Reflecting on the importance of psychologically safe approaches in maternity (and other large) reviews

Maternity care is perhaps the service which is subject to the most polarised and emotionally charged debate; as, arguably, no other service is closer to the heart of the NHS. The impact of poor maternal care on family life, including other children, cannot be counted. 

The UK Parliament Birth Trauma Report as well as (now) several large maternity reviews, including the one we recently supported in Swansea, have all found similar issues. Women, babies, and birth partners have been let down, not listened to, suffered avoidable harm and trauma, parents have been discounted in their grief and not supported in seeking resolution and redress; often leading to compound trauma.  

Fear paralysis 

We also know that the overwhelming majority of staff come to work to deliver safe and effective care and they are also devastated when things go wrong. However, trust between families and staff is at an all-time low and the blame directed generally at maternity services results in fear.  

The same fear not only risks good staff leaving and dissuades new staff from joining, but fear is also felt by the women and families who need to access those services and who don’t have answers to their fundamental questions; will I be safe? will my baby be safe? will people be kind to me?  

The recruitment gains of the last few years and improvements in maternal safety, risk collapsing amidst fear paralysis.  

New approaches are needed to drive the improvements required without creating more trauma for families, staff and organsiations. The national reviews across England and recently announced in Wales should seek to help move the scrutiny to a more productive place, by focussing on the facts, themes, and the data. This is absolutely the time for the balanced, systems-based and thematic approaches advocated by the Patient Safety Incident Response Framework. 

Seeking understanding in a psychologically safe way 

Nurses, midwives, and other members of the medical workforce work in a profession where there can be amazing job satisfaction, but there are also risks of the same workforce experiencing direct and vicarious trauma. Trauma is vastly underecognised and it not only affects individuals, but whole wards and whole organisations can become traumatised; trauma is pervasive within and surrounding maternity services. 

The very staff that we expect to deliver kindness, care and resilience are themselves often experiencing burnout and compassion fatigue (‘the cost of caring’). Trauma is, in our view, an almost completely ignored facet of the ‘safety system’. It can directly impact the way in which staff engage and have conversations; they can experience reduced resilience and apathy to change. This is a fragile grounding upon which to undertake a large (or any) review of maternity services.  

Staff and services, in our experience, want to know how to improve, they want the facts, but they also want the facts given to them in a psychologically safe way.  

The way to do this is by achieving a balance of view through independent, impartial review methods which consider all aspects of the work and safety system and not just certain parts. After all, what we generally see are good staff working within an imperfect system. Imagine the possibilities of great staff being able to work within a great system. 

Understanding the (whole) safety system  

Understanding the experiences of women and families as well as the quality of the clinical care provided to them, is, ofcourse, a fundamental aspect of any maternity review. But these are not the only features of a safety-system which will produce a reliable and importantly, rounded, understanding of care quality. 

Looking at the governance surrounding maternity services and how systems, process and controls work together is vital (both on a historic ‘what happened’ basis and contemporary ‘will it happen again’ basis). Importantly, any review must also include the broader parts of the ‘system of care’ which surround the services (regulation, inspection, other care delivery partners). 

Understanding the experiences of staff in their daily working lives is crucial, particularly how they feel safe in delivery of their role and how they are supported to deliver good care. Ensuring that staff are part of the conversation every step of the way is so important in ensuring they equally help to create the necessary solutions.  

A key ingredient for traingulation is data; and good data creates valuable (actionable) insights. Data is needed to understand not only how population risk factors affect care delivery factors at a very local level. Data also helps us to understand why there are ‘dips’ and ‘spikes’ in outcomes (for example, overlaying staffing numbers, bed occupancy, demand in triage, induction and caesarean rates) all of which allows a thorough understanding of outcomes to emerge such as increases in HIE rates, still-births, and avoidable harms.  

Good qualitative methods also help reliable themes to emerge; in Swansea we found some important ‘linked’ evidential themes reported by women, for example, how poor communication is linked to a loss of sense of control and autonomy and a lack of information can increase the incidence of trauma.  

From our work some very key questions emerged which may be helpful more broadly, in terms of seeking a more rounded understanding of your services; they are: 

1. Trauma needs answers. Do we sufficiently understand and recognise trauma and the impacts of trauma in the women and families that we provide care for – are we sufficiently trauma informed? 
2. How would we recognise and treat burnout, trauma and compassion fatigue in our staff and indeed, at a service and organisational level? How is this impacting on the way they are able to deliver care? 
3. Do our services sufficiently understand our population risk factors and are we sufficiently planning for this through our antenatal care services? Are we helping our staff to really understand local population needs? 
4. Are our services ‘planning for unpredictability’ by thoroughly learning from past events or ‘spikes’, particularly what the data suggests about staffing, acuity, capacity, birth-rate and outcomes? Are we giving our staff the best information to plan? 
5. Do we place an over-reliance upon satisfaction survey data – do we do enough to gain a proper qualitative understanding of how women and families feel about the care they received or the trauma they felt? 

By using all evidence available, by having conversations in a safe, trauma-informed way, by safely surfacing the facts – and understanding the foundational improvements to the safety system which may be required – we can start to build the safe, reliable and kind maternity services that we all collectively want to see.