Baccalaureate nursing students' engagement with end-of-life curriculum: A grounded theory study.

BACKGROUND: The art of being prepared to support patients and their families during end of life experiences is not always emphasized in nurse education. Despite the efforts from the American Association of Colleges of Nursing and End of Life Nursing Education Consortium (ELNEC), only 25% of nursing schools across the United States are using their modules. OBJECTIVE: The purpose of this study was to explore how student nurses engage with end of life education. DESIGN: Qualitative study using a grounded theory approach. SETTING: Baccalaureate nursing program located in the rural agricultural western United States. PARTICIPANTS: Using purposive sampling, a single cohort of baccalaureate student nurses in two focus groups (n = 17; n = 23). METHODS: Using a grounded theory approach, student experiences and engagement with the curriculum were explored. Using the constant comparative method, three researchers coded the data independently and then came together to reach consensus on themes and for the development of the conceptual model. RESULTS: Three categories emerged from the data to describe the student engagement with the curriculum: Novice, Evolving, and Prepared. The central theme for the Novice students was Being Afraid. Students expressed fear over the unknown and not knowing what to say or do. Becoming Aware was the central theme for the Evolving students which included a blend of being aware of their deficiencies as well as the important aspects of end of life care. The final category was Prepared. The theme for this category was Becoming Accomplished, which included recognition of respectful care, disrespectful care, team work, and advocacy. CONCLUSION: End of life education is essential for nursing students to provide appropriate care at end of life, as well as providing improved knowledge, attitudes, and confidence of students. The End of Life Nursing Education Consortium modules, placed strategically within the curriculum, allow nursing students to move through the process of Being Afraid, to Becoming Aware, and finally Becoming Accomplished upon graduation.

Making research real: Innovative approaches for graduate level nursing research.

BACKGROUND: Engaging graduate students in the research process is often challenging. Making research real requires more innovation than lecture alone. PURPOSE: This project is a new curricular approach to Nursing Research, where graduate students collectively engage in the entire research process, from project conception through dissemination. METHODS: The Seven Principles of Good Practice framework was utilized to structure this innovative teaching strategy. Graduate students work together over the course of four semesters with the same faculty member guiding their research study. There are six major components to this innovative curriculum approach: student driven research idea, proposal writing, IRB application process, data collection, data analysis, and dissemination. RESULTS: Student enthusiasm was consistent across all five research projects to date. Students report they have been challenged by the experience but also enjoyed it. The group research project turned something that seemed intimidating into something accomplishable. Students spoke to the idea that through the process of mentoring and collaboration, they gained the needed skills and confidence to embrace their own research agendas. CONCLUSION: Developing and maintaining a student research innovation creates an enriched environment for instilling the passion and practical experience of being a nurse researcher.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative, descriptive design using thematic analysis. SAMPLE: A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007. METHODS: We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge. CONCLUSION: To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Sepsis.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007. METHODS: We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge. CONCLUSION: To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007. METHODS: We coded and thematically organized the 269 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain. CONCLUSION: Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California.

OBJECTIVE: To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee. DESIGN: Qualitative, descriptive design using thematic analysis. SAMPLE: A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007. METHODS: We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework. RESULTS: We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care. CONCLUSION: Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive using thematic analysis. SAMPLE: A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007. METHODS: We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment. CONCLUSION: Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007. METHODS: We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted. CONCLUSION: Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth.

BACKGROUND: Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada. METHODS: Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care. RESULTS: Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43). CONCLUSIONS: Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

Barriers and Facilitators to Implementation of a Multistate Collaborative to Reduce Maternal Mortality From Postpartum Hemorrhage.

OBJECTIVE: To describe the barriers and facilitators to implementing the Association of Women's Health, Obstetric and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project experienced by hospital leaders, project champions, and staff. DESIGN: Qualitative descriptive study with a grounded theory approach. SETTING: Hospital leaders, champions, and staff from hospitals in New Jersey and Georgia. PARTICIPANTS: A total of 21 nurses and physicians who worked at six hospitals shared their experiences with regard to implementation of the AWHONN PPH Project. METHODS: Interviews were recorded and transcribed verbatim. Analysis included open, selective, and theoretical coding with a constant comparative method of grounded theory. Analysis was complete when a central process emerged. RESULTS: Successful implementation of most or all of the program elements was facilitated by support from administrators, positive attitudes, active nurse and physician champions, and an existing culture of safety. When these elements were in place, respondents reported that they believed they made a difference. Barriers to implementation included negative attitudes, lack of champions, poor staff buy in, lack of resources, and lack of support from administrators. When barriers were encountered, respondents felt discouraged and disappointed. CONCLUSION: Although the road to full participation and implementation was difficult for some, lessons were learned by all. Suggestions for future projects include a step-by-step approach that begins with education, the creation and celebration of milestones, and the formation of teams to facilitate buy in and empowerment.

North American Nurses' and Doulas' Views of Each Other.

OBJECTIVE: To analyze factors that lead nurses and doulas to have positive views of each other. DESIGN: A multivariate analysis of a cross-sectional survey, the Maternity Support Survey. SETTING: Online survey with labor and delivery nurses, doulas, and childbirth educators in the United States and Canada. PARTICIPANTS: A convenience sample of 704 labor and delivery nurses and 1,470 doulas. METHODS: Multiple regression analysis was used to examine five sets of hypotheses about nurses' and doulas' attitudes toward each other. Scales of nurses' attitudes toward doulas and doulas' attitudes toward nurses included beliefs that nurses/doulas enhance communication, are collaborative team members, enhance a woman's birth experience, interfere with the ability to provide care, or interfere with relationships with the women for whom they care. RESULTS: For nurses, exposure to doulas in their primary hospitals was associated with more positive views, whereas working more hours, feeling overworked, and a preference for clinical tasks over labor support were associated with more negative views of doulas. For doulas, working primarily in one hospital and certification were associated with more positive views of nurses. Nurses with more positive attitudes toward common obstetric practices had more negative attitudes toward doulas, whereas doulas with more positive attitudes toward common obstetric practices had more positive attitudes toward nurses. CONCLUSION: Our findings show factors that influence mutual understanding and appreciation of nurses and doulas for each other. These factors can be influenced by educational efforts to improve interprofessional collaboration between these maternity care support roles.

Development of a Tool to Measure Nurse Clinical Judgment During Maternal Mortality Case Review.

National task forces have been charged to reduce maternal mortality rates. To do so, they must identify the role of the nurse in accomplishing this goal, but the specific assessments and interventions for which only nurses are responsible have yet to be defined. Clinical judgment, which is the ability to notice, interpret, and respond to potential problems, is a core nurse function. Nurse clinical judgment can be evaluated during chart review with new available tools.