When it’s good to be a bad nurse: expanding risk orders theory to explore nurses’ experiences of moral, social and identity risks in obstetrics units

Abstract

Discourses about health risks can have major implications for individuals and cultures. In this article, we use risk orders theory to examine nurses’ perceptions of patient safety risk in Obstetrics departments of US hospitals. According to risk orders theory, risk discourses can create social worlds that have the capacity to threaten individuals’ social bonds, identity and moral character, and the imaginative potential of entire cultures. Risk orders theory proposes three orders of risk. First-order risks are constructed from claims about tangible dangers that individuals believe result from their actions or inactions. Second-order risks are threats experienced by individuals because of communication about first-order risk, including threats to social relationships or social risks, and threats to the sense of moral character or moral risk. Third-order risks are threats to collective agency and imagination underpinning shared culture. In this article, we draw on data from a survey of obstetric nurses who attended the Association of Women’s Health, Obstetric and Neonatal Nurses conference in 2010 in Las Vegas, Nevada. We use a qualitative thematic analysis of 131 obstetrics nurses’ narrative responses on a critical incident survey to refine theoretical constructs of risk orders theory. We identified a third type of second-order risk, identity risks, or threats to the sense of self. We also identified three types of third-order risks: agency-constraining risks threaten members of a culture’s ability to act freely; agent-constraining risks threaten cultural members’ ability to define themselves freely; double-binding risks threaten their ability to make choices freely. We found that second-order and third-order risks did threaten some obstetrics nurses’ social bonds, identity as a nurse, moral character and imaginative potential.