Bateman N. Sustainability: the elusive element of process improvement. International Journal of Operations and Production Management. 2006; 25:(3)261-276

Begley C. Great fleas have little fleas: Irish student midwives' views of the hierarchy in midwifery. Journal of Advanced Nursing. 2002; 38:(3)310-317

England short of almost 2 500 midwives, new birth figures confirm. 2019. (accessed 22 June 2020)

England short of almost 2 500 midwives, new birth figures confirm. 2019. (accessed 22 June 2020)

Capper T, Muurlink O, Williamson M. Being bullied as a midwifery student: does age matter?. British Journal of Midwifery. 2020; 28:(3)166-171

Carayon Pascale Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics. 2014; 45:14-25

Currie L, Richens Y. Exploring the perceptions of midwifery staff about safety culture?. British Journal of Midwifery. 2009; 17:(12)

Davies S, Coldridge L. No man's land: an exploration of the traumatic experiences of student midwives in practice. Midwifery. 2015; 858-864

Vulnerable groups and access to healthcare: a critical interpretive review. 2005. (accessed 12 July 2021)

Dixon-Woods M, Shaw R, Agarwai S The problem of appraising qualitative research. Quality and Safety in Healthcare. 2004; 13:223-225

Draper ES, Kurinczuk JJ, Kenyon S. MBRRACE-UK Perinatal Confidential Enquiry: Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death.: University of Leicester; 2017

Francis R. Freedom to Speak Up – a review of whistle blowing in the NHS. 2015;

Francis R. The mid Staffordshire NHS Foundation trust inquiry: the Robert Francis report Vol 3.London: Stationary Office; 2013

Hood Laraine A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice. Midwifery. 2010; 26:268-285

Hunter B, Henley J. Work, health and emotional lives of midwives in the United Kingdom: the UK WHELM study, Royal College of Midwives. 2019;

Hunter B, Warren L. Investigating resilience in midwifery – final report.RCM: Cardiff; 2013

Kirkup B. The report of the Morecambe Bay investigation.London: The Stationery Office; 2015

Kohn LT, Corrigan JM, Donaldson MS To err is human: building a safer health system.Washington: National Academies Press; 2000

Liberati EG Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation. BMJ Quality and Safety. 2020; 1-13

Mackintosh N, Sandall J. Overcoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: the role of standardised communication protocols. Social Science and Medicine. 2010; 71:(9)1683-1686

National Guardian's Office. National Guardian's Office annual report. 2020. (accessed 11 June 2020)

The patient safety strategy safer culture, safer systems, safer patients.London: NHS Improvement and NHS England; 2019

The code.London: NMC; 2018

Panagioti M, Keers Khan K Prevalence, severity and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019; 366:(14185)

Pattni N Challenging authority and speaking up in the operating room environment: a narrative synthesis. British Journal of Anaesthetists. 2019; 122:(2)233-244

Bruce Keogh, KBE. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report.: NHS; 2013

Why midwives leave - revisited.London: RCM; 2016

Royal College of Midwives. Findings of the RCM'S survey of the health, safety and wellbeing of midwives and maternity support workers RCM. 2017. (accessed 18 June 2020)

Roycroft M, Bhala NB, Brockbank S, O'Donoghue D, Goddard A, Verma AM. Rostering in a pandemic: Sustainability is key. Future Healthcare Journal. 2020; 7:(3)

Seers K. What is qualitative synthesis?. Evidence Based Nursing. 2012; 15:(4)

Snilstveit B, Oliver S, Vojtkova M. Narrative approaches to systematic review and synthesis of evidence for international development policy and practice. Journal of Development Effectiveness. 2012; 4:(3)409-429

Tarrant C, Leslie M, Bion J, Dixon-Woods M. A qualitative study of speaking out about patient safety concerns in intensive care units. Social Science and Medicine. 2017; 193:8-15

University of Cambridge. Cambridge dictionary. 2020. (accessed 22 June 2020)

Gender equality in the health workforce: analysis of 104 countries. 2019. (accessed 8 March 2021)

Young C, Smythe L, Couper J. Burnout: lessons from the lived experience of case loading midwives international. International Journal of Childbirth. 2015; 5:(3)154-165

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

02 August 2021
18 min read
Volume 29 · Issue 8



There are considerable tensions for healthcare staff between their employee allegiance and contracts, patient safety, and their responsibilities to codes of conduct within professional registration, and the NHS Constitution.


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.


This systematic narrative review was based on the approach of a narrative synthesis, with papers coded using Nvivo software.


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 negative influences of the cultural concepts of power and hierarchy on staff safety are significant within maternity services. 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.

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.

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • Unlimited access to the latest news, blogs and video content

  • Monthly email newsletter