Audrey Lyndon

Predictors of likelihood of speaking up about safety concerns in labour and delivery

Background Despite widespread emphasis on promoting ‘assertive communication’ by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care. Methods The authors developed a scenario-based measure of clinicians assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units. Results The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2–10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations. Discussion This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.

Effective physician-nurse communication: a patient safety essential for labor and delivery

Effective communication is a hallmark of safe patient care. Challenges to effective interprofessional communication in maternity care include differing professional perspectives on clinical management, steep hierarchies, and lack of administrative support for change. We review principles of high reliability as they apply to communication in clinical care and discuss principles of effective communication and conflict management in maternity care. Effective clinical communication is respectful, clear, direct, and explicit. We use a clinical scenario to illustrate an historic style of nurse-physician communication and demonstrate how communication can be improved to promote trust and patient safety. Consistent execution of successful communication requires excellent listening skills, superb administrative support, and collective commitment to move past traditional hierarchy and professional stereotyping.

Tensions and Teamwork in Nursing and Midwifery Relationships

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.

The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study

Objective To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort. Methods This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005–2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors. Results 1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI = 9.4–10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25–34 years: aOR = 1.29; ≥35 years: aOR = 1.41), had ≤high-school education (aOR = 1.63), public/no-insurance (aOR = 1.22) or a cesarean section (primary: aOR = 1.99; repeat: aOR = 1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI = 4.5–5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR = 2.09), Asian (aOR = 1.59), Hispanic (aOR = 1.42), had public/no-insurance (aOR = 1.52), delivered in hospitals with <1,000 births/year (aOR = 1.93), were primiparous (aOR = 2.03), had a multiple birth (aOR = 3.5), diabetes (aOR = 1.47), or chronic hypertension (aOR = 8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR = 3.72; aOR = 4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI = 17.4–32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI = 40.8–74.4). Conclusions The rate of severe sepsis was approximately twice the 1991–2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

Antenatal Steroid Administration for Premature Neonates in California

OBJECTIVES: To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term. METHODS: Clinical data for premature neonates born in 2005–2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors. RESULTS: Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005–2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999–2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001). CONCLUSION: A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups. LEVEL OF EVIDENCE: II

Dancing Around Death Hospitalist–Patient Communication About Serious Illness

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient’s understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

A State-wide Obstetric Hemorrhage Quality Improvement Initiative

PurposeThe 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 Collaboratives (CMQCCs) 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 ApproachIn 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 DescriptionThe 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 ImplicationsIn 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 toolkits enthusiastic adoption at the unit/service level in facilities across the state.

Breastfeeding and Use of Social Media Among First‐Time African American Mothers

OBJECTIVE To describe the use of social media during the antepartum and postpartum periods among first-time African American mothers and their support persons. DESIGN A qualitative critical ethnographic research design within the contexts of family life course development theory and Black feminist theory. SETTING Participants were recruited from community-based, public health, and home visiting programs. PARTICIPANTS A purposive sample was recruited, consisting of 14 pregnant African American women and eight support persons. METHODS Pregnant and postpartum African American women and their support persons were interviewed separately during the antepartum and postpartum periods. Data were analyzed thematically. RESULTS Participants frequently used social media for education and social support and searched the Internet for perinatal and parenting information. Most participants reported using at least one mobile application during their pregnancies and after giving birth. Social media were typically accessed through smartphones and/or computers using different websites and applications. Although participants gleaned considerable information about infant development from these applications, they had difficulty finding and recalling information about infant feeding. CONCLUSION Social media are an important vehicle to disseminate infant feeding information; however, they are not currently being used to full potential. Our findings suggest that future interventions geared toward African American mothers and their support persons should include social media approaches. The way individuals gather, receive, and interpret information is dynamic. The increasing popularity and use of social media platforms offers the opportunity to create more innovative, targeted mobile health interventions for infant feeding and breastfeeding promotion.

Maternal morbidity during childbirth hospitalization in California

Objective: To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization. Methods: Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005–2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models. Results: The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity. Conclusions: Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

Confronting Safety Gaps across Labor and Delivery Teams

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.