Implementation strategies within a complex environment: A qualitative study of a shared decision-making intervention during childbirth

Secondary Qualitative Analysis of Stigmatizing and Nonstigmatizing Language Used in Hospital Birth Settings

OBJECTIVE

To more clearly understand the use of stigmatizing and nonstigmatizing language in electronic health records in hospital birth settings and to broaden the understanding of discrimination and implicit bias in clinical care.

DESIGN

A secondary qualitative analysis of free-text clinical notes from electronic health records.

SETTING

Two urban hospitals in the northeastern United States that serve patients with diverse sociodemographic characteristics during the perinatal period.

PARTICIPANTS

A total of 1,771 clinical notes from inpatient birth admissions in 2017.

METHODS

We used Krippendorff's content analysis of categorial distinction to identify stigmatizing and nonstigmatizing language. We based our categories for the content analysis on our pilot study and preexisting categories described by other researchers. We also explored new language categories that emerged during analysis.

RESULTS

We reviewed 1,771 notes and identified 10 categories that demonstrated stigmatizing language toward patients, nonstigmatizing language toward patients, and stigmatizing language among clinicians. We identified a new stigmatizing language category, Unjustified Descriptions of Social and Behavioral Risks. Positive or Preferred Language and Patient Exercising Autonomy for Birth are two new categories that represent language that empowers patients. Clinician Blame and Structural Care Barriers are new language categories that imply complex interprofessional dynamics and structural challenges in health care settings that can adversely affect the provision of care.

CONCLUSIONS

The results of this study provide a foundation for future efforts to reduce the use of stigmatizing language in clinical documentation and can be used to inform multilevel interventions to reduce bias in the clinical care in birth settings.

Huddles in Hospital Maternity Settings: A Scoping Review

BACKGROUND

The Agency for Healthcare Research and Quality recommends the use of safety huddles, in which clinicians are briefly gathered to review a patient's condition, including new or developing changes in acuity or stability. The Joint Commission describes huddles as a "hallmark" of high-reliability organizations. Previous reviews have confirmed the general utility of huddles, including positive regard by clinicians, but there has not been work specifically looking at huddle use in hospital maternity care settings. Our objective was to identify the ways that huddles have been studied or reported in inpatient maternity settings and synthesize this information with recommendations from professional organizations to identify gaps in the literature published in the United States since 1999.

METHODS

We used Arksey and O'Malley's framework to guide our scoping review. Using the time frame from 1999 to 2024, we searched the following databases: PubMed, CINAHL, SCOPUS, Embase, as well as gray literature and the reference lists and citing articles of the included manuscripts.

RESULTS

We found 160 documents, of which 47 met inclusion criteria, including 11 care bundles, 10 quality improvement projects, and 4 research studies. The remaining 22 were a variety of editorials, position papers, and other gray literature.

DISCUSSION

There is scant research on the use of huddles in hospital maternity care settings, and most literature does not define the participants, timing, or agenda of the huddle. Further research is needed to understand how huddles affect outcomes in maternity settings. Researchers should explicitly define the huddles they are studying. The review protocol was registered at Open Science Framework Registries.

Fostering Informed Consent and Shared Decision-Making in Maternity Nursing With the Advancement of Artificial Intelligence

ABSTRACT

Artificial intelligence (AI), defined as algorithms built to reproduce human behavior, has various applications in health care such as risk prediction, medical image classification, text analysis, and complex disease diagnosis. Due to the increasing availability and volume of data, especially from electronic health records, AI technology is expanding into all fields of nursing and medicine. As the health care system moves toward automation and computationally driven clinical decision-making, nurses play a vital role in bridging the gap between the technological output, the patient, and the health care team. We explore the nurses' role in translating AI-generated output to patients and identify considerations for ensuring informed consent and shared decision-making throughout the process. A brief review of AI technology and informed consent, an identification of power dynamics that underly informed consent, and descriptions of the role of the nurse in various relationships such as nurse-AI, nurse-patient, and patient-AI are covered. Ultimately, nurses and physicians bear the responsibility of upholding and safeguarding the right to informed choice, as it is a fundamental aspect of safe and ethical patient-centered health care.

Assessing patient autonomy in the context of TeamBirth, a quality improvement intervention to improve shared decision-making during labor and birth

BACKGROUND

Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed.

METHODS

We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score.

RESULTS

In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score.

DISCUSSION

Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.

Association of Socioeconomic Variables with Primary Cesarean Section

OBJECTIVES

Socioeconomic characteristics may be associated with cesarean section (CS) rates. We probe the relationship between socioeconomic variables and primary cesarean section (PCS) by studying indicators of socioeconomic status (SES) in a population-based study in New York City.

METHODS

This was a retrospective study of all 80,506 women in New York City who gave birth to a live child during 2018, and who met inclusion and exclusion criteria. Data were drawn from the New York City Department of Health and Mental Hygiene and the US Census. The main outcome measure was performance of PCS as compared with vaginal birth.

RESULTS

Approximately 21% of neonates were delivered by PCS. Multivariate multilevel mixed-effects logistic regression analysis showed higher odds for PCS for women with an upper-middle class median household income of US$108,500 to $380,499 (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.07-1.76, P = 0.001), and the percentage enrolled in the Supplemental Nutrition Assistance Program (OR 1.01, 95% CI 1.001-1.012, P = 0.02). Lower odds for PCS occurred for all middle-class categories of per capita income: US$32,500 to $54,499 (OR 0.91, 95% CI 0.84-0.99, P = 0.02), US$54,500 to $108,499 (OR 0.76, 95% CI 0.66-0.88, P < 0.001), and US$108,500 to $380,499 (OR 0.80, 95% CI 0.66-0.96, P = 0.02). No significant association occurred for women receiving public assistance.

CONCLUSIONS

Patient preferences in favor or against CS may be related to SES. There may be conflicts between obstetric care that is maximally beneficial and a patient's desire for delivery mode. Clinicians should be aware of the potential implications of this dilemma.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers

BACKGROUND

Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA.

METHODS

This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures.

RESULTS

Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research.

CONCLUSIONS

Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Reliability and Validity of a Perinatal Shared Decision-Making Measure: The Childbirth Options, Information, and Person-Centered Explanation

OBJECTIVE

To develop and test the psychometric properties of a shared decision-making tool: Childbirth Options, Information, and Person-Centered Explanation (CHOICEs).

DESIGN

Multiphase instrument development study beginning with item development through a cross-sectional postpartum survey.

SETTING

The cross-sectional postpartum survey was distributed online through convenience and snowball sampling methods.

METHODS

We developed instrument items through an iterative process with key stakeholders. We evaluated reliability based on internal consistency and differential item functioning analysis. We evaluated validity on evidence of construct validity. We used criterion-related item mapping to evaluate whether the measure addressed the full spectrum of shared decision making related to maternity care.

RESULTS

Surveys were completed by 1,171 participants. A Cronbach's αcoefficient of .99 supported internal consistency reliability. Infit and outfit statistics that ranged from 0.92 to 1.55 supported item fit. Differential item functioning analysis showed that CHOICEs scores were invariant between different demographic groups. Significant positive correlations between scores on CHOICEs and the Mothers on Respect index (r = 0.75, p = .01) and the Mothers Autonomy in Decision-Making scale (r = 0.75, p = .01) supported criterion-related validity. Item mapping suggested more items were needed to capture the full spectrum of shared decision making.

CONCLUSION

We recommend using CHOICEs to evaluate shared decision making in maternity care for research and quality improvement projects.