Audrey Lyndon

Abstract

Background: As part of an ongoing study about nurse staffi ng during labor and birth sponsored by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), outcomes that may be linked to aspects of labor nursing were considered. The purpose of this study was to see if labor nurses felt they influenced whether a woman has a cesarean birth. These data were used to determine if cesarean birth should be included as an outcome measure in the multistate labor nurse staffi ng study. Methods: Focus groups were used to explore the role of labor nurses and cesarean birth. Participants were attending the AWHONN national convention in 2015. Two open-ended questions were asked: 1) Do labor nurses influence whether a woman has a cesarean? 2) What specifi c things do you do as a labor nurse to help a woman avoid a cesarean? Results: Two focus groups were held (n = 15 and n = 9). Nurses overwhelmingly agreed nursing care can influence mode of birth. They described multiple strategies routinely used to help a woman avoid a cesarean, which were categorized into three main themes: support, advocacy, and interactions with physicians. Support was emotional, informational, and physical. Advocacy involved advocating for women and helping women advocate for themselves. Nurses tried to focus on positive aspects of labor progress when communicating with physicians. Descriptions of interactions with some physicians implied less than optimal teamwork and lack of collaboration. Conclusion: Labor nurses are likely infl uential in whether some women have a cesarean. They reported consistently taking an active role to help women avoid a cesarean. Promoting vaginal birth as appropriate to the clinical situation was a high priority. Trust, partnership, and respect for roles and responsibilities of each discipline were not evident in some of the clinical situations nurses described.

Abstract

Objective To describe parents' perspectives and likelihood of speaking up about safety concerns in the NICU and identify barriers and facilitators to parents speaking up. Design Exploratory, qualitatively driven, mixed-methods design. Setting A 50-bed U.S. academic medical center, open-bay NICU. Participants Forty-six parents completed questionnaires, 14 of whom were also interviewed. Methods Questionnaires, interviews, and observations with parents of newborns in the NICU were used. The qualitative investigation was based on constructivist grounded theory. Quantitative measures included ratings and free-text responses about the likelihood of speaking up in response to a hypothetical scenario about lack of clinician hand hygiene. Qualitative and quantitative analyses were integrated in the final interpretation. Results Most parents (75%) rated themselves likely or very likely to speak up in response to lack of hand hygiene; 25% of parents rated themselves unlikely to speak up in the same situation. Parents engaged in a complex process of Navigating the work of speaking up in the NICU that entailed learning the NICU, being deliberate about decisions to speak up, and at times choosing silence as a safety strategy. Decisions about how and when to speak up were influenced by multiple factors including knowing my baby, knowing the team, having a defined pathway to voice concerns, clinician approachability, clinician availability and friendliness, and clinician responsiveness. Conclusion To engage parents as full partners in safety, clinicians need to recognize the complex social and personal dimensions of the NICU experience that influence parents' willingness to speak up about their safety concerns.

Abstract

Objective:To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project.Study Design:Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general.Results:Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation.Conclusion:Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.

Abstract

Background Childbirth is a leading reason for hospital admission in the USA, and most labour care is provided by registered nurses under physician or midwife supervision in a nurse-managed care model. Yet, there are no validated nurse-sensitive quality measures for maternity care. We aimed to engage primary stakeholders of maternity care in identifying the aspects of nursing care during labour and birth they believe influence birth outcomes, and how these aspects of care might be measured. Methods This qualitative study used 15 focus groups to explore perceptions of 73 nurses, 23 new mothers and 9 physicians regarding important aspects of care. Transcripts were analysed thematically. Participants in the final six focus groups were also asked whether or not they thought each of five existing perinatal quality measures were nurse-sensitive. Results Nurses, new mothers and physicians identified nurses' support of and advocacy for women as important to birth outcomes. Support and advocacy actions included keeping women and their family members informed, being present with women, setting the emotional tone, knowing and advocating for women's wishes and avoiding caesarean birth. Mothers and nurses took technical aspects of care for granted, whereas physicians discussed this more explicitly, noting that nurses were their 'eyes and ears' during labour. Participants endorsed caesarean rates and breastfeeding rates as likely to be nurse-sensitive. Conclusions Stakeholder values support inclusion of maternity nursing care quality measures related to emotional support and providing information in addition to physical support and clinical aspects of care. Care models that ensure labour nurses have sufficient time and resources to engage in the supportive relationships that women value might contribute to better health outcomes and improved patient experience.

Abstract

PURPOSE: The purpose of our study was to explore how foreign-born Chinese women living in California engage in various traditional and American birth practices.STUDY DESIGN AND METHODS: A descriptive qualitative study was conducted using a grounded theory approach. Chinese women from Mainland China, Hong Kong, and Taiwan who had childbirth experiences in the United States were purposively sampled. Semistructured interviews were conducted with 13 women, with follow-up interviews with 5 women. Interview data were analyzed using grounded theory according to the method of Strauss and Corbin.RESULTS: There are many traditional practices for pregnancy and childbirth. Women investigated the traditions through various means, and built their own perspective on each tradition by integrating an evaluation of the Chinese perspective and an evaluation of the American perspective. Women considered several factors in the process of evaluating the Chinese and American perspectives to reach their own integrated perspective on each tradition. These factors included whether or not the tradition made sense to them, how the traditional practice affected their comfort, nature of available options, attitudes of female elders, previous experiences of their peers and themselves, and outcomes of temporary trials of traditional or nontraditional practices.CLINICAL IMPLICATIONS: Healthcare providers should respect women's diverse perspectives on traditional practices and encourage flexible arrangements. Including the elder generation in health education may be useful in helping women manage conflicts and to support their decisions.

Abstract

Background: Sub-Saharan Africa accounts for approximately 66% of global maternal deaths. Poor person-centered maternity care, which emphasizes the quality of patient experience, contributes both directly and indirectly to these poor outcomes. Yet, few studies in low resource settings have examined what is important to women during childbirth from their perspective. The aim of this study is to examine women's facility-based childbirth experiences in a rural county in Kenya, to identify aspects of care that contribute to a positive or negative birth experience. Methods: Data are from eight focus group discussions conducted in a rural county in western Kenya in October and November 2016, with 58 mothers aged 15 to 49 years who gave birth in the preceding nine weeks. We recorded and transcribed the discussions and used a thematic approach for data analysis. Results: The findings suggest four factors influence women's perceptions of quality of care: responsiveness, supportive care, dignified care, and effective communication. Women had a positive experience when they were received well at the health facility, treated with kindness and respect, and given sufficient information about their care. The reverse led to a negative experience. These experiences were influenced by the behavior of both clinical and support staff and the facility environment. Conclusions: This study extends the literature on person-centered maternity care in low resource settings. To improve person-centered maternity care, interventions need to address the responsiveness of health facilities, ensure women receive supportive and dignified care, and promote effective patient-provider communication.

Abstract

Objective: To evaluate responses of registered nurse members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) to a survey that sought their recommendations for staffing guidelines and their perceptions of the consequences of inadequate nurse staffing. The goal was to use these member data to inform the work of the AWHONN nurse staffing research team. Design: Secondary analysis of responses to the 2010 AWHONN nurse staffing survey. Setting: Online. Participants: AWHONN members (N = 884). Methods: Review of data from an online survey of AWHONN members through the use of thematic analysis for descriptions of the consequences of inadequate nurse staffing during the childbirth process. Results: Three main themes emerged as consequences of inadequate staffing or being short-staffed: Missed Care, Potential for Failure to Rescue, and Job-Related Stress and Dissatisfaction. These themes are consistent with those previously identified in the literature related to inadequate nurse staffing. Conclusion: Based on the responses from participants in the 2010 AWHONN nurse staffing survey, consequences of inadequate staffing can be quite serious and may put patients at risk for preventable harm.

Abstract

Objective: Patient-centred care has become a priority in many countries. It is unknown whether current tools capture aspects of care patients and their surrogates consider important. We investigated whether online narrative reviews from patients and surrogates reflect domains in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and we described additional potential domains. Design: We used thematic analysis to assess online narrative reviews for reference to HCAHPS domains and salient non-HCAHPS domains and compared results by reviewer type (patient vs surrogate). Setting: We identified hospitals for review from the American Hospital Association database using a stratified random sampling approach. This approach ensured inclusion of reviews of a diverse set of hospitals. We searched online in February 2013 for narrative reviews from any source for each hospital. Participants: We included up to two narrative reviews for each hospital. Exclusions: Outpatient or emergency department reviews, reviews from self-identified hospital employees, or reviews of <10 words. Results: 50.0% (n=122) of reviews (N=244) were from patients and 38.1% (n=93) from friends or family members. Only 57.0% (n=139) of reviews mentioned any HCAHPS domain. Additional salient domains were: Financing, including unexpected out-of-pocket costs and difficult interactions with billing departments; system-centred care; and perceptions of safety. These domains were mentioned in 51.2% (n=125) of reviews. Friends and family members commented on perceptions of safety more frequently than patients. Conclusions: A substantial proportion of consumer reviews do not mention HCAHPS domains. Surrogates appear to observe care differently than patients, particularly around safety.

Abstract

Purpose: The purpose of this study was to describe user experience with implementation of an obstetric hemorrhage toolkit and determine the degree of implementation of recommended practices that occurred during a 31-hospital quality improvement learning collaborative. Study Design and Methods: This descriptive qualitative study included semistructured interviews with 22 implementation team leaders and review of transcripts from collaborative reporting calls recorded during the hemorrhage collaborative. Interviews included openended, closed, and ranking questions. Numeric responses were analyzed with descriptive statistics. Open-ended responses and call transcripts were analyzed thematically. Results: Each of the 10 core toolkit components was ranked as currently "implemented" or "implemented and sustained" by at least 77% of interviewees. Most core elements were deemed "critical to retain." Respondents found debriefing the most difficult element of the toolkit to implement and sustain. Organizational context was the overarching theme regarding factors facilitating or constraining implementation. This included organizational structure and culture, previous experience with quality improvement, resources, and clinician engagement. Nurses were deeply involved in implementation and "physician buy-in" was a frequently mentioned facilitator when present and barrier when absent. Clinical Implications: Greater understanding of and attention to organizational context and resources, greater appreciation for nursing involvement, and increased recognition of the role of organizational leadership are needed to facilitate widespread improvement initiatives in maternity care. Implementation science approaches may be useful in achieving national goals for maternal quality improvement and safety.

Abstract

When nurses care for women during labor, they encounter numerous alerts and alarms from electronic fetal monitors and their surveillance systems. Notifications of values of physiologic parameters for a woman and fetus that may be outside preset limits are generated via visual and audible cues. There is no standardization of these alert and alarm parameters among electronic fetal monitoring vendors in the United States, and there are no data supporting their sensitivity and specificity. Agreement among professional organizations about physiologic parameters for alerts and alarms commonly used during labor is lacking. It is unknown if labor nurses view the alerts and alarms as helpful or a nuisance. There is no evidence that they promote or hinder patient safety. This clinical issue warrants our attention as labor nurses.