Social and environmental conditions creating fluctuating agency for safety in two urban academic birth centers

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.