Audrey Lyndon

Abstract

Purpose: The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project Design and Approach: In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project Description: The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical Implications: In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

Abstract

Communication and teamwork problems are leading causes of documented preventable adverse outcomes in perinatal care. An essential component of perinatal safety is the organizational culture in which clinicians work. Clinicians' individual and collective authority to question the plan of care and take action to change the direction of a clinical situation in the patient's best interest can be viewed as their "agency for safety." However, collective agency for safety and commitment to support nurses in their role of advocacy is missing in many perinatal care settings. This article draws from Organizational Accident Theory, High Reliability Theory, and Symbolic Interactionism to describe the nurse's role in maintaining safety during labor and birth in acute care settings and suggests actions for supporting the perinatal nurse at individual, group, and systems levels to achieve maximum safety in perinatal care.

Abstract

Objective To describe maternity nurses' perspectives on how they contribute to safety during labour and birth at two urban academic medical centres in the United States. Design Grounded theory: data were collected using semistructured, open-ended interviews and participant observations with registered nurses (RNs) in two inpatient maternity settings. Data were analysed simultaneously using constant comparison, and dimensional and situational analysis. Participants Purposive sample of 12 RNs working in the two maternity units. Findings Safety was broadly conceptualised by RNs as protecting the physical, psychological and emotional wellbeing of a woman and her family. During labour and birth, safety was maintained by RNs through "skilful anticipation" of situational potential. This required integration of medical and technical knowledge and skill with intimate knowledge of the woman and the operational context of care to achieve accurate situation awareness and appropriate future planning. Conditions and processes promoting skilful anticipation included being prepared, knowing, and envisioning the whole picture. Conclusions In the two settings, maternity RNs made active contributions to safe birth in the context of constrained resources through preparing the environment, anticipating potential problems and trapping errors before they reached the patient. The contributions of maternity nurses to team situation awareness and to creating safety need to be appreciated and administratively supported. Continued research with RNs may reveal previously unrecognised opportunities for safety improvements.

Abstract

Purpose: To describe how nurses would respond in common clinical situations involving disagreement with physician colleagues during labor and birth. Study Design and Methods: An electronic survey, consisting of five clinical disagreement case scenarios along with two open-ended questions regarding how to promote effective interdisciplinary communication and collaboration, was administered via a secure Web site. Seven hundred four obstetric nurses in a mid-size metropolitan area were invited to participate via mail. One hundred thirty-three nurses responded. Data were analyzed using descriptive statistics and thematic analysis of open-ended text responses. Results: Respondents were primarily aged ≥40, experienced in labor nursing, and held a BSN; 35% were members of the Association of Women's Health, Obstetric and Neonatal Nurses, 35% were certified in electronic fetal monitoring, and 33% were certified in inpatient obstetrics. In all five scenarios, most nurses were aware of current evidence and published standards of care (range 52%-86%). However, there was a wide discrepancy between current evidence/standards and what nurses indicated would occur in actual clinical practice. Clinical Implications: In this well-educated and knowledgeable sample of experienced labor nurses, reports of what would occur in clinical practice did not match current evidence or standards of care. Adequate nursing knowledge may not be an accurate predictor of appropriate clinical practice. Confidence in administrative support appears to be one of the key factors in empowering nurses to pursue resolution of disagreements in patients' best interests, whereas medical hierarchy, fear, and intimidation are significant barriers.

Abstract

Objective: To identify processes affecting agency for safety among perinatal nurses, physicians, and certified nurse-midwives. Design: Grounded theory, as informed by Strauss and Schatzman. Setting: Two academic perinatal units in the western United States. Participants: Purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives. Findings: Agency for safety (the willingness to take a stand on an issue of concern) fluctuated for all types of providers depending on situational context and was strongly influenced by interpersonal relationships. While physicians and certified nurse-midwives believed that they valued nurses' contributions to care, their units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Nurses'confidence was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor interpersonal relationships, resulting in a process of redefining the situation as a problem of self. Conclusions: Women and babies should not be dependent on the interpersonal relationships of providers for their safety. Clinicians should be aware of the complex social pressures that can affect clinical decision making. Continued research is needed to fully articulate facilitators and barriers to perinatal safety.

Abstract

Objective: To explore the practice of midwifery within a busy urban tertiary hospital birth setting and to present findings on the relationships between nurses and midwives in providing maternity care. Design/Method: A focused ethnography on midwifery practice conducted over 2 years (2004-2006) in a teaching hospital serving a primarily Medicaid-eligible population in Northern California. Data were collected through participant observations and in-depth interviews with midwives (N = 11) and nurses (N = 14). Practices and relationships among the midwives and nurses were examined in an ethnographic framework through thematic analysis. Findings: Two themes described the nature of nursing-midwifery relationships: tension and teamwork. Tension existed in philosophic approaches to care, definitions of safe practice, communication, and respect. Teamwork existed when the midwives and nurses worked in partnership with the woman to develop a plan of care. Changes were brought about to improve the midwife-nurse relationship during the conduct of the study. Conclusions: Midwives and nurses experienced day-to-day challenges in providing optimal care for childbearing women. The power of effective teamwork was profound, as was the tension when communication broke down. Failure to include nurses resulted in impaired translation of evidence into practice. All stakeholders in birth practices and policy development must be involved in future research in order to develop effective maternity care models.