Abstract
BACKGROUND: Patient safety and professional self-regulation systems both rely on professional colleagues to hold each other accountable for quality of care. OBJECTIVES: To understand how staff nurses manage variations in practices within the group, and negotiate the rules-in-use for quality of care, collegiality, and accountability. DESIGN/METHODS: Ethnographic case study; participant-observation, semi-structured interviews, policy analysis. SETTING: In-patient unit in an urban US teaching hospital. RESULTS: Explicit acknowledgment of conflicts and practice variations was perceived as risky to group cohesion. The dependence of staff on mutual assistance, and the absence of a system of group practice, led to the practice of "mutual deference", a strategy of reciprocal tolerance and non-interference that gave wide discretion to each nurse's decisions about care. CONCLUSIONS: Efforts to improve professional accountability will need to address material constraints and the organization of nursing work, as well as communication and leadership skills.