Audrey Lyndon

Abstract

Missed nursing care is an important measure of nursing care quality that is sensitive to nurse staffing and is associated with patient outcomes in medical-surgical and pediatric inpatient settings. Missed nursing care during labor and birth has not been studied, yet childbirth represents the most common reason for hospitalization in the United States. The Missed Nursing Care (MISSCARE) Survey, a measure of medical-surgical nursing quality with substantial evidence for validity and reliability, was adapted to maternity nursing care using data from focus groups of labor nurses, physicians, and new mothers and an online survey of labor nurses. Content validity was evaluated via participant feedback, and exploratory factor analysis was performed to identify the factor structure of the instrument. The modified version, the Perinatal Missed Care Survey, appears to be a feasible and promising instrument with which to evaluate missed nursing care of women during labor and birth in hospitals.

Abstract

Objective: To evaluate the degree to which registered nurses perceive their labor and delivery units to be adhering to Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines. Design: Prospective, cross-sectional study via an online survey of labor nurses recruited from hospitals in three states. Setting/Local Problem: In late 2016 and early 2017, labor nurses in selected hospitals in California, Michigan, and New Jersey were contacted via e-mail invitation to participate in a study about nursing care during labor and birth. Nurse leaders in each hospital facilitated the invitations. Participants: A total of 615 labor nurses from 67 hospitals. Intervention/Measurements: Descriptive statistics and linear regression models were used for data analysis. Results: Most nurses reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed. Hospitals with annual birth volumes of 500 to 999 range were significantly more likely than hospitals with 2,500 or more annual births to be perceived as compliant with AWHONN staffing guidelines. Conclusion: When the AWHONN staffing guidelines were first published in 2010, there was concern among some nurse leaders that they would not be adopted into clinical practice, yet nurses in our sample overwhelmingly perceived their hospitals to be guideline compliant. There remains much more work to be done to determine nurse-sensitive outcomes for maternity care and to ensure that all women in labor in the United States are cared for by nurses who are not overburdened or distracted by being assigned more women than can be safely handled. In our survey of 615 labor nurses, most reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed.

Abstract

Background: Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record's impact on these dimensions of nurses’ work. Objective: The purpose of this review was to synthesize the literature on the electronic health record's impact on nurses’ cognitive work. Design: Integrative review. Data sources: MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO. Review methods: The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies. Results: Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians’ cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians’ ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses’ work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful. Conclusion: The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.

Abstract

Failure to rescue refers to the inability to prevent death from health care complications. The fact that more than half of severe maternal morbidity and maternal deaths are classified as preventable, and black women have 2 to 3 times the risk for adjusted severe morbidity and maternal mortality suggest there is a problem with failure to rescue in US maternity care. This article reviews national efforts to improve rescue capacity in maternity care and data on communication breakdowns and disrespect in maternity care, and outlines individual and organizational actions that can be taken to improve communication and rescue processes.

Abstract

Background: Nurses can be exposed to hundreds of alarms during their shift, contributing to alarm fatigue. Purpose: The purposes were to explore similarities and differences in perceptions of clinical alarms by labor nurses caring for generally healthy women compared with perceptions of adult intensive care unit (ICU) and neonatal ICU nurses caring for critically ill patients and to seek nurses' suggestions for potential improvements. Methods: Nurses were asked via focus groups about the utility of clinical alarms from medical devices. Results: There was consensus that false alarms and too many devices generating alarms contributed to alarm fatigue, and most alarms lacked clinical relevance. Nurses identified certain types of alarms that they responded to immediately, but the vast majority of the alarms did not contribute to their clinical assessment or planned nursing care. Conclusions: Monitoring only those patients who need it and only those physiologic values that are warranted, based on patient condition, may decrease alarm burden.

Abstract

RATIONALE: Preterm birth and other poor birth outcomes disproportionately affect women of color. Emerging evidence suggests that socially-driven issues such as disrespect, abuse, and discrimination within the health care system influence how people of color experience care during pregnancy, birth, and postpartum, which contributes to poorer outcomes for the mother and baby.OBJECTIVE: As recommended by community partners, we explored how interactions with providers were perceived and understood in the context of seeking care for pregnancy and birth.METHOD: For this constructivist grounded theory study, we recruited 22 self-identified women of color 18 years of age or older and who were between six weeks and one year postpartum. Women participated in interviews exploring their experiences, which were audiorecorded and transcribed. Data were analyzed using dimensional analysis and situational analysis methods.RESULTS: The concepts of information and power surfaced in analysis, in which providers have control over the information they share and "package" information to exert power over women's ability to participate in decision-making. An established relationship with providers and acknowledged levels of privilege or marginalization influenced how information was shared. Contextual factors included provider bias and judgment towards their patients, health care system structural issues, and the overall power dynamic between patient and provider.CONCLUSIONS: Women of color's experiences during pregnancy and birth were influenced by how they were treated by providers, particularly in how information was shared and withheld. The providers' control over information led to a power dynamic that diminished women's ability to maintain autonomy and make health care decisions for themselves and their children. This study provides insight and impetus for change in how providers share information, utilize informed consent, and provide respectful care to women of color during pregnancy and birth care.

Abstract

PROBLEM: Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners. APPROACH: The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS. OUTCOMES: Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS. NEXT STEPS: Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

Abstract

Objective: To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth. Design: Qualitative description using thematic analysis of interview data. Participants: Seventeen women ages 29 to 47 years. Methods: Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care. Results: Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during risk moments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety. Conclusion: Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.

Abstract

The purpose of this study was to examine the concept of delayed, unfinished, or missed nursing care when patient census and acuity exceed nurse staffing resources with nurses who care for women during labor and birth. Focus groups were held during which labor nurses were asked about aspects of nursing care that may be regularly delayed, unfinished, or completely missed during labor and birth, including possible reasons and potential consequences. Seventy-one labor nurses participated in 11 focus groups in 6 hospitals. Nurses focused on support and encouragement as aspects of care that they felt are essential but often not able to be performed when the unit is busy. Nurses seemed to assume technical features of care as a "given" in the background and not always noticed unless missed. They voiced concerns about risks to maternal and fetal well-being when they were short-staffed. Potential outcomes were discussed including cesarean birth, depressed infants at birth, hemorrhage, and negative effects on patient satisfaction, successful breast-feeding, and the overall patient experience. Conclusion: When essential aspects of nursing care are delayed, unfinished, or completely missed, there are potentially negative implications for numerous patient outcomes and patient safety is at risk.

Abstract

Background While breast milk is considered the gold standard of infant feeding, a majority of African American mothers are not exclusively breastfeeding their newborn infants. Objective The overall goal of this critical ethnographic research study was to describe infant feeding perceptions and experiences of African American mothers and their support persons. Methods Twenty-two participants (14 pregnant women and eight support persons) were recruited from public health programs and community based organizations in northern California. Data were collected through field observations, demographic questionnaires, and multiple in-person interviews. Thematic analysis was used to identify key themes. Results Half of the mothers noted an intention to exclusively breastfeed during the antepartum period. However, few mothers exclusively breastfed during the postpartum period. Many participants expressed guilt and shame for not being able to accomplish their antepartum goals. Life experiences and stressors, lack of breastfeeding role models, limited experiences with breastfeeding and lactation, and changes to the family dynamic played a major role in the infant feeding decision making process and breastfeeding duration. Conclusions for Practice Our observations suggest that while exclusivity goals were not being met, a considerable proportion of African American women were breastfeeding. Future interventions geared towards this population should include social media interventions, messaging around combination feeding, and increased education for identified social support persons. Public health measures aimed at reducing the current infant feeding inequities would benefit by also incorporating more culturally inclusive messaging around breastfeeding and lactation.