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Working to support cultures of safety in maternity and neonatal services: a qualitative interview study with service leaders and unit/safety leads.

Nicola Mackintosh,Sarah Chew,Natalie Armstrong,P. Duncan,Matt Hill,Tony Kelly,L. Sutton,Janet Willars,Carolyn Tarrant

Published 2025 in Midwifery

ABSTRACT

BACKGROUND Recent inquiries have demonstrated the significance of safety cultures within maternity and neonatal services. Research has highlighted the benefits of shifting attention away from safety incidents and towards learning about how the mundane, 'normal' accomplishments of safety are shaped by local cultures. However, we still have much to learn about the role of different staff groups in creating conditions that nurture and sustain local safety cultures. AIMS To explore how staff in middle-management positions worked to influence safety cultures at local maternity and neonatal unit and service level. METHODS We used a qualitative design, starting with scores obtained from a safety culture survey to identify high-performing organisations in England, in line with a positive deviance approach. Thirteen service leads and 23 unit/safety leads participated in interviews. Analysis used the constant comparative approach, combined with a theoretically-focused coding framework. FINDINGS Our research revealed how service and unit/safety leads influenced their local cultures of safety: through working across boundaries between the executive board and frontline practice on maternity and neonatal safety priorities; engaging with the service user voice, bringing this into the boardroom and the ward; and using horizon-scanning and political connections to manage the interface between policy initiatives and local practice. CONCLUSIONS AND IMPLICATIONS Staff in middle-management roles play an important role in nurturing and sustaining local cultures of safety, through boundary working within and outside the organisation and with different stakeholders. This demonstrates the importance of supporting staff in such roles, in efforts to develop local safety cultures. STATEMENT OF SIGNIFICANCE PROBLEM: problematic cultures/sub-cultures are acknowledged as a contributing factor to failures within healthcare services What is already known: research has highlighted the benefits of shifting attention away from safety incidents and 'extraordinary events', and towards learning how the mundane, 'normal' accomplishments of safety are shaped by local cultures What this paper adds: this paper highlights the important boundary work that staff in middle-management positions undertake to create the conditions that nurture and sustain local safety cultures.

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