ABSTRACT

BACKGROUND: Despite evidence demonstrating the safety of a trial of labor for women with a history of cesarean, nearly half of California's birth hospitals do not support vaginal birth after cesarean (VBAC). Increasing access to VBAC can contribute to a reduction in cesarean birth and the optimization of perinatal health outcomes.

METHODS: Thematic analysis was used to identify key themes in 157 comments volunteered by obstetric nurses during a structured survey of all civilian hospitals with perinatal units in California.

RESULTS: Nurses described significant efforts of specific providers, or change agents, required to support VBAC at their institutions. A sense of pride was evident in comments from nurses who associated VBAC support with high quality care. Nurses identified insufficient anesthesia coverage, the influence of professional organizations, and lack of provider willingness as barriers to VBAC.

CONCLUSION: Clinical data support increased access to VBAC. However, many non-clinical factors at the institutional and individual level function as barriers to VBAC. More studies are needed that: 1) demonstrate the safety of VBAC in smaller community hospitals; and, 2) investigate the perceptions of emergency obstetric providers with regard to VBAC. Maternal health providers who care for women with a history of cesarean should discuss the risks and benefits associated with a trial of labor and elective repeat cesarean to support informed choice and refer patients to centers that support VBAC if their institution does not.

Effective handoff communication is critical in promoting patient safety. At change of shift, nurses exchange patient information, but little is known about nursing handoff practices and patient safety.

The purpose of this research was to examine nurses' perspectives on handoff practices that promote patient safety and to identify conditions and processes that pose risks for patient care.

This grounded theory study was conducted in two medical-surgical units in an urban academic institution with a purposive sample of 21 nurses using semistructured interviews and 87 ethnographic observations. Data were collected and analyzed simultaneously using constant comparison and positional mapping.

Nurses maintained patient safety during handoffs by painting a full picture of patients so that oncoming nurses were well-prepared with information to prioritize assessments and detect changes in a patient's condition. Processes that promoted painting a full picture were organizing information, asking and answering questions skillfully, and engaging in respectful dialogue. Conditions that facilitated painting a full picture were respect, trust, time, private space, and face-to-face oral communication. Interpersonal tensions, lack of time, interruptions, and noise often hindered nurses' practices and jeopardized patient safety. Nurses' perceptions of the effectiveness of handoffs often depended on the position of the nurse in the handoff as either the oncoming or offgoing nurse.

Quality handoff information depended on an offgoing nurse arriving at handoff with a grasp of their patients. To acquire a grasp, nurses gathered and synthesized information throughout their shift. As nurses did so, they were actively constructing the story of the patient. Processes that facilitated constructing the story were receiving good handoff reports, assessing the patient, cueing in, and writing it down. While constructing the story, nurses were prioritizing assessments and detecting patient changes. Poor handoff reports, staffing constraints, and unpredictable patient flow challenged nurses in constructing the story. Nurses may arrive at the handoff with a poor grasp posing risks for patients.

Future research interventions need to consider the position of the nurse in the handoff. Research comparing handoff practices in units with good and poor clinical environments is needed.

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive Work

Abstract

Background and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications.

Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States.

Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work.

Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings.

Assertive communication has been identified as key to maintaining safe operations in inpatient perinatal care. Perinatal nurses are positioned to detect and deflect evolving threats to patient safety, but evidence suggests nurses do not always take assertive action in response to clinical problems, and may be ignored when they do raise concerns. In contrast, evidence also suggests a direct effect for nursing on patient safety, but little is known specifically about how nurses keep patients safe. The purpose of this study was to articulate the direct contributions perinatal nurses make to maintaining safe care, and to identify processes affecting nurses' and other clinicians' agency for safety, or willingness to take a stand on issues of concern. This grounded theory study was conducted in two urban academic perinatal units with a purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives, using semi-structured interviews and participant observation. Data were collected and analyzed in an iterative fashion using the constant comparative method, dimensional, and situational analysis. Nurses maintained safety during labor and birth through skillful anticipation of the potential embedded in given clinical situations. They integrated medical and technical knowledge and skill with intimate knowledge of the woman and the operational context of care. Conditions and processes promoting skillful anticipation included being prepared, knowing, and envisioning the whole picture. Lack of available resources, fatigue, and environmental distractions challenged skillful anticipation and patient safety. Agency for safety fluctuated for all types of providers depending on the specifics of the situation. Agency was strongly influenced by interpersonal relationships. While physicians and CNMs believed they valued nurses' contributions to care, the units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Pervasive, mutually reinforcing segregation of activities by discipline impeded information flow, challenging safety. Nurses' confidence in their assessments was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor relationships, resulting in a process of redefining the situation as a problem of self and potential lack of persistence regarding their concerns.

Adult mothers with negative decision-making experiences during labor have increased risk for problems such as postpartum depression, yet little is known about adolescent mothers' experiences of decision-making during labor. Despite their developmentally unique decision-making processes, in the United States adolescent mothers have the decision-making rights of adults during labor. The purpose of this study was to develop theory exploring adolescent mothers' experiences of decision-making during labor and birth.

For this constructivist grounded theory study interviews were conducted with 18 adolescent mothers. Childbirth classes for adolescents in a West Coast urban area were also observed. Data collection and analysis were conducted concurrently using constant comparison, situational analysis, and dimensional analysis.

Adolescent mothers felt their decision-making during labor was setting the tone for early motherhood. Adolescents made decisions in the context of their belief that during labor they would go into mother mode and gain the strength to give birth and care for their child. Conditions affecting decision-making included the support available, expectations, communication and perceived locus of control. Key decision-making processes included `going natural' versus `going epidural'; being strong for the baby; and interpreting the perceived cues of others. Consequences included increased feelings of confidence for adolescents who felt their decisions reflected good mothering, and persistent feelings of regret and anxiety for adolescents who felt pressured into unwanted decisions.

Adolescent mothers reported feeling most supported when they had a supportive ally, yet often made decisions in the context of unpredictable availability and degree of support. Conditions influencing having a supportive ally included adolescents' familiarity with the support provider, the expertise of the support provider and the consistency of support. During decision-making, key processes of the supportive ally included facilitating communication, making space for decisions and validating hard choices. Adolescents who had a supportive ally for decision-making during labor and birth reported feeling empowered, while mothers without a supportive ally could feel silenced in decision-making.

Further research is needed to investigate the relationship between adolescent mothers' experiences of decision-making during labor and outcomes such as postpartum mood disorders, and should incorporate conceptual frameworks drawing from current theories of adolescent development and decision-making.

Identification of patients at risk for deterioration initially started with studies that focused predictors of cardiopulmonary and neurovascular demise. This spawned research to evaluate the utility of predictor models followed by the performance studies of early warning track and trigger systems in adults. Mandates to provide emergency services early in the course of instability in the 1990s fueled research to analyze the outcomes of rapid response systems and early warning systems in both adults and pediatrics. Recently studies have looked at system and human factors that impact failure to rescue. Given the dearth of systems research in early prevention of deterioration in pediatrics this study was designed to explore what nurses do during deterioration and the factors that impact their actions.

Interview and observations of 13 pediatric nurses and 16 parents of pediatric patients admitted to a non ICU environment were conducted at one academic children’s hospital in the Northwest USA. Grounded theory methods were used to guide data collection and analysis. Findings describe nursing actions associated with nursing surveillance of instability as well as factors that facilitate or impede surveillance efficacy. We present a theoretical model for how nurses and parents integrate their roles in surveillance of pediatric patients. We also further developed a sociotechnical model of nursing surveillance.

While breast milk is considered the gold standard of infant feeding, a majority of African American mothers are choosing to not exclusively breastfeed their newborn infants. With the highest rates of infant mortality, premature birth, low birth weight and very low birth weight; African American infants can benefit greatly from an increase in breastfeeding initiation and continuation. 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. The specific aims were: 1) to describe and analyze the process African American women undergo when deciding on an infant feeding method; 2) to describe the barriers and facilitators encountered during this decision making process as it unfolds over time from antepartum through birth and the early postpartum period; 3) to understand the role social support persons, specifically grandmothers and parenting partners of the babies play in the decision making process. Participants were recruited from public health programs and community based organizations in the Bay Area. Twenty two participants were enrolled; 14 pregnant women and eight support persons. Data were collected through field observations and multiple in-person interviews. A total of 43 audio-recorded interviews were completed from March 2013 to June 2014. Participants were able to describe the benefits of breastfeeding. Most participants noted an intention to exclusively breastfeed during the antepartum period and expressed guilt for not being able to exclusively breastfeed during the postpartum period. Combination feeding (the use of both breast milk and formula feeding) was a common occurrence and the use of social media for social and educational support was frequently noted. Life experiences (e.g. challenging family dynamics and difficulty with latch), public health programs (home visitors), and changes to the family dynamic (lack of support) played a significant role in the infant feeding decision making process. These data suggest that while exclusivity goals are not being met; African American women are breastfeeding. Future interventions geared towards this population should include social media, messaging around combination feeding and increased education for identified social support persons.

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