Perinatal safety: from concept to nursing practice

Defining Speaking Up in the Healthcare System: a Systematic Review

BACKGROUND

Communication issues have been shown to contribute to healthcare errors. For years healthcare professionals have been told to "speak up." What "speak up" means is unclear, as it has been defined and operationalized in many ways. Thus, this study aimed to systematically review the literature regarding definitions and measurements of speaking up in the healthcare system and to develop a single, comprehensive definition and operationalization of the concept.

METHODS

PubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete databases were searched from 1999 to 2020. Publications were included if they mentioned speaking up for patient safety or any identified synonyms. Articles that used the term speaking up concerning non-health-related topics were excluded. This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 294 articles met the inclusion criteria, yet only 58 articles focused on speaking up. While the most common synonym terms identified were "speak up" and "raise concern," only 43 articles defined speaking up. Accordingly, a modified definition was developed for speaking up-A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

DISCUSSION

Speaking up is considered important for patient safety. Yet, there has been a lack of agreement on the definition and operationalization of speaking up. This review demonstrates that speaking up should be reconceptualized to provide a single definition for speaking up in healthcare.

Linking Patient Safety Climate With Missed Nursing Care in Labor and Delivery Units: Findings From the LaborRNs Survey

OBJECTIVE

This study aimed to explore the association of nurses' perceptions of patient safety climate with missed nursing care in labor and delivery (L&D) units.

METHODS

We recruited nurse respondents via email distribution of an electronic survey between February 2018 and July 2019. Hospitals with L&D units were recruited from states with projected availability of 2018 state inpatient data in the United States. Measures included the Safety Attitudes Questionnaire Safety Climate Subscale and the Perinatal Missed Care Survey. We estimated the relationship between safety climate and missed care using Kruskal-Wallis tests and mixed-effects linear regression.

RESULTS

The analytic sample included 3429 L&D registered nurses from 253 hospitals (response rate, 35%). A majority of respondents (65.7%) reported a perception of good safety climate in their units, with a mean score of 4.12 (±0.73) out of 5. The mean number of aspects of care occasionally, frequently, or always missed on respondents' units was 11.04 (±6.99) out of 25. χ2 Tests showed that six mostly commonly missed aspects of care (e.g., timely documentation) and three reasons for missed care (communications, material resources, and labor resources) were associated with safety climate groups ( P < 0.001). The adjusted mixed-effects model identified a significant association between better nurse-perceived safety climate and less missed care ( β = -2.65; 95% confidence interval, -2.97 to -2.34; P < 0.001) after controlling for years of experience and highest nursing education.

CONCLUSIONS

Our findings suggest that improving safety climate-for example, through better teamwork and communication-may improve nursing care quality during labor and birth through decreasing missed nursing care. Conversely, it is also possible that strategies to reduce missed care-such as staffing improvements-may improve safety climate.

Parents' Perspectives on Navigating the Work of Speaking Up in the NICU

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.

Nursing practice implications of the year of ethics

e 2015 ANA Code of Ethics is foundational to professional nursing practice and is aligned with AWHONN’s core values, standards of care and position statement on ethical decision-making in the clinical setting. Understanding the roles and responsibilities of nurses to ensure an ethical practice environment is critical to perinatal health outcomes and sta engagement and to the prevention of moral distress.

The expected and actual communication of health care workers during the management of intrapartum: An interpretive multiple case study

BACKGROUND

Daily activities within a health care organisation are mediated by information communication processes (ICP) involving multiple health care professionals at different levels of care. Effective perinatal management requires critical information to be accurately communicated. If there is a breakdown in this communication patient safety is at risk for various reasons such as: inadequate critical information, misconception of information and uninformed decisions being made. The purpose of this study was to interpret the complexities around ICP in order to contribute to the effective management of the intrapartum period.

METHODS

Multi method, multiple case study approach was used to understand the ICP during the management of the intrapartum period. During the study, the expected ICP, the actual ICP, the challenges involved and the desired ICP were analysed. Twenty-four in-depth interviews with skilled birth attendants (SBAs) employing observer-as-participant roles, field notes, and document review methods were utilised to gather the data. Thematic analysis was utilised to analyse the data using Atlas TI software.

RESULTS

The study revealed three subthemes which emerged from the expected ICP, whilst three others that emerged formed the theme actual ICP. The subthemes from the expected ICP included: accessibility of obstetric services, expected referral, recommended tools, expected communication and expected documentation. The theme actual ICP held three emerging subthemes: the handover processes, collaborative information seeking, information communicated and referral processes.

CONCLUSION

This study showed that what was expected was not what was actually happening. The requirements of the policies and protocols need to be effectively implemented to improve practice building these into current biomedical guidelines.

Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review

BACKGROUND

Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care.

METHODS

Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists.

RESULTS

The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours.

CONCLUSIONS

Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination.

Nurses' perspectives on the intersection of safety and informed decision making in maternity care

OBJECTIVE

To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety.

DESIGN

Constructivist grounded theory.

SETTING

Four hospitals in the western United States.

PARTICIPANTS

Forty-six (46) nurses and physicians practicing in maternity units.

METHOD

Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991).

RESULTS

The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication.

CONCLUSIONS

The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.

A collaborative interdisciplinary approach to electronic fetal monitoring: report of a statewide initiative

Intrapartum electronic fetal monitoring (EFM) is one of the most common procedures in obstetrics. Current consensus statements provide clinicians with a common language for EFM as well as provide a basis for a simplified approach to interpretation and management. This article presents a summary of the content and implementation of a statewide initiative in interdisciplinary EFM education and training designed to give clinicians of all backgrounds a shared mental model in EFM. Challenges to implementation at individual institutions may include physician and nursing engagement as well as time and cost constraints.

Ethical decision making in intrapartum nursing

Nurses are confronted daily with making ethical decisions in practice, in which the "right" or best course of action must be determined. However, for intrapartum nurses, the seemingly ordinary nature of ethical issues means that these concerns may be viewed merely as clinical or logistical problems to be solved, leaving the ethical dimensions obscured. This has consequences not only for women and the provision of safe, family-centered maternity care but also for the quality of nurses' work environments and degree of moral distress experienced. This article explores ethical aspects of intrapartum nursing by applying ethical principles and moral reasoning to an "everyday" situation encountered by intrapartum nurses in practice. Implications for practice and the development of healthy moral communities are considered.

"The midwifery two-step": a study on evidence-based midwifery practice

INTRODUCTION

To date, there has been little documentation of how practice-based midwifery networks in the United States might influence the transfer and development of knowledge in childbearing and women's health care. The first phase of this participatory action research project was to conduct a qualitative study with a community of midwifery practices to understand their perspectives on evidence-based practice and how an organized network could facilitate their work.

METHODS

Midwives within the community of interest were invited by letter or e-mail to participate in individual or small group interviews about knowledge transfer, primary concerns of evidence-based practice, and potential for a midwifery practice-based research network. Participatory action research strategies and organizational ethnographic approaches to data collection were used to guide qualitative interviews.

RESULTS

Eight midwifery practices enrolled in the study with 23 midwives participating in interviews. They attended births at 2 hospitals in the community. Two broad areas of discourse about evidence-based practice were identified: 1) challenges from influential persons, finances and resources, and the cultural perception of midwifery, and 2) strategies to foster best practice in the face of those challenges. The midwives believed a research network could be useful in learning collectively about their practices and in the support of their work.

DISCUSSION

Evidence-based practice is a goal but also has many challenges in everyday implementation. Practice-based research networks hold promise to support clinicians to examine the evidence and form strong coalitions to foster best clinical practice. The second phase of this study will work with this community of midwives to explore collective strategies to examine and improve practice.

P.U.R.E. Communication: A Strategy to Improve Care-Coordination for High Risk Birth

High-risk birth can be an emotionally-charged and sometimes emergent event that requires a cohesive multidisciplinary team. Communication breakdowns in perinatal emergencies are known to contribute to errors and adverse patient outcomes. One approach to breaching these barriers is the Purposeful, Unambiguous, Respectful, and Effective, P.U.R.E. process. P.U.R.E. is a method of communication that emphasizes coordination and recognizes the contributions of each member of the team. The purpose of this article is to describe how the P.U.R.E. process works and how teamwork strategies, group skills training, and structured communication techniques complement it.

Critical interactionism: an upstream-downstream approach to health care reform

Currently, per capita health care expenditures in the United States are more than 20% higher than any other country in the world and more than twice the average expenditure for European countries, yet the United States ranks 37th in life expectancy. Clearly, the health care system is not succeeding in improving the health of the US population with its focus on illness care for individuals. A new theoretical approach, critical interactionism, combines symbolic interactionism and critical social theory to provide a guide for addressing health care problems from both an upstream and downstream approach. Concepts of meaning from symbolic interactionism and emancipation from critical perspective move across system levels to inform and reform health care for individuals, organizations, and societies. This provides a powerful approach for health care reform, moving back and forth between the micro and macro levels. Areas of application to nursing practice with several examples (patients with obesity; patients who are lesbian, gay, bisexual, and transgender; workplace bullying and errors), nursing education, and research are also discussed.