A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center.

BACKGROUND: Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs. METHODS: We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively. RESULTS: Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs. CONCLUSIONS: Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.

A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses' Work During Clinical Emergencies.

BACKGROUND: Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration. METHODS: The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190. FINDINGS: Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians' multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet. CONCLUSION: Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.

Systems-Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration.

BACKGROUND: Maternal morbidity and mortality are at their highest recorded levels in the United States, with more than 50% of maternal deaths deemed preventable. Women in labor often experience gradual morbidity, but signs of worsening condition may not be noticed by clinicians. Nurses are well-positioned to notice these signs, but performance obstacles inhibit nurses' work. There is scant literature describing the obstetric work system. This study sought to identify the systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration. METHODS: A convergent parallel mixed methods design combining survey data from the adapted Performance Obstacles for ICU Nurses instrument and semistructured interviews with registered nurses, certified nurse midwives, and physicians was used. Data were collected on the labor and delivery floor of a tertiary care center in Boston from July 2021 through August 2021. Interviews were coded using Bradley's integrated deductive and inductive methods and the Systems Engineering Initiative for Patient Safety (SEIPS) categories. RESULTS: Data included 46 surveys and 16 interviews. Identified performance obstacles were in the categories of tasks, tools and technology, and physical environment. Emergent themes included swamped, feeling inadequate, and is this safe? CONCLUSION: Issues with task overload, tools, and technology inhibit nurses' abilities to respond appropriately to women in labor who experience clinical deterioration. Emergent themes imply a relationship between task overload and burnout. Health care administrators should improve staffing, decrease nurse task load, and include bedside nurses in the redesign of tools and technology to mitigate the harms of performance obstacles.

Prevention of Failure to Rescue in Obstetric Patients: A Realist Review.

BACKGROUND: At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue. AIMS: To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events. METHODS: A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety. RESULTS: Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork. LINKING EVIDENCE TO ACTION: Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.

Correction: Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

[This corrects the article DOI: 10.2196/25070.].

Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

BACKGROUND: The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. OBJECTIVE: The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar's general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. METHODS: To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. RESULTS: We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. CONCLUSIONS: With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.