Faculty Bibliography

BACKGROUND & OBJECTIVES/OBJECTIVE:Little is known about how parents think about neonatal intensive care unit (NICU) safety. Due to their physiologic immaturity and small size, infants in NICUs are especially vulnerable to injury from their medical care. Campaigns are underway to integrate patients and family members into patient safety. This study aimed to describe how parents of infants in the NICU conceptualise patient safety and what kinds of concerns they have about safety. METHODS:This mixed-methods study employed questionnaires, interviews and observation with parents of infant patients in an academic medical centre NICU. Measures included parent stress, family-centredness and types of safety concerns. RESULTS:46 parents completed questionnaires and 14 of these parents also participated in 10 interviews (including 4 couple interviews). Infants had a range of medical and surgical problems, including prematurity, congenital diaphragmatic hernia and congenital cardiac disease. Parents were positive about their infants' care and had low levels of concern about the safety of procedures. Parents reporting more stress had more concerns. We identified three overlapping domains in parents' conceptualisations of safety in the NICU, including physical, developmental and emotional safety. Parents demonstrated sophisticated understanding of how environmental, treatment and personnel factors could potentially influence their infants' developmental and emotional health. CONCLUSIONS:Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental and emotional safety domains may result in safety improvements.

BACKGROUND:There is limited collaboration between hospitals and primary care despite parallel efforts to improve postdischarge care transitions. OBJECTIVE:To understand what primary care leaders perceived as barriers and facilitators to collaboration with hospitals. METHODS:Qualitative study with in-depth, semistructured interviews of 22 primary care leaders in 2012 from California safety-net clinics. RESULTS:Major barriers to collaboration included lack of institutional financial incentives for collaboration, competing priorities (e.g., regulatory requirements, strained clinic capacity, financial strain) and mismatched expectations about role and capacity of primary care to improve care transitions. Facilitators included relationship building through interpersonal networking and improving communication and information transfer via electronic health record (EHR) implementation. CONCLUSIONS:Efforts to improve care transitions should focus on aligning financial incentives, standardizing regulations around EHR interoperability and data sharing, and enhancing opportunities for interpersonal networking.

Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study's multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study's findings to other settings.

OBJECTIVE:To explore clinician perspectives on whether they experience difficulty resolving patient-related concerns or observe problems with the performance or behavior of colleagues involved in intrapartum care. DESIGN/METHODS:Qualitative descriptive study of physician, nursing, and midwifery professional association members. PARTICIPANTS AND SETTING/METHODS:Participants (N = 1932) were drawn from the membership lists of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), American College of Obstetricians and Gynecologists (ACOG), American College of Nurse Midwives (ACNM), and Society for Maternal-Fetal Medicine (SMFM). METHODS:Email survey with multiple choice and free text responses. Descriptive statistics and inductive thematic analysis were used to characterize the data. RESULTS:Forty-seven percent of participants reported experiencing situations in which patients were put at risk due to failure of team members to listen or respond to a concern. Thirty-seven percent reported unresolved concerns regarding another clinician's performance. The overarching theme was clinical disconnection, which included disconnections between clinicians about patient needs and plans of care and disconnections between clinicians and administration about the support required to provide safe and appropriate clinical care. Lack of responsiveness to concerns by colleagues and administration contributed to resignation and defeatism among participants who had experienced such situations. CONCLUSION/CONCLUSIONS:Despite encouraging progress in developing cultures of safety in individual centers and systems, significant work is needed to improve collaboration and reverse historic normalization of both systemic disrespect and overt disruptive behaviors in intrapartum care.

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.

Nursing for Women's Health convened a group of nurse researchers for a roundtable discussion about the relationship of research to the profession of nursing, how research drives evidence-based practice and how nurses can get involved in research and in its application to the care of women and newborns.

OBJECTIVE:To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety. DESIGN/METHODS:Constructivist grounded theory. SETTING/METHODS:Four hospitals in the western United States. PARTICIPANTS/METHODS:Forty-six (46) nurses and physicians practicing in maternity units. METHOD/METHODS:Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991). RESULTS:The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication. CONCLUSIONS:The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.