UCSF

Assertive communication has been identified as key to maintaining safe operations in inpatient perinatal care. Perinatal nurses are positioned to detect and deflect evolving threats to patient safety, but evidence suggests nurses do not always take assertive action in response to clinical problems, and may be ignored when they do raise concerns. In contrast, evidence also suggests a direct effect for nursing on patient safety, but little is known specifically about how nurses keep patients safe. The purpose of this study was to articulate the direct contributions perinatal nurses make to maintaining safe care, and to identify processes affecting nurses' and other clinicians' agency for safety, or willingness to take a stand on issues of concern. This grounded theory study was conducted in two urban academic perinatal units with a purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives, using semi-structured interviews and participant observation. Data were collected and analyzed in an iterative fashion using the constant comparative method, dimensional, and situational analysis. Nurses maintained safety during labor and birth through skillful anticipation of the potential embedded in given clinical situations. They integrated medical and technical knowledge and skill with intimate knowledge of the woman and the operational context of care. Conditions and processes promoting skillful anticipation included being prepared, knowing, and envisioning the whole picture. Lack of available resources, fatigue, and environmental distractions challenged skillful anticipation and patient safety. Agency for safety fluctuated for all types of providers depending on the specifics of the situation. Agency was strongly influenced by interpersonal relationships. While physicians and CNMs believed they valued nurses' contributions to care, the units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Pervasive, mutually reinforcing segregation of activities by discipline impeded information flow, challenging safety. Nurses' confidence in their assessments was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor relationships, resulting in a process of redefining the situation as a problem of self and potential lack of persistence regarding their concerns.