Nurse-physician communication during labor and birth: implications for patient safety

Canadian care providers' and pregnant women's approaches to managing birth: minimizing risk while maximizing integrity

We employed grounded theory to explain how Canadian pregnant women and care providers manage birth. The sample comprised 9 pregnant women and 56 intrapartum care providers (family doctors, midwives, nurses, obstetricians, and doulas [individuals providing labor support]). We collected data from 2008 to 2009, using focus groups that included care providers and pregnant women. Using concurrent data collection and analysis, we generated the core category: minimizing risk while maximizing integrity. Women and providers used strategies to minimize risk and maximize integrity, which included accepting or resisting recommendations for surveillance and recommendations for interventions, and plotting courses vs. letting events unfold. Strategies were influenced by evidence, relationships, and local health cultures, and led to feelings of weakness or strength, confidence or uncertainty, and differing power- and responsibility-sharing arrangements. The findings highlight difficulties resisting surveillance and interventions in a risk-adverse culture, and the need for attention to processes of giving birth.

The impact of nursing characteristics and the work environment on perceptions of communication

Failure to communicate openly and accurately to members of the healthcare team can result in medical error. The purpose of this study was to explore the impact of nursing characteristics and environmental values on communication in the acute care setting. Nurses (n = 135) on four medical-surgical units in two hospitals completed a survey asking nurses' perceptions of communication, work environment, and nursing demographics. LPNs perceived significantly higher levels of open communication with nurses than did RNs (P = .042). RNs noted higher levels of accuracy of communication among nurses than did LPNs (P < .001). Higher experience levels resulted in greater perceptions of open communication. Only environmental values (e.g., trust, respect) were a significant predictor of both openness and accuracy of communication. These findings suggest understanding the environment (e.g., presence or absence of trust, respect, status equity, and time availability) is a foundational step that must occur before implementing any strategies aimed at improving communication.

The impact of interprofessional collaboration on the effectiveness, significance, and future of advanced practice registered nurses

Interprofessional collaboration was essential for the conduct of research that demonstrated the effectiveness and significance of advanced practice registered nurses (APRNs) in providing care, in reducing health care costs, and in developing innovative models of care for the nation's citizens. If the 2010 Affordable Care Act is to be implemented, APRNs, with their expertise and numbers, are essential to its implementation. Continued interdisciplinary collaboration is needed to expand the scope of APRN state practice regulations, to change reimbursement for APRN services, and to mute opposition to these changes by medical organizations.

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.

When is collaboration not collaboration? When it's militarized

In adopting the medical lobby's preferred definition of collaboration where midwives are legally compelled to seek endorsement for their care plan from an obstetrician, Determination 2010 connotes a form of militarized collaboration and thus negates all that genuine collaboration stands for--equality, mutual trust and reciprocal respect. Using Critical Discourse Analysis, the first half of this paper analyses the submissions from medical, midwifery and consumer peak organisations to the Maternity Services Review and Senate reviews held between 2008 and 2010 showing that Determination 2010 privileges the medical lobby worldview in adopting a vertical definition of collaboration. The second half of the paper responds to the principal assumption of Determination 2010--that midwives do not voluntarily collaborate. It argues by reference to a qualitative inquiry conducted into select caseload maternity units in South Australia, Victoria and New South Wales during 2009-2010 that this presupposition is erroneous. The evidence shows that genuine collaboration is possible without legislative force but it requires a coalition of the willing among senior midwives and obstetricians to institute regular interdisciplinary meetings and clinical reviews and to model respectful behaviour to new entrants.

Exploring the concept of nurse-physician communication within the context of health care outcomes using the evolutionary method of concept analysis

Nurse-physician communication in nursing and medicine and its relationship to health care outcomes have been studied, but there is an absence of a concept analysis using the evolutionary method. This article (1) explores the meaning of nurse-physician communication within the context of health care outcomes using the process for concept analysis proposed by Rodgers; (2) aims to clarify the concept's definition, surrogate and related terms, attributes and antecedents; (3) provides a clearer understanding of what the consequences of the concept are; and (4) suggests an operational definition. A clearer conceptualization is needed to help provide knowledge for nurses, thus guiding their practice and also theory and research.

Managing disruptive behaviors in the health care setting: focus on obstetrics services

Disruptive behaviors can have a significant negative impact on staff relationships, communication flow, task responsibility, and team collaboration, all of which can adversely impact patient outcomes of care. Addressing disruptive behaviors in a positive manner by emphasizing the benefits of mutual understanding, shared goals and priorities, and adherence to accepted standards of care will enhance communication flow and improve the process and outcomes of care. This is particularly relevant in the obstetrics setting, where care is delivered over a continuum of time, with multiple different members of the health care team playing a vital role as the patient progresses from labor to delivery. Critical strategies for success include having strong organizational commitment and leadership support, raising provider insight and awareness, implementing appropriate policies and procedures, providing appropriate educational and training programs, and facilitating action-oriented interventional support.

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from $27,591,610 between 2003-2006 to $2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009. Instituting a comprehensive obstetric patient safety program decreased compensation payments and sentinel events resulting in immediate and significant savings.

Strategies for safe care of critical care perinatal patients

In most inpatient settings, the complexity of care required by individual patients coupled with the wide range of services provided within a single institution mean patients are routinely cared for in highly specialized units. Service lines, such as surgical services; intensive care; emergency services; and maternity, typically operate cooperatively, but independently, within larger facilities. Units are distinguished from one another, not only by their mission, geographic location, and work processes, but by the expertise and specialty knowledge of clinicians who practice there. From a patient safety perspective, specialty care is advantageous because it promotes clinical benchmarking, standardization of practice norms, acquisition and maintenance of specialty knowledge and skills, and interdisciplinary teamwork.

Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety

Physician-nurse communication has been identified as one of the main obstacles to progress in patient safety. Breakdowns in communication between physicians and nurses often result in errors, many of which are preventable. Recent research into nurse/physician communication has borrowed heavily from team literature, tending to study communication as one behavior in a larger cluster of behaviors. The multicluster approach to team research has not provided enough analysis of and attention to communication alone. Research into communication specifically is needed to understand its crucial role in teamwork and safety. A critique of the research literature on nurse/physician communication published since 1992 revealed 3 dominant themes: settings and context, consensus building, and conflict resolution. A fourth implicit theme, the temporal nature of communication, emerged as well. These themes were used to frame a discussion on sensemaking: an iterative process arising from dialogue when 2 or more people share their unique perspectives. As a theoretical model, sensemaking may offer an alternative lens through which to view the phenomenon of nurse/physician communication and advance our understanding of how nurse/physician communication can promote patient safety. Sensemaking may represent a paradigm shift with the potential to affect 2 spheres of influence: clinical practice and health care outcomes. Sensemaking may also hold promise as an intervention because through sensemaking consensus may be built and errors possibly prevented. Engaging in sensemaking may overcome communication barriers without realigning power bases, incorporate contextual influences without drawing attention away from communicators, and inform actions arising from communication.

Creating a collaborative culture in maternity care

Effective collaboration between professional groups is increasingly seen as an essential element in good quality and safe health care. This is especially important in the context of maternity care, where most women have straightforward labour and birth experiences, but some require rapid transfer between care providers and settings. This article presents current accounts of collaboration--or lack of it--in maternity care in the United Kingdom, United States, and Australia. It then examines tools designed to measure collaboration and teamwork within general health care contexts. Finally, a set of characteristics are proposed for effective collaboration in maternity care, as a basis for further empirical work in this area.

Perceptions of effective and ineffective nurse-physician communication in hospitals

PROBLEM

Nurse-physician communication affects patient safety. Such communication has been well studied using a variety of survey and observational methods; however, missing from the literature is an investigation of what constitutes effective and ineffective interprofessional communication from the perspective of the professionals involved. The purpose of this study was to explore nurse and physician perceptions of effective and ineffective communication between the two professions.

METHODS

Using focus group methodology, we asked nurses and physicians with at least 5 years' acute care hospital experience to reflect on effective and ineffective interprofessional communication and to provide examples. Three focus groups were held with 6 participants each (total sample 18). Sessions were audio recorded and transcribed verbatim. Transcripts were coded into categories of effective and ineffective communication.

FINDINGS

The following themes were found. For effective communication: clarity and precision of message that relies on verification, collaborative problem solving, calm and supportive demeanor under stress, maintenance of mutual respect, and authentic understanding of the unique role. For ineffective communication: making someone less than, dependence on electronic systems, and linguistic and cultural barriers.

CONCLUSION

These themes may be useful in designing learning activities to promote effective interprofessional communication.

Intra-operative decision making: more than meets the eye

Operating room teams consist of team members with diverse training backgrounds. In addition to differences in training, each team member has unique and complex decision making paths. As such, team members may function in the same environment largely unaware of their team members' perspectives. The goal of our work was to use a theory-based approach to better understand the complexity of knowledge-based intra-operative decision making. Cognitive task analysis methods were used to extract the knowledge, thought processes, goal structures and critical decisions that provide the foundation for surgical task performance. A triangulated and iterative approach is presented.

Multi-professional patterns and methods of communication during patient handoffs

OBJECTIVE

Health information technology has been shown to influence the communication patterns of healthcare providers. The goal of this study was to learn more about how healthcare providers communicate and exchange patient clinical information during patient handoffs (transfers) between units in an acute care setting.

METHODS

Convenience sampling was used to select five patient handoffs. Questionnaires were distributed to providers identified through observation and snowball sampling. Social network analysis methodology was used to develop sociograms of the emergent communication patterns and identify the role of individual providers in the handoff process based on the number of contacts with other providers and incoming and outgoing communication activity. Individual handoff network size ranged from 11 to 20 providers. Participants were asked to describe the method of communication they used to access or share clinical information with other providers, their preferred method of communication; their satisfaction with the available options; and their suggestions for how the process could be improved.

RESULTS

The network patterns that emerged uncovered the overlapping use of synchronous and asynchronous communication methods (verbally via phone or in person; or written via paper charts and/or an electronic records). No particular professional group dominated or coordinated information flow; instead each handoff network exhibited unique communication patterns and information coordination by two or more influential providers from nursing, medicine, or pharmacy. Most (84%) participants preferred verbal communication. Overall satisfaction with the current communication process varied by unit: 82% of emergency department providers and 54% of the providers working in the admitting units stated they were satisfied or very satisfied. Recommendations for improvement included converting all units to the electronic health record, electronic handoff communication modules and asynchronous multi-professional communication logs.

CONCLUSIONS

The results of this exploratory study provide a foundation for future research examining how network structure and communication principles can be used to design health information technology that compliments the non-linear information gathering and dissemination behaviors of providers from multiple professions.

Perinatal safety: from concept to nursing practice

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.

A collaborative protocol on oxytocin administration: bringing nurses, midwives and physicians together

Oxytocin is a high-alert drug for which safety precautions are crucial. Clear communication between nurses, physicians and midwives is vital when oxytocin is used. A collaborative process to updating an oxytocin administration protocol results in trust and respect among health care providers.

Women and their partners' perceptions of the key roles of the labor and delivery nurse

This descriptive qualitative study examined the perspectives of women and their partners regarding the key roles of the labor and delivery nurse during labor and birth.Ten couples were interviewed separately.The data analysis, conducted through independent and team analysis, was both iterative and interpretive. Participants identified four key roles of the labor and delivery nurse: support person, educator, patient advocate, and provider of continuity. Nurses provided both physical and emotional support.As an educator, they normalized the birth experience and served as a coach for the couple. Nurses advocated on behalf of the woman in labor, particularly when there was an adverse event. The continuity of care provided by the nurses wove the above roles into a cohesive whole. Findings provide important information for nursing educators, supervisors, and hospital administrators to reinforce the meaningful roles nurses serve in the labor and birth experiences of women and their partners.

Oxytocin, excessive uterine activity, and patient safety: time for a collaborative approach

Oxytocin use for induction or augmentation of labor is a common occurrence in labor and delivery, as well as a common source of conflict between obstetric providers and nurses. Allegations regarding inappropriate oxytocin use and excessive uterine activity arise in obstetric litigation in both the United States and abroad, and oxytocin was recently added to the Institute for Safe Medical Practices list of high-alert medications, making oxytocin administration a significant risk management issue. Current efforts at standardization of terminology related to uterine activity, recent research on the relationship of excessive uterine activity to fetal oxygenation and outcome, and clinical success with adoption of standardized oxytocin administration provide clinicians with evidence to create a structured, collaborative approach to oxytocin administration in labor. This article provides a brief overview of relevant literature and suggests strategies for the implementation of such a collaborative approach.

Oxytocin: new perspectives on an old drug

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

Effect of crew resource management training in a multidisciplinary obstetrical setting

OBJECTIVE

To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting.

METHOD

Design--A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting--Labour and delivery units of a large university-affiliated hospital. Participants--Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention--All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation.

RESULTS

Most participants valued the experience highly and 63-90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P<0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3-6.3) to OR 4.7, 95% CI (1.2-17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2-4.8) to OR 3.0, 95% CI (1.0-8.8)].

CONCLUSION

The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwork.

The emergence of high-tech birthing

The journey from "normal" to high-tech childbirth has taken place gradually over the past century. This article gives a historic review of maternity care and defines normal birth according to care practices adapted from the World Health Organization. The issues facing today's consumers, care providers, and caregivers that have led to the high-tech approach to birth are discussed. Recommendations for nursing practice are proposed to balance a normal approach to childbirth with a high-tech clinical environment.

Can medical simulation and team training reduce errors in labor and delivery?

Patient safety is one of the most pressing challenges in health care today, and there is no question that medical errors occur and that patients are worried about them. Currently, there is a belief that the availability of medical simulations and the knowledge gained from the science of team training may improve patient outcomes, and there is a paradigm shift occurring in many universities and training programs. This article discusses two strategies that, when combined, may reduce medical error in the labor and delivery suite: team training and medical simulation.

Disruptive behavior in obstetrics: a hidden threat to patient safety

OBJECTIVE

This study was to determine the frequency of disruptive behavior on labor and delivery units, its effect on work performance, and its contribution to adverse outcomes.

STUDY DESIGN

One hundred questionnaires were sent to nurse managers of labor and delivery units in selected hospitals in Washington, Oregon, and California regarding the occurrence of disruptive behavior and the consequences of this behavior with respect to patient safety.

RESULTS

Fifty-six percent of questionnaires were returned. Disruptive behavior was currently occurring on 60.7% of the units. Multiple professionals demonstrated the behavior. Nurses had left the unit and there were reported adverse outcomes as a consequence of this behavior.

CONCLUSION

Disruptive behavior occurs frequently on labor and delivery units on the West Coast. This behavior contributed to the nursing shortage, near misses, and adverse occurrences, and was exhibited by a broad range of professionals. The behavior was not always effectively managed by the organization.