Clinical Disagreements During Labor and Birth:

Transcription

1 KATHLEEN RICE SIMPSON, PHD, RNC,, AND AUDREY LYNDON, PHD, RNC, CNS Clinical Disagreements During Labor and Birth: How Does Real Life Compare to Best Practice? Abstract Purpose: To describe how nurses would respond in common clinical situations involving disagreement with physician colleagues during labor and birth. Study Design and Methods: An electronic survey, consisting of five clinical disagreement case scenarios along with two openended questions regarding how to promote effective interdisciplinary communication and collaboration, was administered via a secure Web site. Seven hundred four obstetric nurses in a mid-size metropolitan area were invited to participate via mail. One hundred thirty-three nurses responded. Data were analyzed using descriptive statistics and thematic analysis of openended text responses. Results: Respondents were primarily aged 40, experienced in labor nursing, and held a BSN; 35% were members of the Association of Women s Health, Obstetric and Neonatal Nurses, 35% were certified in electronic fetal monitoring, and 33% were cer- tified in inpatient obstetrics. In all five scenarios, most nurses were aware of current evidence and published standards of care (range 52%-86%). However, there was a wide discrepancy between current evidence/standards and what nurses indicated would occur in actual clinical practice. Clinical Implications: In this well-educated and knowledgeable sample of experienced labor nurses, reports of what would occur in clinical practice did not match current evidence or standards of care. Adequate nursing knowledge may not be an accurate predictor of appropriate clinical practice. Confidence in administrative support appears to be one of the key factors in empowering nurses to pursue resolution of disagreements in patients best interests, whereas medical hierarchy, fear, and intimidation are significant barriers. Key Words: Clinical disagreements; Perinatal patient safety; Standards of care; Reasonably prudent nurses; Disruptive behavior. January/February 2009 MCN 31

2 Clinical disagreements or conflicts often arise between nurses and physicians regarding the optimal plan of care for a mother and fetus during labor and birth. Such disagreements require rapid resolution when the safety of the mother and/or the baby may be at stake. Risk of patient harm and liability exposure in perinatal practice is typically centered on specific issues in clinical management, such as oxytocin administration, nonreassuring (indeterminate or abnormal) fetal heart rate (FHR) patterns, second stage labor, operative vaginal birth, and neonatal resuscitation (American College of Obstetricians and Gynecologists [ACOG], 2004; Simpson & Knox, 2003b). These same issues are common sources of clinical disagreement (Simpson, James, & Knox, 2006). Excellence in practice requires nurses to be aware of current evidence and published standards and effective in resolving conflict in patients best interest. If disagreements cannot be resolved successfully and an adverse outcome results in a lawsuit, nurses are held to applicable standards of care. Standards of care are defined during litigation by published materials (guidelines from applicable professional associations, such as the Association of Women s Health, Obstetric and Neonatal Nurses [AWHONN], ACOG, and the American Academy of Pediatrics [AAP], and current scientific evidence) and by what a reasonably prudent nurse would do in the same or similar situation (Dunn, Gies, & Peters, 2005; Meadow, 2005). Although adherence to published standards or guidelines is relatively easy to determine, there are limited data on what labor nurses actually would do in common situations of clinical disagreement. As a result, this second component of the standard of care is based on expert opinion, rather than evidence, regarding what a reasonably prudent labor nurse would do in response to clinical disagreements in everyday practice. Research suggests a significant disconnect between expert testimony and actual practice (Meadow, 2005). The purpose of this study was to describe how nurses report they would respond to a variety of common clinical situations involving disagreement with physician colleagues during labor and birth to better understand interdisciplinary clinical disagreements and develop supportive evidence for the reasonably prudent nurse standard. Study Design and Methods An electronic survey that consisted of five short clinical case scenarios with multiple choice and free text responses and two open-ended questions regarding how to promote effective communication and collaboration with physicians and barriers to doing so was administered via a secure Web site. Scenarios were developed by comparing opinions of 10 expert labor nurses concerning the most common sources of clinical disagreements with physician colleagues during labor and birth with the most commonly identified sources of adverse perinatal outcomes in closed-claim databases. Scenarios and response choices for selected topics were refined in three iterations of consensus building with the expert panel. Scenarios were based on the expert panel s consensus on the five most common areas of clinical disagreements IN ALL FIVE SCENARIOS, MOST NURSES WERE AWARE OF CURRENT EVIDENCE AND PUBLISHED STANDARDS OF CARE, BUT THERE WAS A WIDE DISCREPANCY BETWEEN CURRENT EVIDENCE/STANDARDS AND WHAT NURSES INDICATED WOULD OCCUR IN ACTUAL CLINI- CAL PRACTICE. during labor and birth, identified as oxytocin management during uterine hyperstimulation, physician response to a nonreassuring FHR pattern, second stage labor management during a nonreassuring FHR pattern, notification of the neonatal resuscitation team to attend birth when the FHR pattern was suggestive of potential fetal compromise, and multiple attempts via vacuum extractor to achieve vaginal birth. Each scenario had two questions with multiple choice responses. 1. What do you believe is the best action based on available evidence and national standards (e.g., what would you find if you looked for the answer in a current textbook or practice publication from a national professional association such as AWHONN, ACOG, or AAP)? 2. What do you believe would actually occur in contemporary clinical practice (e.g., what do you think most nurses would do)? The possible choices for responses included the best action based on evidence and national standards and guidelines and possible passive and work-around responses based on the observations of actual clinical practice by the 32 VOLUME 34 NUMBER 1 January/February 2009

3 Table 1. EXAMPLES OF PARTICIPANTS RESPONSES BY CLASSIFICATION Classification of Response Best evidence/standard of care Examples It s important to let the doctor know that with higher doses of pitocin, uterine hyperstimulation occurred. I would reassure the doctor the pitocin will be increased if contractions begin to space out or if dilation would slow down. If there were no signs of improvement in the fetal tracing and the physician continues to refuse to come in, I would notify him that I felt it was in the best interest of the patient to have a direct evaluation from a physician and if he would not be coming in now, I would call in his back-up. Passive If I let the [neonatal] team come anyway, the doctor will yell at them (and me). It s better to let them know to be on standby rather than having an argument in front of the patient. There s not much the nurse can do when the doctor is at the perineum and using the vacuum. Talking about it later doesn t help, unless there was an adverse outcome. Passive-aggressive I would watch to see if the physician documents thoroughly what happened in the record. If there is any discrepancy or omission, I would complete an incident report and flag the record for QI review. I responded to an emergency call light; a request for another vacuum extractor. I went into the room and observed the physician apply and pop off the vacuum twice. When I asked how long and the number of previous attempts, I was told twice as many. I threw the new vacuum extractor on the floor and asked the physician if he wanted to or could attempt forceps and I would be happy to get another physician, an OB in the nurses station. Work-around At our facility, I would notify the resident and have them call MD for bedside evaluation. I would be willing to increase the pitocin to see if the strength of the contraction could be maximized but I would increase it slower than the normal protocol maybe 1 mu every min and watch the heart rate tracing closely. panel of nurse experts. An open-ended text field labeled comments was the third item for each scenario. The second question was framed in the context of what the participant believed most nurses would do rather than how they personally would handle the conflict situation to reduce social desirability bias and allow for a more candid response if their personal response to the second question did not match the response to the first question. After the scenarios, participants were asked to comment on what they thought could promote communication and collegial relationships with physician colleagues and what they considered barriers to good communication and collegial relationships. Institutional review board approval was obtained from St. John s Mercy Medical Center in St. Louis, Missouri. Seven hundred four nurses in a mid-size metropolitan area who indicated obstetrics as their specialty during nursing license renewal were invited to participate in the on-line survey via mailed postcards that contained explanatory material and the Web address of the secure server. One hundred thirty-three nurses responded (response rate = 20% after correcting for 46 returned, undelivered mail). Data were analyzed using descriptive statistics and thematic analysis of open-ended text responses (Braun & Clarke, 2006). Openended responses were systematically coded from two perspectives. Text responses to the clinical scenarios were first coded deductively according to whether they represented best evidence/standard of care, or a passive, passiveaggressive, or work-around solution to the disagreement (See Table 1). All free text responses were then analyzed inductively by searching for themes that occurred within specific questions and across the data set. Themes were identified, reviewed, and refined in an iterative process until consensus was reached on the analysis. Results Participants were primarily aged 40 years or older (64%), experienced in labor nursing (54% > 10 years), stably employed (56% employed > 5 years at the same hospital), and held a BSN (75%). Thirty-five percent were members of AWHONN, 35% were certified in electronic fetal monitoring, and 33% were certified in inpatient obstetrics through the National Certification Corporation. Nearly one fourth (24%) of the sample reported having been deposed in a medical malpractice case. In all five scenarios, most nurses were aware of current evidence and published standards and guidelines (range 52%-86%) (see Table 2). However, there was a wide discrepancy between current evidence/standards/guidelines and what nurses indicated would occur in actual clinical practice. In scenarios about management of oxytocin-induced uterine hyperstimulation, presence of the neonatal resuscitation team when there was evidence of potential fetal compromise, and second stage care during a nonreassuring FHR pattern, only 22.5% to 28% of participants indicated January/February 2009 MCN 33

4 Table 2. RESULTS OF SURVEY PARTICIPANTS RESPONSES TO THE CLINICAL CASE SCENARIOS Clinical Case Scenario Physician orders to increase the oxytocin rate during uterine contractions occurring every 2 min, cervical change 1 cm/hr, and previous periods of hyperstimulation at the higher rate ordered Appropriate Action Do not increase the rate of oxytocin Knowledge of Appropriate Clinical Action Would Actually Implement Appropriate Clinical Action 80% 22.5% Most Common Alternative Clinical Action 54%: Increase the oxytocin rate, but keep a careful watch on the FHR and decrease the rate if the FHR becomes nonreassuring Physician refusal to come in to see a patient with a nonreassuring FHR pattern unresponsive to the usual intrauterine resuscitation measures Notify the charge nurse 86% 65% 22.5%: Wait 15 min and call again to request that the physician come see the patient Physician refusal to allow attendance at birth by the neonatal resuscitation team when the FHR pattern suggested potential fetal compromise Tell the physician that you would prefer to have the neonatal resuscitation team attend the birth 72% 28% 33%: Ignore the physician s comments (perhaps act like the comments weren t heard or that you couldn t get in contact with the neonatal team) and allow the team to come as planned Physician orders to continue pushing during the second stage of labor when the FHR pattern was nonreassuring despite request to stop pushing temporarily Stop pushing; insist that the physician come in to see the patient 52% 22.5% 59%: Be slow to start pushing again Further attempts by physician for operative vaginal birth when number of vacuum pulls and pop-offs exceeded unit policy and manufacturer guidelines Discretely let physician know he or she has exceeded the number of pulls and maximum time of vacuum application agreed upon by department and as stated in unit policy; if physician continues with the procedure, notify charge nurse 77% 47% 16%: No action, but hope the baby is born soon; encourage the mother to push as hard as she can that actual practice would be consistent with current evidence/standards/guidelines. In scenarios on multiple attempts at vacuum-assisted birth by the physician and physician refusal to come to the hospital to see a woman with a nonreassuring FHR, actual practice was somewhat more likely to approximate current evidence/standards/guidelines (47% and 65%, respectively). Open-Ended Responses to Scenarios Oxytocin Nurses reported using direct and work-around (often passiveaggressive) strategies for managing conflict between the physician s plan and what the nurse believed was right for the patient. Although only 22.5% indicated the appropriate action would occur in clinical practice, some gave sophisticated examples of how they would approach the situation directly: I think I would try to initiate a conversation with the MD about his goals for this patient and for him/her to explain why we would want to mess with adequate labor in the face of [a] previous hyperstim[ulation] event. Sometimes by talking this through, the MD will verbalize the real meaning for the desire to rush this process. Often this is enough for the MD to hear himself and back off the pitocin increase in light of clinical data. Nurses reported that their response to the scenario would be heavily influenced by their relationship with the specific physician. When they had a good physician relationship this situation would not be particularly problematic; however when they were dealing with a problem physician, they reported using more indirect, passive-aggressive, and conflict-avoidance techniques, such as agreeing to the plan but either stalling the increases or not doing them at all. 34 VOLUME 34 NUMBER 1 January/February 2009

5 It actually depends on the doctor and his personality. I know that there were times when I had a doc who would throw a fit if I didn t up the pitocin, so I would pacify him by agreeing to, but never would. Indirect strategies for managing the situation included stalling, extending the time between oxytocin increases, using smaller dosing increments (e.g., 1 mu), and relying on technology to bolster their argument by requesting an intrauterine pressure catheter. The nurses expressed a strong desire for collaborative discussion and management of labor with physicians in response to this scenario, but the reality of their practice environments appeared to be one of pervasive fear of and intimidation by physicians. The nurses repeatedly expressed fear of the physician response to their efforts to maintain a safe labor pattern: A few [nurses] would argue that the pitocin didn t need to be turned up but they would have hell to pay from that physician. Nonreassuring Fetal Heart Rate Responses to this scenario indicated that this was an everyday problem and a source of frustration for labor nurses. Unfortunately, this is a common problem, but over time I feel that the staff has come to realize this is a no win situation and the nurse will make sure something is done for the patient ASAP. Many nurses described how they would obtain a bedside evaluation by working through alternate channels: The house doctor would call the attending physician the next time since my clinical judgment was dismissed. Participants who wrote comments were overwhelmingly aware of the need to initiate the chain of command in this scenario; however, their creativity in finding alternative paths to obtaining a bedside evaluation or initiating the chain of command also demonstrated that many worked in organizations that did not have cultures supporting the value of nursing judgment or importance of nurses role in activating responses to prevent patient harm: I hate it when I have to keep calling them. The doctors should respond to the first call and trust me when I say I need them. Neonatal Resuscitation Team In response to this scenario, many participants reported that their institutions took a more proactive approach when it came to neonatal safety. This was most often demonstrated through an institutional policy giving authority to the circulating nurse to call the resuscitation team or a culture of collegiality around resuscitation practices. I don t work with any physicians that would cancel a call to the resus[citation] team In my institution it is the nurse s prerogative to call the team and hospital policy to do so in this type of situation. If the physician continued to behave this way he/she would be quickly over-ruled by the charge nurse and the nursery physician. However, nurses also indicated that they thought the most common action would be a conflict avoidance strategy of ignoring the physician s comments and allowing the team to come as planned. This work-around method to ensure the neonatal team was in attendance at the birth despite the physician s objections suggests that nurses may attempt to secure the necessary resources or consultation for their patients in ways that minimize direct conflict or confrontation. Second Stage Labor Management Nurses who commented on this scenario indicated awareness of the standard and the need for a bedside evaluation by the physician and interventions to reduce fetal stress. The nurses reflected on their role as the primary person actually managing a woman s labor at the bedside and how this could be an advantage for them in doing what they thought was right for the patient. Most of the time the doctors are not in the room when we are pushing. It is easy to do what we know needs to be done for the patient and the baby. However, despite this situational autonomy, fear of the physician response was still prominent: I have seen some nurses continue to push through some of the ugliest variables because the physician was hard to deal with. I feel the nurses are sometimes afraid to confront the physician by insisting he come to see his patient. As in the nonreassuring FHR scenario, calling in another physician was commonly raised as a strategy for resolving the situation in the patient s interest. Operative Vaginal Birth The vacuum-assisted birth scenario was described as a nowin situation for nurses, in which they often felt relatively helpless to intervene. They commented frequently on the difficulty of challenging a physician in front of the patient, no matter how discretely: I think this is a particularly hard situation to be in because most nurses don t want to start something in front of the patient. Avoiding conflict in a clinical situation entirely driven by the physician, such as operative vaginal birth, was predominant. Few nurses (16%) reported being willing to discuss the situation with the physician even in private after the birth. Barriers to Effective Interdisciplinary Communication and Collaboration Open-ended responses revealed hierarchy, fear of and intimidation by physician colleagues, and lack of administrative support when conflict occurs as primary barriers to effective communication and perinatal teamwork. These themes were evident within clinical scenario responses and responses to the open-ended questions about promoters of January/February 2009 MCN 35

6 and barriers to effective communication and collegial relationships. They are also linked together. Physicians had higher social status and were afforded more power by the conduct of hospital administrators. This in turn created a power gradient that nurses found intimidating. Definitely hierarchy is the biggest factor. Doctors perceive they have more power than nurses. Hospitals treat them as if they do have more power and can do pretty much what ever they want to do. We need nurse leaders and hospital leaders to put a stop to this attitude that we have to keep the doctors happy and they can do just about anything because they are doctors. Preconceived opinions that physicians are the last word or the only opinion that counts Some physicians do not appreciate nurses suggestions. Hospitals cater to doctors too much and accept behavior that is really unacceptable. This power gradient allowed some physicians to engage in explicitly intimidating and bullying behaviors, which nurses described as a serious impediment to effective teamwork and their ability to respond according to the best evidence/standards of care. Nurses being intimidated by the LOUD VOICE, Wrath of Rudeness or shunning Physicians who make it their life s work to make nurses feel inferior Fear of retaliation, intimidating comments and behaviors by physicians Hospitals promote a climate of conflict between doctors and nurses by not backing the nurses when a conflict occurs. They are too afraid of losing their customer the physician. It begins with smaller issues that [hospitals] overlook like yelling at the nurses and slamming the phone in their ear. Hospitals must expect different behavior from their physicians or nothing will change. The pervasive influence of hierarchical relationships was also implicitly represented by the lack of respect nurses felt for their clinical judgments and their contributions to the care of patients and reflected in their perception that they lacked administrative support for maintaining the standards or guidelines when that entailed challenging a physician. If you refused to turn up the pit my supervisor will say that the doctor complained that I did not follow her order and that she does not want me to take care of her patients anymore. I don t feel that my manager would stand up for me. Too many nurses are afraid to stand their ground in fear of job retribution or loss. If physicians knew that when a labor nurse spoke up and disagreed with the plan of care that she represented the hospital and had its backing 100%, I think they would respect nursing more. Promoting Effective Communication and Collaboration Mutual respect, interdisciplinary policy-making, discussion, education, and strong administrative support for nursing judgment were identified as key to promoting collegial relationships and effective communication. These characteristics represent the antithesis of hierarchical relationships that were reported as barriers to communication and to nurses being able to respond to scenarios according to the standards of care. Nurses clearly yearned for more collegial practice environments in which clinicians would have more opportunities for interaction, colleagues would treat each other with kindness and consideration, and the different but equal contributions of nurses and physicians would be respected. Basic courtesy to really listen, using the same language (with the same meaning) and create TEAM instead of US v. THEM. There needs to be understanding and appreciation of all roles. Physicians and nurses who train and practice together develop rapport and trust and a sense of each others abilities for an environment of safe care practices and ongoing improvement. Unfortunately this was not reality for many study participants. The hospital should support doctors and nurses equally. Inappropriate and often abusive physician behavior is tolerated that would not be tolerated from a nurse. Doctors should not be deferred to just because they are doctors. The hospital should acknowledge and support the contributions of nurses. Limitations There were several limitations to this study. The response rate of 20% was less than anticipated. We learned that asking potential participants to type in a long Web address to access the survey site was not the best recruitment method. A better method would have been to send an to potential participants with an embedded Web address that could be directly accessed from the body of the . This approach also would have allowed a second request for participation to those who had not responded. Further followup with a paper copy of the survey might also have increased response (Asch, Jedziewski, & Christakis, 1997; Dillman, 2007). We used a list of nurses who indicated that obstetrics was their specialty during their last license renewal, but we asked that participants be direct care providers. Some of those who received the invitation to participate were likely in administrative roles and thus did not respond. It is possible that there was a response bias, with nurses who had negative experiences with clinical disagreements with physician colleagues being more likely to participate. Although the national percentage of obstetrical nurses who 36 VOLUME 34 NUMBER 1 January/February 2009

7 have given a deposition in a medical malpractice case is unknown, a rate of 24% in our sample seems higher than expected. It is well known that poor interdisciplinary communication is involved in perinatal injuries and deaths (Joint Commission, 2007). These adverse outcomes are often followed by litigation. Nurses who had been deposed may have been more likely to have been involved in an adverse outcome associated with poor communication. However, even assuming a biased sample, the reported level of fear, intimidation, and lack of administrative support is potentially harmful to mothers and babies and creates a hostile work environment. We were unable to directly measure how nurses would respond to the common clinical disagreements described in the scenarios. By reducing the social desirability bias in phrasing the question regarding responses, the goal was to encourage responses that would approximate clinical reality. The responses suggested that this method was successful. Although the question was posed What do you think most nurses would do? nearly all participants answered in the first person (e.g., I would ). Others differentiated what they would do from what they believed other nurses or less experienced nurses would do. Clinical Implications In this well-educated and knowledgeable sample of experienced labor nurses, responses of what would occur in clinical practice did not match current evidence, published standards, or guidelines. Adequate nursing knowledge may not be an accurate predictor of appropriate clinical practice. The sample characteristics (e.g., education, certification, membership in their professional organization) are indicative of a high degree of professionalism. Free text responses reflected a careful, thoughtful, cautious, practical approach to handling each clinical disagreement, similar to terms used to describe a reasonably prudent nurse. Although most participants responses may not have matched current evidence/standards/guidelines, they may provide insight as to what reasonably prudent nurses would actually do in the same or similar situation. Depth and intensity of free text responses indicated an unacceptably pervasive sense of fear and intimidation as a component of medical hierarchy in work environments of nurses who responded. Physician behaviors noted by the HOSPITALS PROMOTE A CLIMATE OF CONFLICT BETWEEN DOCTORS AND NURSES BY NOT BACKING THE NURSES WHEN A CONFLICT OCCURS. THEY ARE TOO AFRAID OF LOSING THEIR CUSTOMER, participants, such as demeaning comments, yelling, hanging up during telephone conversations, and lack of respect are consistent with disruptive clinician behavior described by ACOG (2007) and the Joint Commission (2008). This level of fear and intimidation raises concerns for patient safety during labor and birth. Conflict avoidance or work-arounds were often reported, especially when nurses indicated they had witnessed or been subjected to disruptive behavior with the physician THE PHYSICIAN HOSPITALS MUST EXPECT DIFFERENT BEHAVIOR FROM THEIR PHYSICIANS OR NOTHING WILL CHANGE. previously, consistent with findings that victims of such behaviors may intentionally avoid additional interactions to minimize further opportunity for abuse (Institute for Safe Medication Practices [ISMP], 2004; Rosenstein & O - Daniel, 2005). What s best for the patient rather than conflict avoidance, fear, and intimidation should be the basis for action. Nurses clearly have an ethical duty to protect patients from harm (American Nurses Association, 2001). However, nurses are placed in a difficult bind when their ethical responsibility to patients is in direct conflict with perceived need for self-protection. Confidence in administrative support seems to be one of the key factors in empowering nurses to pursue resolution of disagreements in patients best interests, yet nurse managers are also often caught in the middle when clinical conflicts occur. As leaders they are responsible in part for maintaining patient volume, which is often linked to physician satisfaction. Physicians who are unhappy may chose to take their patients to a competing hospital. Nurses in administrative roles may be reluctant to address disruptive behavior for fear of offending the physician and subsequently losing patient volume. Despite study limitations, findings are consistent with other research, which suggests that disruptive behavior threatens patient safety (ISMP, 2004; Rosenstein & O - Daniel, 2005; Veltman, 2007) and that the decision to speak up about patient concerns is a complex social process January/February 2009 MCN 37

8 KEEPING PATIENTS SAFE REQUIRES TRANSFORMATIONAL LEADERSHIP AND RECOGNITION OF NURSES CONTRIBUTIONS TO SAFE CARE. (Blatt, Christianson, Sutcliffe, & Rosenthal, 2006; Lyndon, 2008). Although it may be perpetrated by a small minority, impact of disruptive behavior can be significant (ISMP, 2004; Rosenstein & O Daniel, 2005; Veltman, 2007). While some physician organizations are beginning to address this issue (ACOG, 2007), abusive behaviors still occur and must stop. It is unethical for individuals and organizations to continue to place both bedside nurses and nurse administrators in the untenable position of facing potential personal and organizational retribution when they fulfill their responsibilities to advocate for patients. Keeping patients safe requires transformational leadership and recognition of nurses contributions to safe care (Page, 2004). Essential steps include implementing and enforcing a zero tolerance for abuse policy, applied equally to all. Organizations should adopt standards for healthy work environments, such as those proposed by the American Association of Critical- Care Nurses (AACN, 2005; Page, 2004). Even when disruptive behavior is addressed in a timely and appropriate manner, the nurse may not be privy to the outcome and may not feel adequately supported. A system that visibly values all team members and provides adequate follow-up of reports of disruptive behavior is essential to build trusting relationships among staff nurses, physicians, and administrators. Effective perinatal teamwork is critical to safe care for mothers and babies (JCAHO, 2004). Adverse perinatal events are known to be linked to problems with team interactions and communication (JCAHO, 2004; Joint Commission, 2007; Simpson & Knox, 2003a). Interdisciplinary team training and consensus on key clinical issues such as FHR pattern definitions and oxytocin management may be effective in promoting safer care. In a recent study, team training and interdisciplinary fetal monitoring education culminating in a national certification exam as components of a comprehensive program to reduce adverse perinatal events resulted in a significant decrease in patient harm and costs of malpractice claims and an improvement in staff s perception of the overall safety climate (Funai et al., 2007). Standardization of definitions used to describe FHR patterns and a standard oxytocin policy were additional components of this successful program. Because disagreements regarding FHR pattern interpretation and management of hyperstimulation were noted to be common by our study participants, findings from the study by Funai et al (2007) may support strategies to minimize clinical conditions in which these types of disagreements arise. Nurses in this study described behaviors that were not consistent with what they have the right to expect from fellow professionals when differences in opinion arise in clinical situations. A unit culture with expectations that professionals will act professionally in all interactions is requisite. Standards for professional behavior should be outlined explicitly in institutional policies (Joint Commission, 2008) and reaffirmed by leaders and each team member on an annual basis during contract renewal and performance reviews (Porto & Lauve, 2006). The different but equal contribution of nurses to the care process and ultimate clinical outcomes should be recognized and valued. The leadership team should actively encourage and support reporting of disruptive behavior (Porto & Lauve, 2006). Accountability for individual actions and meaningful follow-up with clear actionable implications when disruptive behavior occurs is essential (Porto & Lauve, 2006). Each case should be addressed in a timely manner rather than delaying interventions until trends are apparent. All healthcare organizations should provide an environment in which each member of the team is able to practice effectively in an atmosphere of interdisciplinary respect and collaboration (AACN, 2005; Joint Commission, 2008; Porto & Lauve, 2006). This environment is created by a shift away from a model focused on physicians as customers toward a model that values the contributions of all providers and support staff (Porto & Lauve, 2006). Service to the true customers (mothers and babies) should be the foundation of obstetrical care. Kathleen Rice Simpson is a Perinatal Clinical Nurse Specialist, St. John s Mercy Medical Center, St. Louis, MO, and 38 VOLUME 34 NUMBER 1 January/February 2009

9 an Editorial Board Member of MCN. Dr. Simpson can be reached via at Audrey Lyndon is an Assistant Professor, Department of Family Health Care Nursing, University of California San Francisco School of Nursing. The authors have no conflict of interest or any financial relationship with any companies mentioned in the article. References American Association of Critical-Care Nurses. (2005). AACN Standards for establishing and sustaining healthy work environments: A journey to excellence. Aliso Viejo, CA: Author. American College of Obstetricians and Gynecologists. (2004) ACOG survey of professional liability. Washington, DC: Author. American College of Obstetricians and Gynecologists. (2007). Disruptive behavior (Committee Opinion No. 366). Washington, DC: Author. American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author. Asch, D. A., Jedziewski, K., & Christakis, N. A. (1997). 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