AWHONN Research Team

Transcription

1 Safety Consequences of Inadequate Staffing during Labor and Birth Audrey Lyndon, PhD, RN Associate Professor Department of Family Health Care Nursing UCSF School of Nursing This research was supported by the Association of Women s Health, Obstetric and Neonatal Nurses AWHONN Research Team Kathleen Simpson Audrey Lyndon Joanne Spetz Gay Landstrom AWHONN staff: Catherine Ruhl Debra Bingham, Ben Scheich, Brea Onokpise, & Kirsten Wisner also provided support for this work. 1

2 Background: Nsg Care and Outcomes Higher nurse staffing rates associated with: Fewer medication errors Decrease in patient mortality Fewer missed crucial aspects of care Lower rates of adverse outcomes Less patient falls Less failure to rescue / mortality Higher patient satisfaction Sources: Aiken 2002, 2011; Dabney, 2015; Kalisch 2009, 2011, 2012; Schubert 2012 Missed Nursing Care RN hours per patient day (nurse staffing levels) are a significant predictor of missed care Patients who are mentally alert are aware of missed (or delayed) essential care; consistent with nurses on the same unit Sub optimal staffing / HPPD, communication, collaboration, trust / accountability, orientation, teamwork Patient falls, pressure ulcers, infections Magnet hospital designation Perceptions of staff nurses and nurse leaders 2

3 Perinatal Nursing Care & Patient Outcomes Influence of nursing care in the perinatal setting has not been studied Data are limited to medical surgical units, ICUs in acute care hospitals We conducted a series of studies to develop groundwork for examining perinatal staffing Secondary Analysis of AWHONN member survey on staffing 2010 AWHONN member survey Please give the staffing task force your input on what they should consider in the development of recommendations for staffing of perinatal units N = 884 members participated 3

4 Themes Care that could not be done at all or could not be done as completely as needed when there were not enough nurses Potential for adverse outcomes because nurses could not carefully assess, monitor, or identify changes or deterioration in patients conditions in a timely manner Negative professional implications for nurses Comparable to existing data Consistent with those identified in the literature related to inadequate nurse staffing Themes names as per existing staffing research: Missed care (Kalisch et al., 2009) Failure to rescue (Aiken et al., Clarke, 2004) Job related stress and dissatisfaction (Aiken et al., 2002; Purcell et al., 2011) 4

5 Low resources Inadequate nurse staffing Nurses too busy 1 nurse is responsible for 2 women in labor receiving oxytocin 1 nurse is responsible for 2 mothers / 2 babies in the OB PACU 1 nurse is responsible for 5 mother baby couplets Decision making about care (What absolutely needs to be done?; What can wait?; What can be skipped?) Prioritizing Rationing Patient care prioritized over medical record documentation Less frequent assessments Less comprehensive assessments Less emotional and physical supportive care Less teaching to prepare for discharge Delayed care Unfinished care Missed care Incomplete or inadequate maternal fetal assessment during labor labor progress evaluation assessment of effect of medication on uterine activity and fetal wellbeing breastfeeding support and teaching assessment of maternal status and newborn status immediately after birth maternal and newborn care during postpartum maternal teaching prior to discharge Reduced Opportunity to identify problems Ability to intervene as necessary Risk of failure to rescue and subsequent preventable patient harm Adapted from Simpson, Lyndon & Ruhl, Consequences of Inadequate staffing include Missed care, potential failure to rescue, and job stress and dissatisfaction. JOGNN, 45, Tachysystole Deteriorating fetal status Depressed baby at birth Postpartum hemorrhage Newborn hypoglycemia Unsuccessful breastfeeding Newborn hyperbilirubinemia Mother or infant falls Inadequate knowledge for self care and/or baby care Low resources Inadequate nurse staffing Nurses too busy 1 nurse for 2 women in labor receiving oxytocin 1 nurse for 2 mothers / 2 babies in the OB PACU 1 nurse for 5 mother baby couplets Decision making about care (What absolutely needs to be done?; What can wait?; What can be skipped?) Prioritizing Rationing Patient care prioritized over medical record documentation Less frequent assessments Less comprehensive assessments Less emotional/physical supportive care Less teaching to prepare for discharge 5

6 Delayed care Unfinished care Missed care Reduced Opportunity to identify problems Ability to intervene as necessary Risk of failure to rescue and subsequent preventable patient harm Incomplete or inadequate: maternal fetal assessment during labor labor progress evaluation assessment of effect of medication on uterine activity and fetal wellbeing breastfeeding support and teaching assessment of maternal status and newborn status immediately after birth maternal and newborn care during postpartum maternal teaching prior to discharge Tachysystole Deteriorating fetal status Depressed baby at birth Postpartum hemorrhage Newborn hypoglycemia Unsuccessful breastfeeding Newborn hyperbilirubinemia Mother or infant falls Inadequate knowledge for self care / baby care Instrument Modification Adapted an established tool for med surg nursing care (Kalisch et al., 2009) to nursing care during labor and birth 21 essential aspects of medsurg care Extensive psychometric testing / validity and reliability evaluated 6

7 Instrument Modification 95 labor nurses, 23 new mothers, 9 physicians participated in 17 focus groups to provide feedback re: the role of labor nurse e.g., most important aspects of care, what they do to influence outcomes Survey was tested by 24 labor nurses to help to refine final version; estimated time to complete was 10 to 15 minutes Settings Washington DC & Baltimore Region: 2RN groups per site at 4 hospitals births, urban & suburban, diverse patient populations Rural Missouri: 1 group in hospital with 750 births St. Louis: 2 groups with RNs, 2 groups with mothers; 8500 births, suburban Northern CA: 2 groups with physicians; teaching & community 7

8 RNs: Missed Care &Consequences Adapted from Simpson & Lyndon. Consequences of delayed, unfinished, or missed nursing care during labor and birth. JPNN 2017 Jan/Mar;31(1): All Groups: What is Important? (RNs) What specific aspects of care during labor and birth contribute to patient outcomes? Tell us some of the specific things you do that make a difference for patients (Mothers) What did you think made a difference in your outcomes? (Physicians) What aspects of nursing care do you consider most important to influencing outcomes during labor and birth? Are the Joint Commission Perinatal Care Measures nurse sensitive? 8

9 Support and Advocacy Keeping women and their families informed Being present with women Setting the emotional tone Knowing and advocating for women s wishes Avoiding cesarean birth New Mothers To me it was being informed. I just really wanted to know what was going on I was concerned and the nurses informing you of where you should be and what you re doing was very helpful. Someone else mentioned cheerleader. She was definitely a super cheerleader I felt very empowered and encouraged. 9

10 Nurses & Physicians A good partner will lower your C section rate, no question. A good partner [will] facilitate vaginal delivery. Not just Pitocin; it may be a nurse who s comfortable with patients in different positions. [Physician] When you can answer all their questions or help [women] work through the process, that gives them a lot of confidence. [RN] Sometimes [women are] just not comfortable telling the doctor what they really want.they feel like they can t say Well, can we not do that?.i think [advocating for them] that s a big thing, a big part of what we do. [RN] Existing Measure Nurse Sensitivity 10

11 Nursing Role in Mode of Birth Convened to query specifically about potential influence on cesarean birth N = 24 experienced labor nurses via 2 focus groups Sequential questions for discussion: Do labor nurses influence whether a woman has a cesarean? What specific things do you do as labor nurse to help a woman avoid a cesarean? (Simpson & Lyndon, 2016) Results Nurses overwhelmingly felt they contribute to whether a woman has a cesarean birth Offered list of factors and list of things they routinely do to mitigate risk Themes: support, advocacy, interactions with physicians 11

12 Support: emotional, informational, physical just being continually present with mom can really help her psychologically with her pain Definitely position change works. That peanut ball is awesome.you do things to assist that baby s rotation coming down use of Pitocin effectively and correctly, not oversaturating her uterus but giving her enough Advocacy Advocating for women s wishes Speaking up on women s behalf Coaching & Empowering Advocating not to admit them too early The more you encourage her that she can do it they feel empowered to say I m doing fine, I want to keep going 12

13 Nurse Physician Interactions Working around them rather than with them Mistrust, withholding information, keeping physicians out of the room Wanting more autonomy on labor management Negotiations Physicians should not be micromanaging the labor ( Why is she on her side? Why does she have that ball? ) There are some doctors I can sit with and talk to and they will listen to me. Then there are others that say, I m the doctor. Consult with them away from the patient. They re more open to suggestion when you discuss things in private. 13

14 Withholding Information You have to tell them nursing lies, you learn, pretty early on that technically she s complete but I m going to say that she s 9 because she can labor down and I don t have somebody coming in and making me push. So you learn to bend the truth a little bit to advocate for your patient.i hate that we re tricking them, but Conclusions New mothers, nurses, and physicians value having nurses engaged in individualized supportive care during labor Remarkable level of consensus on this point Most stakeholders believe cesarean rates and breastfeeding may be nurse sensitive Nurses believe that understaffing can have significant consequences for patient outcomes 14

15 In Process Initial study using the Nursing Care During Labor Survey, capturing frequency of: Nurse reported missed care in labor and birth Nurse reported staffing relative to AWHONN guidelines Safety culture, burnout, decisional regret Hopefully Coming Next Year The LABOR RNs Study: Looking at Birth Outcomes and their Relationship to Registered Nurse Staffing We will need your help! 15

16 Questions & Discussion Thank you! 16

17 References Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), doi: /mlr.0b013e b6e Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2009). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), doi: /01.nna d7 Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S., Rafferty, A. M.,... consortium, Rn Cast. (2014). Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf, 23(2), doi: /bmjqs Clarke, S. P., & Aiken, L. H. (2003). Failure to Rescue: Needless deaths are a prime example of the need for more nurses at the bedside. American Journal of Nursing, 103(1), Dabney, B. W., & Kalisch, B. J. (2015). Nurse Staffing Levels and Patient-Reported Missed Nursing Care. J Nurs Care Qual, 30(4), doi: /ncq Friese, C. R., Kalisch, B. J., & Lee, K. H. (2013). Patterns and correlates of missed nursing care in inpatient oncology units. Cancer Nurs, 36(6), E doi: /ncc.0b013e318275f552 Kalisch, B. J. (2006). Missed nursing care: a qualitative study. J Nurs Care Qual, 21(4), ; quiz Retrieved from Kalisch, B. J. (2009). Nurse and nurse assistant perceptions of missed nursing care: what does it tell us about teamwork? J Nurs Adm, 39(11), doi: /nna.0b013e3181bd61ac Kalisch, B. J., Doumit, M., Lee, K. H., & Zein, J. E. (2013). Missed nursing care, level of staffing, and job satisfaction: Lebanon versus the United States. J Nurs Adm, 43(5), doi: /nna.0b013e31828eebaa Kalisch, B. J., Gosselin, K., & Choi, S. H. (2012). A comparison of patient care units with high versus low levels of missed nursing care. Health Care Manage Rev, 37(4), doi: /hmr.0b013e e Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: a concept analysis. J Adv Nurs, 65(7), doi: /j x Kalisch, B. J., Landstrom, G., & Williams, R. A. (2009). Missed nursing care: errors of omission. Nurs Outlook, 57(1), 3-9. doi: /j.outlook Kalisch, B. J., & Lee, K. H. (2010). The impact of teamwork on missed nursing care. Nurs Outlook, 58(5), doi: /j.outlook Kalisch, B. J., & Lee, K. H. (2012a). Congruence of perceptions among nursing leaders and staff regarding missed nursing care and teamwork. J Nurs Adm, 42(10), doi: /nna.0b013e31826a1fa4 Kalisch, B. J., & Lee, K. H. (2012b). Missed nursing care: Magnet versus non-magnet hospitals. Nurs Outlook, 60(5), e doi: /j.outlook Kalisch, B. J., McLaughlin, M., & Dabney, B. W. (2012). Patient perceptions of missed nursing care. Jt Comm J Qual Patient Saf, 38(4), Retrieved from Kalisch, B. J., Tschannen, D., Lee, H., & Friese, C. R. (2011). Hospital variation in missed nursing care. Am J Med Qual, 26(4), doi: /

18 Kalisch, B. J., Tschannen, D., & Lee, K. H. (2011). Do staffing levels predict missed nursing care? Int J Qual Health Care, 23(3), doi: /intqhc/mzr009 Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012). Missed nursing care, staffing, and patient falls. J Nurs Care Qual, 27(1), doi: /ncq.0b013e318225aa23 Kalisch, B. J., & Williams, R. A. (2009). Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm, 39(5), doi: /nna.0b013e3181a23cf5 Kalisch, B. J., Xie, B., & Dabney, B. W. (2014). Patient-reported missed nursing care correlated with adverse events. Am J Med Qual, 29(5), doi: / Kalisch, B., Tschannen, D., & Lee, H. (2011). Does missed nursing care predict job satisfaction? J Healthc Manag, 56(2), ; discussion Retrieved from Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2011). Nurse outcomes in Magnet(R) and non-magnet hospitals. Journal of Nursing Administration, 41(10), doi: /nna.0b013e31822eddbc Kendall-Gallagher, D., Aiken, L. H., Sloane, D. M., & Cimiotti, J. P. (2011). Nurse specialty certification, inpatient mortality, and failure to rescue. J Nurs Scholarsh, 43(2), doi: /j x Lake, E. T., Germack, H. D., & Viscardi, M. K. (2015). Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals. BMJ Qual Saf. doi: /bmjqs Lake, E. T., Staiger, D., Horbar, J., Kenny, M. J., Patrick, T., & Rogowski, J. A. (2015). Disparities in perinatal quality outcomes for very low birth weight infants in neonatal intensive care. Health Serv Res, 50(2), doi: / Lucero, R. J., Lake, E. T., & Aiken, L. H. (2010). Nursing care quality and adverse events in US hospitals. Journal of Clinical Nursing, 19(15-16), doi: /j x Lyndon, A., Simpson, K. R., & Spetz, J. (2016, October 20-22, 2016). Stakeholder views of nursing influence on birth outcomes. Paper presented at the American Academy of Nursing 2016 Transforming Health, Driving Policy Conference, Washington, DC. Rafferty, A. M., Clarke, S. P., Coles, J., Ball, J., James, P., McKee, M., & Aiken, L. H. (2007). Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies, 44, Schubert, M., Clarke, S. P., Aiken, L. H., & de Geest, S. (2012). Associations between rationing of nursing care and inpatient mortality in Swiss hospitals. Int J Qual Health Care, 24(3), doi: /intqhc/mzs009 Simpson, K. R., & Lyndon, A. (2016a). Consequences of Delayed, Unfinished, or Missed Nursing Care During Labor and Birth. J Perinat Neonatal Nurs. doi: /jpn Simpson, K. R., & Lyndon, A. (2016b). Labor Nurses' Views of their Influence on Cesarean Birth. MCN Am J Matern Child Nurs. doi: /nmc Simpson, K. R., Lyndon, A., & Ruhl, C. (2016). Consequences of Inadequate Staffing Include Missed Care, Potential Failure to Rescue, and Job Stress and Dissatisfaction. J Obstet Gynecol Neonatal Nurs, 45(4), doi: /j.jogn Simpson, K. R., Lyndon, A., Wilson, J., & Ruhl, C. (2012). Nurses' perceptions of critical issues requiring consideration in the development of guidelines for professional registered nurse staffing for perinatal units. J Obstet Gynecol Neonatal Nurs, 41(4), doi: /j x Tschannen, D., Kalisch, B. J., & Lee, K. H. (2010). Missed nursing care: the impact on intention to leave and turnover. Can J Nurs Res, 42(4), Retrieved from