Best Practices for Telehealth in Nurse-Led Care Settings-A Qualitative Study

The COVID-19 pandemic in the US prompted a sudden shift to telehealth in nurse-led care sites which provide services to diverse geolocations. Using a lens of intersectionality, this study characterizes provider and patient-perceived best and promising practices emerging from geographical variation. The aim of this study was to identify best practices of implementing telehealth in nurse-led care models in Colorado through patient and provider experiences of the sudden implementation of telehealth that can enhance health equity. In this exploratory/descriptive qualitative study, a purposive sample of 18 providers and 30 patients were interviewed using a guide informed by the RE-AIM implementation and evaluation framework to capture the contextual experiences related to the sudden shift to telehealth. Textual theme analysis and reflexive team strategies guided the interpretation. Four primary themes of perceived best practices were identified: using multiple modalities, tailoring triage and scheduling, cultivating safety through boundaries and expectations, and differentiating established versus new patient relationships. The findings suggest that telehealth is a flexible and powerful tool to enhance the delivery of equitable care through nurse-led care models within diverse communities such as the one represented in this study. Nurse leaders are positioned to participate in innovative research and create policies and protocols to ensure telehealth is a viable resource to deliver equitable, safe, and accessible high-quality healthcare.

Perinatal Telehealth: Meeting Patients Where They Are

INTRODUCTION

Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities.

METHODS

This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context.

RESULTS

Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources.

DISCUSSION

This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service.

METHODS

We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors.

RESULTS

When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression.

DISCUSSION

No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

The Pathophysiology of Labor Dystocia: Theme with Variations

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care.

Concepts and metrics of clinician attention: a scoping review protocol

INTRODUCTION

There is growing emphasis on the importance of both the cognitive and behavioural phenomenon of attention for clinicians engaged in patient care. Aspects of attention such as cognitive load, distraction and task switching have been studied in various settings with different methodologies. Using the protocol described here, we aim to systematically review the medical literature in order to map the concept of attention and to synthesise diverse concepts and methods under the broader category of research focused on 'attention'.

METHODS AND ANALYSIS

Following the methodology described by the Joanna Briggs Institute and Arksey and O'Malley, our scoping review conducts an iterative search of Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline (PubMed) and EMBASE (Ovid). An initial limited search based on key concepts and terminology will generate relevant articles which in turn will be mined for additional keywords and index terms to guide a formal literature search. Our multidisciplinary team will extract data into a matrix, including a small random sample of the same studies (to ensure concordance), and present the results in a descriptive narrative format.

ETHICS AND DISSEMINATION

As a secondary analysis, our study does not require ethics approval, and we will ensure that included studies have appropriate approval. We anticipate results will identify diverse ways of conceptualising clinician attention and will provide a foundation for developing additional metrics and study methods to optimise attention in the clinical environment. We will disseminate results through journals and conferences and coordinate with colleagues doing work in adjacent fields.

Innovations in Prospective Perinatal Research as a Result Of the COVID-19 Pandemic

In 2020, in‐person research activities were stopped because of the spread of the novel coronavirus, severe acute respiratory syndrome coronavirus 2, and the resulting disease, coronavirus disease 2019. Our collaborative team of nurse and midwife scientists at universities across the United States adapted research activities to continue prospective perinatal research during the pandemic. These adaptations included development of new research techniques and the implementation of previously developed, but underused, strategies to conduct research from a distance. These strategies included online recruitment, virtual enrollment and consent, qualitative data collection via video conferencing, new applications of smart phone technology, wearable biological measurement, and participant self‐collection of biological samples. In addition to allowing research to continue during the pandemic, these innovative strategies may increase access to research for low‐income, rural, and racially diverse pregnant and postpartum populations. Decreased travel requirements, flexible scheduling, wearable devices, and the capacity to self‐collect biologic samples may improve recruitment and the experience of research participation. The rapid implementation of these research strategies has advanced innovation toward wider, more inclusive and increasingly diverse perinatal research access, and many of these strategies will continue to be used and refined.

Women's Experiences of the Effect of Financial Strain on Parenting and Mental Health

OBJECTIVE

To develop a conceptual theory to describe how financial strain affects women with young children to inform clinical care and research.

DESIGN

Qualitative, grounded theory.

SETTING

Participants were recruited from the waiting area of a pediatric clinic and an office of the Special Supplemental Nutrition Program for Women, Infants, and Children embedded within the largest safety-net academic medical center in New England. Participants were interviewed privately at the medical center or in the community.

PARTICIPANTS

Twenty-six English-speaking women, mostly single and African American/Black, with at least one child 5 years old or younger, were sampled until thematic saturation was met.

METHODS

We used grounded theory methodology to conduct in-depth, semistructured interviews with participants who indicated that they experienced financial strain. We analyzed the interview data using constant comparative analysis, revised the interview guide based on emerging themes, and developed a theoretical model.

RESULTS

Five interrelated themes emerged and were developed into a theoretical model: Financial Strain Has Specific Characteristics and Common Triggers, Financial Strain Is Exacerbated by Inadequate Assistance and Results in Tradeoffs, Financial Strain Forces Parenting Modifications, Women Experience Self-Blame, and Women Experience Mental Health Effects.

CONCLUSION

For women with young children, financial strain results in forced tradeoffs, compromised parenting practices, and self-blame, which contribute to significant mental health problems. These findings can inform woman-centered clinical practice and advocacy interventions. Women's health care providers should identify families experiencing financial strain, provide referrals to financial services, and join advocacy efforts to advance social policies that address the structural causes of poverty, such as increased minimum wage and paid family leave.

The experiences of midwives in integrated maternity care: A qualitative metasynthesis

OBJECTIVES

To conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice.

DESIGN

A qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice.

SAMPLE AND SETTING

Participants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner.

FINDINGS

Three overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down.

KEY CONCLUSIONS

The findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women.

IMPLICATIONS FOR PRACTICE

Integrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.

A qualitative meta-synthesis of women's experiences of labor dystocia

PROBLEM

Researchers have prioritized understanding and differentiating the pathophysiologic mechanisms to improve precision in diagnosis and individualization of care, however the experiences of women with labor dystocia have been underexamined.

BACKGROUND

Management of labor dystocia has been identified as an opportunity for reducing the rate of unnecessary cesarean births and the associated risks to women and their infants. This meta-synthesis explores women's experiences of labor dystocia to enrich the discussion of care practices and contextualize discussions of shared decision making in what is most meaningful to women.

QUESTIONS

How does prolonged labor influence women's experience of birth and motherhood? What are women's experiences with decision-making about labor augmentation during prolonged labor?

METHODS

Sandelowski and Barroso's meta-synthesis approach was used to analyze primary qualitative studies of women's experiences of labor dystocia. Through inductive thematic synthesis and reciprocal translation, themes identified in qualitative research, quotations, and coded meaning units were aggregated and interpreted into derived categories and themes.

FINDINGS

Fourteen qualitative studies were analyzed. Women experienced labor dystocia as a transition from healthy labor to abnormal labor requiring medical support consistent with Transition Theory by Meleis. Six new categories and thirty themes were identified. Each category and theme reflects a distinct component of the experience of labor dystocia.

DISCUSSION/CONCLUSION

There is wide variation in the way women experience labor dystocia. Facilitation of the transition from healthy labor to labor dystocia can be supported by a fluid, adaptable method of caring for women in the face of uncertainty and loss of choice.

Primary Prevention of Urinary Incontinence: A Case Study of Prenatal and Intrapartum Interventions

A wealth of information is available regarding the diagnosis and treatment of urinary incontinence. However, there is a dearth of quality information and clinical practice guidelines regarding the primary prevention of urinary incontinence. Given the high prevalence of this concern and the often cited correlation between pregnancy, childbirth, and urinary incontinence, women's health care providers should be aware of risk factors and primary prevention strategies for stress urinary incontinence (SUI) in order to reduce associated physical and emotional suffering. This case report describes several common risk factors for SUI and missed opportunities for primary prevention of postpartum urinary incontinence. The most effective methods for preventing urinary incontinence include correct teaching of pelvic floor muscle training (PFMT; specifically Kegel exercises), moderate combined physical exercise regimens, counseling and support for weight loss, counseling against smoking, appropriate treatment for asthma and constipation, and appropriate labor management to prevent pelvic organ prolapse, urethral injury, and pelvic floor muscle damage.

Gas Chromatographic Methods for Determination of γ-BHC in Technical Emulsifiable Concentrates and Water-Dispersible Powder Formulations and in Lindane Shampoo and Lotion: Collaborative Study

Although the gas chromatographic separation of the isomers of BHC was demonstrated two decades ago, the present AOAC method of analysis of BHC for gamma-isomer (lindane) content is based on a separation carried out on a liquid chromatographic partition column. A method of analysis has been developed that uses an OV-210 column for separation of the gamma-isomer from the other isomers and impurities in technical BHC. Di-n-propyl phthalate was chosen as an internal standard. The same system allows quantitation of lindane in lotion and shampoo after these products are extracted with ethyl acetate-isooctane (1 + 4). The analytical methods were subjected to a collaborative trial with 10 laboratories. The coefficient of variation for technical BHC was 2.83%. For the water-dispersible powder and emulsifiable concentrate, the coefficients of variation were 2.89% and 4.62%, respectively. Coefficients of variation for 1% lindane lotion and shampoo were 4.36% and 11.92%, respectively. The method has been adopted official first action.

Gas chromatographic methods for determination of gamma-BHC in technical emulsifiable concentrates and water-dispersible powder formulations and in lindane shampoo and lotion: collaborative study

Although the gas chromatographic separation of the isomers of BHC was demonstrated two decades ago, the present AOAC method of analysis of BHC for gamma-isomer (lindane) content is based on a separation carried out on a liquid chromatographic partition column. A method of analysis has been developed that uses an OV-210 column for separation of the gamma-isomer from the other isomers and impurities in technical BHC. Di-n-propyl phthalate was chosen as an internal standard. The same system allows quantitation of lindane in lotion and shampoo after these products are extracted with ethyl acetate-isooctane (1 + 4). The analytical methods were subjected to a collaborative trial with 10 laboratories. The coefficient of variation for technical BHC was 2.83%. For the water-dispersible powder and emulsifiable concentrate, the coefficients of variation were 2.89% and 4.62%, respectively. Coefficients of variation for 1% lindane lotion and shampoo were 4.36% and 11.92%, respectively. The method has been adopted official first action.