Nurses Count: Tracking Performance to Improve Cesarean Delivery Rates

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates

BACKGROUND

The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes.

PURPOSE

Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers.

METHODS

We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated.

RESULTS

Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions.

CONCLUSIONS

Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Fifty Years of the Rise in Cesarean Birth in the United States and Opportunities for Improvement

Factors that shaped and promoted cultural norms in the 1900s continue to influence current obstetric practice today. The incidence of cesarean birth too often has little to do with the health needs of the woman or the fetus and more to do with multiple factors over which the woman has no control. Nurses and midwives can reduce unnecessary cesarean births and have the necessary knowledge, competence, and skills to help women give birth without medical intervention.

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points

OBJECTIVE

To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.

DATA SOURCES

Medical record data from nine hospitals in Washington State from January 2016 through September 2018.

STUDY DESIGN

Retrospective, observational cohort design using an aggregated database of birth records.

DATA COLLECTION/EXTRACTION METHODS

Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared.

PRINCIPAL FINDINGS

The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.

CONCLUSION

Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.

Mothering the Mother: An Educational Program for Nurse-Provided Continuous Labor Support

Continuous labor support (CLS) is associated with improved outcomes including decreased cesarean birth, increased 5-minute APGAR scores, decreased postpartum depression, and decreased nurse turnover rates. Despite this, CLS is not consistently practiced perhaps due to lack of education regarding the benefits of CLS and nurse staffing levels on birthing units. This article will discuss CLS benefits and implementation of an educational program designed to enhance nursing practice with regard to CLS and an educational program designed to provide five skills to perinatal nurses in order to enhance clinical practice. Pretest and posttests were administered and there was a significant knowledge increase related to nurse-provided CLS (p = .001) after attending the program.

Variation in Cesarean Birth Rates by Labor and Delivery Nurses

OBJECTIVE

To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses.

DESIGN

Retrospective cohort study.

SETTING

One high-volume labor and delivery unit at an academic medical center in a major metropolitan area.

PARTICIPANTS

Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation.

METHODS

Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses.

RESULTS

Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile.

CONCLUSION

The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

Workplace Challenges: The Impact of Personal Beliefs and the Birth Environment

This article reviews 2 workplace challenges faced by the perinatal nurse: the impact of personal beliefs and issues within the birth environment. It also explores how these challenges inform the birth practices of the perinatal nurse. The methods employed for this review are focus groups and a concept analysis. Two focus groups (n = 14) and a concept analysis based on a process defined by Walker and Avant provided a set of birth practices performed by the perinatal nurse who facilitates normal birth. Assertiveness was identified as a primary attribute of the perinatal nurse and several suggestions are identified as empirical referents or methods of measuring the abstract concepts, to identify the workplace challenges of the perinatal nurse. Development of effective processes, designed to overcome the many challenges facing the perinatal nurse, will assist in improving perinatal care for women and newborns.