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Scholarly Works (3 results)

  • Thesis
  • Peer Reviewed
UC San Francisco Electronic Theses and Dissertations (2019)

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.

    Cover page: The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2014)

    Background & objectives

    Little is known about how parents think about neonatal intensive care unit (NICU) safety. Due to their physiologic immaturity and small size, infants in NICUs are especially vulnerable to injury from their medical care. Campaigns are underway to integrate patients and family members into patient safety. This study aimed to describe how parents of infants in the NICU conceptualise patient safety and what kinds of concerns they have about safety.

    Methods

    This mixed-methods study employed questionnaires, interviews and observation with parents of infant patients in an academic medical centre NICU. Measures included parent stress, family-centredness and types of safety concerns.

    Results

    46 parents completed questionnaires and 14 of these parents also participated in 10 interviews (including 4 couple interviews). Infants had a range of medical and surgical problems, including prematurity, congenital diaphragmatic hernia and congenital cardiac disease. Parents were positive about their infants' care and had low levels of concern about the safety of procedures. Parents reporting more stress had more concerns. We identified three overlapping domains in parents' conceptualisations of safety in the NICU, including physical, developmental and emotional safety. Parents demonstrated sophisticated understanding of how environmental, treatment and personnel factors could potentially influence their infants' developmental and emotional health.

    Conclusions

    Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental and emotional safety domains may result in safety improvements.
      Cover page: Parents’ perspectives on safety in neonatal intensive care: a mixed-methods study
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2017)

      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.
        Cover page: Parents' Perspectives on Navigating the Work of Speaking Up in the NICU
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