Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation

Abstract

BackgroundReducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of ‘what good looks like’.ObjectiveWe aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement.MethodsWe conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group.ResultsWe identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification.ConclusionsThis large qualitative study has enabled the generation of a new plain language framework—For Us—that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units.

Relationships and trust: Two key pillars of a well‐functioning freestanding midwifery unit

“…Within this working environment, staff were engaged with their colleagues and the families in their care. Engaged staff perform better and share a pride in continuously improving self and the service provided 16,45 …”

“…McCourt et al 10,11 stressed the need for integrated services that foster positive interprofessional relationships as key features for service quality and safety, yet their study also highlighted the risk of tense relationships between MUs and obstetric units (OUs) 11 . Sandall et al 15 argue that relationships are the pathway to safe, high‐quality maternity care, and Liberati et al 16 also stress that an organizational culture underpinned by teamwork, cooperation, and positive working relationships is a key characteristic of safe maternity units. However, MU performance can suffer from a lack of focus on philosophy of care, and MUs sometimes struggle with a low number of annual births and/or with high transfer rates 10,11 .…”

Current Resources for Evidence‐Based Practice, January/February 2021

“…However, I do not think that this fact limits generalizability to a US setting. There are a lot of data showing that birthing people in the United States from different socioeconomic, geographical, racial, and ethnic backgrounds experience the negative consequences of poor clinical outcomes, physical and psychological trauma, and unsatisfying birth experiences as a consequence of their needs being violated 1–5 …”

“…These are not only essential for patients to feel empowered and have a satisfying childbirth experience; they are also essential for providing a safe birth. Safe birth environments are universally characterized as those that reinforce ethical and respectful behavior as well as the presence of cooperative teamwork, something not possible without open communication 3,7 . What is clear is that respectful care has to become a priority in all perinatal units if patients are going to receive the care they deserve and the outcomes reflective of one of the richest countries in the world.…”

Safe care on maternity units: a multidimensional balancing act

“…This is the primary question posed by Liberati and colleagues in this issue of BMJ Quality & Safety. 1 The authors propose a framework distilled from observations on a group of highperforming units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours of total observations at six different maternity care sites.…”