We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.
Communication breakdown remains a leading contributor to adverse events in the United States. Previous studies indicate that clinicians may not always speak up when they have concerns about safety or performance and that the quality of the work environment is associated with patient outcomes. Human fallibility may be inevitable but should be open for discussion, especially within labor-and-delivery teams. In this study, 4 organizations, each committed to improving the birth process, have come together to study the kinds of high-stakes, emotional disagreements that are especially likely to be problematic.
Studies in other contexts suggest that when high-stakes conversations go poorly, they fail in 2 very different, but predictable, ways: silence and violence. People’s emotions kick in, and they move toward flight or fight. Silence, the flight response, includes failing to speak up at all, sidestepping true concerns, and taking concerns to the wrong people. Violence, the fight response, includes verbal and physical attacks (sarcasm, putdowns, and insults) and various ways of controlling, labeling, or dismissing the other person.
Silence in organizations is both common and costly. When people do not voice their concerns, the problems they have observed persist, a norm of silence is bolstered, organizational members become less committed, and the system itself becomes less capable. This problem of organizational silence has been found across many health care professions, ranging from chairs of medicine to residents, midwives, and nurses. When silence takes the form of health care workers’ inability to address each other’s fallibilities, patient safety is put at risk. In contrast, organizations that have made a commitment to programmatic changes that include promoting teamwork and effective communication have demonstrated improvements in patient outcomes.
Various forms of violence, including intimidation, disruptive behavior, and bullying, are also common within organizations and come with a price. These behaviors produce lower levels of commitment and higher turnover, greater burnout, and even revenge. Furthermore, violence within organizations also leads to silence. As professionals or staff with greater formal or informal power inappropriately assert their position, those who experience it are far less likely to speak up about future concerns.
The experience of organizational violence can be powerful in silencing witnesses as well as direct recipients because it undermines psychological safety. Organizational violence has been found across health care professions, including horizontal aggression among nurses, intimidation of residents, physicians’ disruptive behavior, and managerial bullying. The American College of Obstetricians and Gynecologists (ACOG), The Joint Commission, and others have called for health care organizations to formally manage disruptive behaviors and build positive partnerships to improve patient outcomes and experience in childbirth.
Surveys are available to measure unit- and hospital-level safety culture, and several programs are available to help facilities improve communication and teamwork (eg, TeamSTEPPS ; MoreOB ). However, the scope of concerns regarding safety and performance in US labor-and-delivery units remains unknown.
As the aims of the present study, we sought to investigate the occurrence of clinician concerns about safety and performance in labor-and-delivery units. This study focused on concerns that arise among physicians, midwives, and nurses during labor and birth and explored whether and how they were voiced.
The birth process can create an urgent need for skillful communication. Although birth is usually a normal, physiological process and most occur without problems, its dynamic nature requires swift, coordinated action when complications do arise. Risks to the mother and fetus may be known in advance or may develop suddenly. In either case, circumstances can be ambiguous and complex, conditions can change quickly, and caregivers must rely on one another to recognize and resolve evolving problems.
Caregivers need to discuss their concerns about their colleagues’ plans or actions. Yet the need to remain at the bedside may inhibit direct engagement in disagreement in front of women and their families. Delay in fully open communication can amplify risk or delay needed treatment. And yet research has shown that it can be difficult to speak up across professions, especially when power gradients exist as they do within labor-and-delivery teams.
Our interest was in mapping 4 kinds of concerns health care professionals are likely to have: concerns about dangerous shortcuts, missing competencies, disrespect, and performance problems. Previous studies have found that these concerns are prevalent, but are rarely addressed, within populations of critical care and operating room nurses. Our goal was to document how common these concerns are within labor-and-delivery teams, how costly they are judged by team members, and how discussable they are within the team.
Materials and methods
This study was conducted among the members of 4 professional organizations whose members attend labor and birth: the American College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric and Neonatal Nurses, and the Society for Maternal-Fetal Medicine. From a convenience sample of those members with active e-mail addresses on file, we randomly selected half of the members from each organization to receive a multiple-choice survey. The survey was delivered by the associations via an e-mail describing the study that included direct link to a secure survey platform.
Our ability to calculate a response rate was limited because the associations did not all have the capacity to track detailed information about survey delivery. The profession of each respondent was tracked by using a unique link for each professional association. No personal identifiers were collected. The Western Institutional Review Board determined the study to be exempt.
The survey was adapted from previous studies by an expert panel of physicians, nurses, and midwives who each had experience in the labor-and-delivery setting. A copy of the survey is available as an Appendix online . The behaviors of interest were defined as follows:
- 1.
Dangerous shortcuts were defined as shortcuts that could have been dangerous to a patient (for example, not washing hands, not changing gloves when appropriate, failing to check armbands, forgetting to perform a safety check, or not following an agreed-upon protocol).
- 2.
Missing competency was defined as not as skilled as he/she should have been (for example, not up to date on a procedure, policy, protocol, medication, or practice or was lacking basic skills).
- 3.
Disrespect was defined as demonstrated disrespect (was condescending, insulting, or rude or yelled, shouted, used profanity, or name called).
- 4.
Performance problems were defined as a performance problem (poor attention to detail, poor initiative, uncooperative, lazy, etc) that undermined teamwork, productivity, safety, patient experience, or quality of care.
Respondents were asked to rate how common, costly, and discussable each problem was within their labor-and-birth teams. These terms were defined in the following text.
Discussable problems
“Think of the person whose shortcuts create the most danger for patients. Who have you spoken with about the problem?” Respondents selected from a list of people they might have spoken with and selected all that applied.
The survey also asked participants to think of times when they had not spoken to the target of their concern and to select from a list of possible reasons for their silence. This question was designed to help to delineate the reasons for organizational silence within labor and delivery.
Results
A total of 3282 survey responses were collected. The breakdown of respondents included 985 physicians, 414 midwives, and 1884 nurses. The nurses included 895 staff nurses, 419 charge nurses, 368 manager/director nurses, and 195 other nurses.
Table 1 shows how common, costly, and discussable the 4 problems were for each of the 3 professions. These 4 concerns were common across professions: 92% of physicians, 93% of midwives, and 98% of nurses observed 1 or more of these 4 concerns within the last year. As seen in Table 2 , these concerns were also judged to be costly: 66% of physicians, 59% of midwives, and 77% of nurses said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving. And yet these concerns were largely not discussed: only 9% of physicians, 13% of midwives, and 13% of nurses who had 1 or more of the 4 concerns spoke to the person on each occasion and shared their full concern. Although the majority of health care providers did not speak to the person they deemed most responsible, many did speak to someone, as shown in Table 1 . Physicians, midwives, and staff nurses were at least as likely to discuss their concerns with coworkers and managers as with the person involved.
| Type of concern | Reported observing problem within the last year, n (%) | Reported they spoke with person involved and shared full concern, n (%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Physicians (n = 985) | Midwives (n = 414) | Staff nurses (n = 898) | Charge nurses (n = 420) | Nurse managers/directors (n = 386) | Physicians (n = 985) | Midwives (n = 414) | Staff Nurses (n = 898) | Charge nurses (n = 420) | Nurse managers/directors (n = 386) | |
| Shortcuts | 594 (61) | 290 (71) | 757 (85) | 375 (90) | 338 (88) | 280 (47) | 106 (37) | 201 (27) | 146 (39) | 240 (71) |
| Missing competencies | 702 (73) | 288 (73) | 686 (78) | 345 (83) | 291 (77) | 240 (34) | 94 (33) | 114 (17) | 94 (27) | 175 (60) |
| Disrespect | 580 (61) | 282 (70) | 762 (86) | 381 (91) | 333 (88) | 162 (28) | 74 (26) | 125 (16) | 104 (27) | 197 (59) |
| Performance problems | 685 (72) | 300 (76) | 770 (87) | 383 (92) | 326 (87) | 200 (29) | 67 (22) | 112 (15) | 105 (27) | 204 (63) |
| Type of concern | Physicians, n (%) | Midwives, n (%) | Staff nurses, n (%) | Charge nurses, n (%) | Nurse managers/directors, n (%) |
|---|---|---|---|---|---|
| Professionals reporting a patient was seriously harmed a | |||||
| Shortcuts | 78 (8) | 38 (9) | 86 (10) | 25 (6) | 48 (12) |
| Missing competencies | 139 (14) | 49 (12) | 128 (14) | 58 (14) | 58 (15) |
| Professionals reporting seriously considering transferring or leaving position | |||||
| Disrespect | 74 (8) | 52 (13) | 153 (17) | 56 (13) | 40 (10) |
| Professionals reporting situation(s) undermined patient safety | |||||
| Performance problems | 492 (50) | 227 (55) | 549 (61) | 284 (68) | 263 (68) |
a Serious harm defined as any harm listed requiring medication or treatment or more, up to and including patient death.
We examined this phenomenon more closely within the group of nurse respondents because we could compare staff nurses with charge nurses and with nurse managers/directors. Staff nurses were more likely to discuss these problems with their manager than with the person who was involved in the problem. They worked through the hierarchy rather than addressing the problem on their own. We found that nurses in more powerful roles reported speaking up more often than staff nurses; 63% of nurse managers/directors and 30% of charge nurses indicated they spoke to the person and shared their full concern.
Across professions, caregivers cited 2 primary reasons for not speaking up to the target of their concerns: (1) they worried that the person will become harder to work with (47%); and (2) they did not want conflict in front of a patient (38%). Additionally, staff and charge nurses cited 2 other reasons: (1) they feared the person would retaliate against them (38%); and (2) they had seen the person get angry at someone else who had confronted them (27%).
Comment
The intent of this survey was to determine whether health care professionals working within labor and delivery teams observe problems with performance that could affect safety and whether they speak up and resolve the concerns they have with one another. The results indicate a clear problem: participants in our study had concerns, concerns they believed could have an impact on patient safety and staff morale, and yet they were often unwilling or unable to enter into dialogue with the person at the center of their concerns. They feared speaking up would make the person harder to work with, result in a conflict played out in front of a patient, and frequently considered the way the person has acted in the past and worried about possible retaliation. Although many discussed their concerns with coworkers and managers, the data from managers showed that only 63% voiced their concerns to the target, suggesting a lack of organizational accountability for creating an environment in which concerns are openly discussed and addressed.
Study limitations include the use of a convenience sample from the professional associations. This method of sampling does not ensure access to the entire population of professionals working in labor-and-delivery settings and may not be generalizable to all settings. It is possible that nonresponse bias has skewed our results if professionals who do not perceive problems with communication and competence in labor and delivery did not respond to the survey. Furthermore, our survey delivery method hampered our ability to calculate a response rate. In the future, researchers will need to carefully consider the trade-offs between focused data collection in contained settings that can achieve a higher response rate vs the wide reach but lower response rates typical of electronic survey delivery.
Another concern is that the data reflect individual experience. Although it is unlikely, we could not determine whether some hospitals are more represented in our sample than others. If some hospitals are more represented, then it could happen that several respondents were thinking of the same incident. This is an issue that might be addressed in future studies by considering how unit- and hospital-level data from safety culture surveys may be related to the type of individual-level data collected in our study. Despite these limitations, the number of responses from across professional associations and the consistency of our findings with other literature suggest significant cause for concern.
Organizational silence undermines a team’s ability to course correct, learn as a team, and maintain quality and safety. Despite important progress in interdisciplinary collaboration in obstetrics, our findings suggest that there is room for improvement regarding organizational silence across all the professions involved in labor and delivery, including physicians, midwives, and nurses.
Our findings are consistent with studies in labor-and-delivery units and other settings indicating that hierarchy, disruptive behavior, and lack of perceived support from management for expressing concerns undermine patient safety and that these problems cut across professional boundaries.
Speaking up to just anyone is not enough. To make a difference in patient care, quality, and morale, labor-and-delivery professionals need to acquire the skills to voice their concerns directly to the involved clinicians in a timely and respectful fashion and be supported by their health care organizations when they do so. Clear accountability and commitment from all parties at this critical intersection of individual and organizational responsibility will lead to a safer and more satisfying environment for both patients and health care professionals.
The optimal strategy for improving dialog is not known and would likely vary from unit to unit. Table 3 contains several suggestions for improving dialog within labor-and-delivery teams. These suggestions draw on research from a wide variety of disciplines. Our data show that communication regarding safety concerns in labor and delivery settings is clearly an area in need of further study.
