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

02 August 2021
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.

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