Making midwifery work visible: The multiple purposes of documentation

Investigating midwives and nurses reporting of 'infant feeding at hospital discharge': an online survey across NSW Australia

BACKGROUND

The collection of data on 'infant feeding at hospital discharge' is used to monitor breastfeeding outcomes, health service benchmarking, and research. While some Australian states have clear definitions of this data collection point, there is no operational definition of 'infant feeding at hospital discharge' in the Australian state of New South Wales. Little is known about how midwives interpret the term 'infant feeding at hospital discharge', in particular, the timeframe used to calculate these important indicators. The purpose of this study was to explore midwives' and nurses' practices of reporting 'infant feeding at hospital discharge' in the Australian state of New South Wales.

METHODS

An online survey was distributed across public and private maternity hospitals in New South Wales, Australia. The survey asked midwives and nurses their practice of reporting 'infant feeding at discharge' from categories offered by the state Mothers and Babies report of either "full breastfeeding", "any breastfeeding", and "infant formula only". The Qualtrics survey was available from December 2021 to May 2022.

RESULTS

There were 319 completed surveys for analysis and all 15 NSW Health Districts were represented. Some participants reported using the timeframe 'since birth' as a reference (39%), however, the majority (54%, n = 173) referenced one of the feeding timeframes within the previous 24 h. Most midwives and nurses (83%, n = 265) recommended 24 h before discharge as the most relevant reference timeframe, and 65% (n = 207) were in favour of recording data on 'exclusive breastfeeding' since birth.

CONCLUSION

This study identified multiple practice inconsistencies within New South Wales reporting of 'infant feeding at hospital discharge'. This has ramifications for key health statistics, state reporting, and national benchmarking. While the Baby Friendly Hospital Initiative accreditation requires hospitals to demonstrate and continuously monitor at least a 75% exclusive breastfeeding rate on discharge, only 11 New South Wales facilities have achieved this accreditation. We recommend introducing an option to collect 'exclusive breastfeeding' on discharge' which is in line with participant recommendations and the Baby Friendly Hospital accreditation. Other important considerations are the updated World Health Organization indicators such as, "Ever breastfed"; "Early initiation of breastfeeding" (first hour); "Exclusively breastfed for the first two days after birth".

A pre-post interventional study to reduce time spent on clinical documentation by nurses and midwives

AIM

To evaluate the impact of a co-designed intervention to reduce time spent on clinical documentation and increase time for direct patient care.

DESIGN

A pre- and post-test interventional study with multi-method evaluation, reported according to the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs guidelines.

METHODS

An intervention to decrease the burden of documentation was co-designed and implemented. Pre- and post-intervention data were collected via time and motion studies and the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey. Documentation audits were conducted to assess intervention fidelity.

RESULTS

Twenty-six shifts were observed (13 pre-intervention, 13 post-intervention). Although the coronavirus pandemic contributed to decreases in staffing levels by 38% (from 118 to 73 staff), the number of task episodes completed increased post-intervention, across all shift patterns. Documentation took less time to complete post-intervention when assessing time per episode. A mean increase of 201 episodes was observed on morning shifts, 78 on evening shifts and 309 on night shifts. There were small increases for time spent on direct patient care compared to pre-intervention but there was less time per episode. Results from the BurDoNsaM survey indicated that participants felt documentation took less time post-intervention. Documentation audits found completion improved as staff gained familiarity, but deteriorated when staffing levels were reduced.

CONCLUSION

The intervention was able to reduce time spent completing documentation, increasing the time available for direct patient care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Completing clinical documentation is part of the daily work of nurses and midwives. Clinical documentation needs to accurately capture key information in a concise and streamlined manner to avoid unnecessary burdens and release time for direct patient care.

IMPACT

This study tested a co-designed intervention to address the burden of clinical documentation for nurses and midwives, The intervention reduced time spent on clinical documentation and increased time for direct patient care, This study could be replicated to reduce the burden of clinical documentation in other settings and benefit clinicians and patients by releasing more time for direct patient care.

REPORTING METHOD

The study is reported using the Transparent Reporting of Evaluations with Nonrandomised Evaluations Designs (TREND) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

The research project and intervention evaluated in this study were co-designed through a clinician-researcher collaboration. A research team that consisted of clinically based nurses and midwives and nurse scientists was formed to address the burden of clinical documentation. As the end-users of clinical documentation, the clinically based nurse and midwife co-investigators were involved in the design, conduct, interpretation of the data, and preparation of the manuscript.

Midwives' perspectives about using individualized care plans in the provision of immediate postpartum care in Uganda; an exploratory qualitative study

INTRODUCTION

Individualized care planning has been slowly integrated into practice in Uganda with minimal documentation of how the concept is applied in providing care. This study explored the perceptions of midwives about the use of individualized care plans (ICPs) in the provision of immediate postpartum care.

METHODS

An exploratory descriptive qualitative approach was used in this study. We interviewed fifty midwives from 37 health facilities in Uganda's greater Mpigi region. The midwives, who were certificate and diploma holders, were purposively enrolled in the selected facilities. Deductive content analysis was done based on the COM-B model.

RESULTS

Four themes emerged from the data namely; compatibility, motivation, opportunities, and the midwives' suggested strategies and targets for improved individualized care planning. The midwives were aware of individualized care planning and they utilized it in their provision of immediate postpartum care especially when assessing clients for risks, preparing clients for referral, caring for Human Immunodeficiency virus (HIV) exposed babies and their mothers, and educating/ supporting first-time mothers (automatic motivation). Having a good nurse-patient relationship, privacy, and ample time to care for the clients were noted as motivators for individualized care plan use, while poor documentation of care, high patient load, and perceived patients' lack of understanding of the complexities of illness in the immediate postpartum period were the barriers (social opportunity) identified by midwives to the use of individualized care planning.

CONCLUSION

There are still capability, motivation, and opportunity hindrances to the use of individualized care planning. Staff recruitment, training, and harmonization of the documentation forms may improve the use of care plans in the postpartum period.

Pandemic-related stress in pregnant women during the first COVID-19 lockdown and neonatal development

BACKGROUND

Maternal stress and psychopathology have a negative effect on mothers and neonates. Maternal stress may affect neonatal growth and development both physically and psychologically.

PURPOSE

To study the impact of pandemic-related pregnancy stress and maternal psychopathological symptoms during the COVID-19 lockdown in 2020 on neonatal development.

METHODS

A two-phase prospective study was carried out on a sample of 181 pregnant women ranged from 18 to 40 years old in Spain (Europe). Phase 1: Pandemic-related pregnancy stress (PREPS), Prenatal Distress Questionnaire (PDQ), Perceived Stress Scale (PSS) and the revised version of the Symptom Checklist-90 (SCL-90-R) were used to assess psychological symptoms during the lockdown. In the follow-up (Phase 2), obstetric, birth-related and anthropometric variables were collected from 81 pregnant women-neonates dyads.

RESULTS

Primiparous women showed higher psychopathological symptoms and higher levels of pandemic-related pregnancy stress than multiparous women. A multiple linear regression model showed that pandemic-related pregnancy stress could predict the length of neonate by adjusting for maternal age and gestational age, especially for primiparous women.

IMPLICATIONS FOR RESEARCH

Studies assessing neonates development should evaluate the long-term effect of the COVID-19 pandemic on neonates´ length.

IMPLICATIONS FOR PRACTICE

States the relation between pandemic-related pregnancy stress and neonatal development by being able to track the effects on neonates whose mothers had high levels of stress during the COVID-19 pandemic.

Woman-centred care and integrated electronic medical records within Australian maternity settings: Point prevalence audit and observational study

OBJECTIVE

Transition to paperless records brings new challenges to midwifery practice across the continuum of woman-centred care. There is limited and conflicting evidence on the relative benefits of electronic medical records in maternity settings. This article aims to inform the use of integrative electronic medical records within the maternity services' environment with attention to the midwife-woman relationship.

DESIGN

This descriptive two-part study includes 1) an audit of electronic records in the early period following implementation (2-time points); and 2) an observational study to observe midwives' practice relating to electronic record use.

SETTING

Two regional tertiary public hospitals PARTICIPANTS: Midwives providing care for childbearing women across antenatal, intrapartum and postnatal areas.

FINDINGS

400 integrated electronic medical records were audited for completeness. Most fields had high levels of complete data in the correct location. However, between time 1 (T1) and time 2 (T2), persistent missing data (foetal heart rate documented 30 minutely T1 36%; T2 42%), and incomplete or incorrectly located data (pathology results T1:63%; T2 54%; perineal repair T1 60%; T2 46%) were identified. Observationally, midwives were actively engaged with the integrative electronic medical record between 23% to 68% (median 46%; IQR 16) of the time.

CONCLUSION

Midwives spent a significant amount of time completing documentation during clinical episodes of care. Largely, this documentation was found to be accurate, yet exceptions to data completeness, precision and location remained, indicating some concerns with software usability.

IMPLICATIONS FOR PRACTICE

Time-intensive monitoring and documentation may hinder woman-centred midwifery care.

What are dually diagnosed patients' problems represented to be in mental health? A WPR analysis of the multistability purpose of digital health records

No previous studies have investigated how political measures, opinions and views of people with dual diagnoses, organisational requirements and professional values are purposefully communicated, mediated and/or integrated in digital records in mental health care. It remains unclear how health records function as both clinical vehicles for documentation, audit and quality assurance in patient care as well as political vehicles of power to articulate and reproduce idealised relations among actors and their roles in mental health. Informed by Bacchi's 'What's the problem represented to be' (WPR) approach, we consider how problems of dually diagnosed persons with co-occurring mental health conditions and drug use (DDPs) are represented and how the tools required to fix the patients' problems are communicated and legitimised in 10 digital health records consisting of 3830 pages of data. In the discussion, we distinguish their multiple purposes by discussing how their structure is shaped by broader discourses in health care. Then, we consider how the structure of records delineates professionals' autonomy, discretionary action and service provision in ways that limit possibilities for including mental health patients' experiences and exclude service users' voices from care planning.

Multiple Gestations and Assisted Reproductive Technologies: Qualitative Study of the Discourse of Health Professionals in Spain

Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time.

Documentation Practice and Associated Factors Among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia

BACKGROUND

Nursing documentation is an integral and vital professional nursing practice that refers to the process of recording nursing activities concerned with the care given to individual clients to ensure continual effective, safe, quality, evidence-based, and individualized care.

OBJECTIVE

To assess documentation practice and identify its associated factors among nurses in six Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia.

METHODOLOGY

An institutional-based cross-sectional study was conducted among 430 nurses and 421 medical records. Simple random sampling was employed for the selection of nurses and charts after the total sample size had been allocated proportionally for each hospital. Data were collected by using a self-administered questionnaire and review of records, and entered and analyzed by using EpiData version 3.1 and statistical package for social sciences version 20.0, respectively. Logistic regression was used to identify the associated factors.

RESULTS

In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation practice was found in 38.5% of medical records. Age (AOR, 95% CI 3.54, 1.170-10.8), attitude (AOR, 95% CI 5.66, 3.17-10.11), in-service training (AOR, 95% CI 2.53, 1.477-4.35), nurse to patient ratio (AOR, 95% CI 2.24, 1.24-4.047), motivation (AOR, 95% CI 4.60, 2.721-7.76), and familiarity with standards of nursing documentation (AOR, 95% CI 1.98, 1.137-3.44) were found to have a statistically significant positive association with documentation practice.

CONCLUSION

Poor documentation practice was due to the identified factors. So, it is better to put further effort toward improving documentation practice through providing training on standards of documentation and enhancing the favorable attitude of nurses toward documentation practice by motivating them regarding documentation activities.

A guidance framework to aid in the selection of nursing and midwifery care process metrics and indicators

AIM

To describe the development of a guidance framework to assist nurses and midwives in selecting nursing and midwifery care process metrics and indicators for use in practice.

BACKGROUND

Process metrics are measures of care provision activities by nurses and midwives.

METHODS

Phase 1 was a rapid review assessment of the literature conducted to identify an initial framework. Six electronic databases were searched with Google Scholar and reference tracking performed. Phase 2 was expert review of the developing framework by nursing and midwifery experts in practice, academia and an international expert in quality care metrics.

RESULTS

The literature assessment yielded 28 papers with 59 metric attributes identified. From this, a six-domain framework was developed. Following expert review, the framework was reduced to four domains: "Process Focused," "Important," "Operational" and "Feasible."

CONCLUSIONS

This is the first framework specifically to guide nurses and midwives in selecting nursing and midwifery process metrics and indicators.