done to support the client and therefore I think that the clients feel that they have the right to abuse and say whatever they like to staff … and staff generally feel unsupported. And there's things in place to support the staff … but I think on the ground floor the staff don't believe it.’

(Currie and Richens, 2009)

Bullying was cited by maternity staff in every single paper researched for this narrative and hierarchical language showed staff fearing that they ‘were little fish … about to be fried’ (Hood et al, 2010), and that ‘great fleas have little fleas upon their backs to bite 'em. And little fleas have lesser fleas, and so ad infinitum.’ (Begley, 2002), inferring that the act of bullying as a learned behaviour perhaps in a process of initiation into the profession:

‘She (the mentor) is the bully of the unit; other staff join in to avoid being the next victim.’ Older student 15

(Capper et al, 2020)

Subordination was described as a common method of midwifery management assertion of power in seven of the papers:

‘…respectfully asked the senior midwife, who had a few other midwives with her, if I could be allocated a labouring woman if one came in. She unleashed a barrage of questions at me, including: “Why was I asking now?” She then stared at me for about five seconds and said nothing; I found this very intimidating.’ Older student 10

(Capper et al, 2020)

Findings 2: working conditions

Working conditions were influenced by poor organisational and structural working conditions, and institutional normalisation of dysfunctional relationships, and interpersonal elements, and for the most part, these appeared to be fundamentally due to inadequate management of power and hierarchy which could have positively influenced working conditions had these been better managed.

2.1 Poor organisational and structural working conditions

Poor organisational and structural working conditions were linked to dangerous workloads, with Davies and Coldridge (2015) discussing the case of a student who was told to ‘Get the red box!’, without knowing what the red box actually was, where it was kept or what it was for. In this situation, the allocation of responsibility was completely inappropriate and poorly managed as a newborn baby's life depended on the contents of the red box. Poor management was a recurring theme where misappropriated power affected delays in help and therefore safety, also mentioned in the following quotation:

‘There's quite a delay sometimes in getting help or knowing how to get help. That's been apparent from a few incidents that we've had over the last year but although … we feel that we've got a clear pathway to protect staff and, and other patients, other users … in reality, it doesn't always work out that way and it's pretty much at the mercy of whichever security guard is on or whichever manager is covering or whatever…

(Currie and Richens, 2009)

Lack of breaks was mentioned many times throughout six of the papers reviewed, with staff repeating the same point, that they were working 12.5-hour shifts with no breaks which added to their stress, exhaustion and workplace adversity. Overwhelmingly, these featured the most within the research paper ‘Why Midwives Leave’ (RCM, 2016):

‘I was often working 12.5 hours with no breaks. My unit was struggling with employing enough midwives-we had a shortage of thirty full-time midwives in the unit. I was not able to deliver the care I wanted as decisions were often made about women's birth without her full involvement. It was not safe to look after 15 mums and babies on a postnatal ward by one midwife. We were not listened to when we raised issues over staffing and safety.’ Midwife, England, left midwifery in the last six months

(RCM, 2016)

Although other papers simply echoed the same point:

Every shift we are short staffed and therefore over worked, don't get breaks and leave late. We do not get paid enough for the responsibility we have. It is terrifying sometimes the pressure we have, the fear of litigation, the fear of something awful happening.’

(DGH) (Hunter and Henley, 2019)

2.2 Institutional normalisation of ‘dysfunctional relationships

All included research papers cited institutional normalisation of dysfunctional relationships within working conditions, with several papers pointing out that these occurred on labour ward specifically such that some would avoid returning to this environment, or express deep concern about working there. This suggests that the abuses of both power and hierarchy are feeding into a system so much so that it has become commonplace institutional behaviour with staff left unsupported and yet still held accountable, threatening their safety on a professional register. This fear was powered by the terror of potential emergencies and poor outcomes during deliveries:

‘Who was going to get their head on the chopping block for it you know? “You do know you might have to go to court over it … you might have to go to court don't you?’”… I was baffled by this, this change, gone from the sadness then to the fear … it was … very surreal … And that was, wow, such a moment for me, and I thought do I want to be in this profession where clearly this should be all about the parents now and supporting the midwife and the staff who were in there?

(M10) (Davies and Coldridge, 2015)

These dysfunctional relationships appeared to boil down to poor communication, exhaustion and low morale, with participants feeling that colleagues were cruel, and at times plain liars. Participants in ‘scrutiny and fear’ described ‘barefaced lies’ told in legal proceedings that left them flabbergasted with both the legal and medical fraternity (Hood et al, 2010), although clearly some midwives had behaviour that was no better:

‘I remember going away washing my hands for some reason, following the procedure needed to wash my hands, and I was standing facing the wall and I heard the midwife saying, “Well, I did offer an interpreter and she refused”, I was mouthing at the wall, “you fucking liar” ‘cos I knew she was lying.’

(Davies and Coldridge, 2015)

It is likely that this lack of honesty comes from a cultural lack of trust in being able to be honest about both personal and institutional failings, and this normalisation of dysfunctional relationships has allowed a professional lack of integrity to fester in staff engagement.

Poor communication was evidenced in six of the papers and summed up in this quotation which illustrates the lack of support and inevitability of staff walking away:

‘The matron was there. “It has been a bit of a bad night” and she said, “I have heard all about it, and I don't want to hear anymore”. And I thought, well you know that's great …”I have heard all about it, I don't want to hear anymore”, and I said, “Okay” and (sounds upset) obviously, this midwife I was working with was in floods of tears and I was expected to be okay … off I went, and she went on sick leave after that, I didn't see her again.

(M2) (Davies and Coldridge, 2015)

2.3 Interpersonal elements

The scope of interpersonal elements showed a reciprocal relationship where some staff struggled to draw a line between work and home life, so that when workplace adversity weighed down on staff, they appeared unable to distinguish or place perspective on how their job was affecting them personally.

This quotation shows just how deeply staff can struggle with personal challenges and taking a rational perspectives between work and home life:

‘Another midwife revealed that she experienced significant suicidal ideations. She explained how before the inquiry, she was dealing and coping with some personal circumstances but the pressures were exacerbated by the inquiry, leading her to consider taking her own life.’

(Hood et al, 2010)

Power and hierarchy influence staff safety in maternity services by creating challenges to staff safety, which appear to essentially derive from poor communication. The workplace adversity described by participants seems to be linked with 1) psychological vulnerability 1.1) anxiety about the job, and 1.2) dysfunctional relationships, alongside 2) working conditions 2.1) poor organisational and structural conditions 2.2) institutional normalisation of dysfunctional relationships and 2.3) interpersonal elements feeding into an obstructive culture.

The outliers to this research

The outliers to this research, the papers providing conflicting findings of a higher order against the general feel of the papers synthesised, bring opportunities for a cultural change. The following quotations illustrate that healthy, psychologically safe working conditions are out there being practiced within maternity services with very positive versions of power and hierarchy deployed:

‘Labour ward is fabulous since the new superintendent came, she's excellent, she has just uplifted the place, she is just such a bonus around the place. She's somebody that you can go and talk to and say “look, this happened and that happened” and she'll sort it out.’

(Hospital 7) (Begley, 2002)

And:

‘Another band came out and she took me into the clinical room, and she shut the door … (voice breaking) and she gave me a hug, and this wasn't your most “touchy feely” band 7 generally, and she said, “if my daughter was going to deliver here, I would be so happy if you were looking after her” and that kind of, it made all the difference … I was very inexperienced and obviously quite distressed, and it made, that made a huge difference and I felt it gave me the puff of wind I needed to go back in and carry on my responsibilities…

(M10) (Davies and Coldridge, 2015)

There was insight from student midwives which evidenced that they could absolutely see that what they were experiencing was not acceptable, and it was a joy for me as a midwifery researcher to read of student participants saying that they wanted to be a part of the change that was clearly necessary:

‘I want to become a team leader so I can become in charge and make sure that new students aren't treated the same way.’

Younger student 3 (Capper et al, 2020)

Discussion

Power and hierarchy were found to influence staff safety in maternity services by creating challenges to staff safety which appear to essentially derive from poor communication. The workplace adversity described by participants seems to be linked with psychological vulnerability and working conditions through the dysfunctional relationships created by a pre-existing hierarchy, feeding into an obstructive culture.

Of these papers, eight involved the subtheme of futility of speaking out but rather than staff showing a healthy encouragement and engagement for this process of maintaining safety in healthcare, they all without exception evidenced just how negatively the act of speaking out was perceived, received and repaid by management. This enforced a silence which allowed pervasive anxiety to flourish, and effectively this ‘straightjacketed gaslighting phenomenon’ left staff feeling powerless to do the right thing in contributing to improving healthcare safety. Similarly, Pattni et al (2019) conducted a narrative synthesis on the complications of challenging authority within the theatre environment, specifically reviewing barriers to speaking up, and concluding that such barriers are modifiable but largely dependent on a culture of openness. Tarrant et al's (2017) ‘Speaking Out’ paper tackled this topic within intensive care environments, surmising that hierarchical chastisement had the potential to complicate ‘safety voices’ amongst staff and suggesting that greater sophistication was necessary to appreciate the social controls utilised within healthcare. It is suggested that it is now time to mandate for staff to challenge poor behaviour within the macro, mezzo and micro level healthcare environment without the psychological vulnerability of either personal or professional redress, in order to improve both patient and staff safety.

Participants described a great sadness at discovering that colleagues had experienced similar emotions allied with symptoms of exhaustion, having for the most part endured the loneliness of their suffering unsupported 159–160 (Young et al, 2015). This clearly links with dangerous workloads but also links with psychological vulnerability in the spiral of this narrative synthesis and the challenges to staff safety. Staff knew that something was wrong but didn't know how to rectify their situation. In the RCM (2016), ‘Why Midwives Leave’ paper there were many direct quotations from staff aligning their exhaustion with understaffing and an unsafe workload, with genuine concerns that they ‘might make a tragic mistake’. To this end, it is suggested that it is now time to address politically the imbalance of workforce planning, with a strategic review of working conditions, to secure staff both in the medium and long term, in order to improve both patient and staff safety.

Liberati et al (2020) explored seven features of safety within maternity, devising a plain language framework based on their ethnographic research conducted within maternity services settings. Key features identified included a general commitment to safety at all levels of the hospital hierarchy; alongside ‘systems and process designed for safety’. Mackintosh and Sandall (2010) researched the potential role of gender and professional hierarchy in influencing communication, particularly with relevance to speaking out and asking for help (Mackintosh and Sandall, 2010). Their conclusion was that gendered hierarchies may complicate safety within healthcare such that an acknowledgement of this phenomenon mediated in a shared policy of communication might enable a shared understanding and appreciation for team safety within healthcare, in what is after all 70% predominantly female occupation worldwide (World Health Organization et al, 2019). It is suggested that it is time to adopt a human factors system-engineering approach into working policies and guidelines for safety at all levels of the healthcare systems hierarchy, and to reflect anthropomorphic design principles (Carayon et al, 2014), including sustainable rostering for a healthy work life balance (Roycroft et al, 2020), in order to improve both patient and staff safety.

Each of these papers considered a strong need for improved education on the topic of staff wellbeing, and recognition of the urgent need to challenge a culture which so directly affects safety within healthcare. The negative influences of the cultural subthemes of power and hierarchy on staff safety are significant within maternity services. The research papers included within this narrative synthesis were taken over a timespan of two decades, echoing contemporary recommendations and evidencing that no real improvements in staff welfare have occurred over time. It is suggested that it is now time for staff wellbeing to become a mandatory inclusion within both healthcare training and employment contracts, in order to improve both patient and staff safety.

Conclusion

The uncomfortable reality is that the professional benefits of silence often outweigh the balance of personal integrity. Disconfirmation findings, those which stood out as different from the rest, evidenced the possibilities that healthy, psychologically safe working conditions could offer for healthcare staff in improving their prevailing culture.

Opportunities for future research include the transferability of these recommendations to nursing as another predominantly female profession, reviewing whether gender is a factor in the subservience and vulnerability of these workforces. Future research could also explore whether these same findings exist for other female dominated professions (ie nursing) to assess whether these same recommendations may be applicable elsewhere. There is also a question mark over the social worth of maternity services provision which warrants further exploration. Further research in this arena would benefit from a contextual appreciation of how different healthcare leadership structures and settings by ‘country’ or ‘region’, and ‘governance’ shape their staff experiences of both personal and professional safety.

Recommendations

• It is suggested that it is now time to mandate for staff to challenge poor behaviour within the macro, mezzo and micro level healthcare environment without the psychological vulnerability of either personal or professional redress, in order to improve both patient and staff safety
• It is suggested that it is now time to politically address the imbalance of workforce planning, with a strategic review of working conditions, to secure staff both in the medium and long term, for both patient and staff safety
• It is suggested that it is now time to adopt a human factors system-engineering approach into working policies and guidelines for safety at all levels of the healthcare systems hierarchy, and to reflect anthropomorphic design principles, including sustainable rostering for the benefit of both patient and staff safety
• It is suggested that it is now time for staff wellbeing to become a mandatory inclusion within both healthcare training, and employment contracts to improve both patient and staff safety.

Key points

• Barriers to employee voice negatively influence safety within maternity services
• Staff feel the negative effects of power and hierarchy from their employers, and also from patients too
• The management of power and hierarchy could have positive influences on working conditions had these been better managed
• Safety in this paper has been reviewed as a negative construct and this has to be acknowledged as a shortcoming in the general discussion of both risk and harm within healthcare safety

CPD reflective questions

• How can you as a practising midwife recognise and respect the contribution that people make towards their own health and wellbeing?
• To what extent do you feel able to act as an advocate for the vulnerable, challenging poor practice?
• What enables you to work with colleagues to preserve the safety of those in your care?
• Do you feel able to deal with differences of professional opinion?
• What can be done to support colleagues in the appropriate delegation of tasks according to abilities?