Managing the tension between caring and charting: Labor and delivery nurses' experiences of the electronic health record.

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.

Career mobility of maternal care providers in Mali: a mixed method study on midwives and obstetric nurses.

BACKGROUND: An important strategy to reduce maternal and child mortality in Mali is to increase the number of deliveries assisted by qualified personnel in primary care facilities, especially in rural areas. However, placements and retention of healthcare professionals in rural areas are a major problem, not only in Mali but worldwide, and are a challenge to the health sector. The purpose of this study was to map the mobility of midwives and obstetric nurses during their work lives, in order to better understand their career paths and the role that working in rural areas plays. This article contributes to the understanding of career mobility as a determinant of the retention of rural health professionals. METHODS: A mixed method study was conducted on 2005, 2010, and 2015 cohorts of midwives and obstetric nurses. The cohorts have been defined by their year of graduation. Quantitative data were collected from 268 midwives and obstetric nurses through questionnaires. Qualitative data had been gathered through semi-structured interviews from 25 midwives and stakeholders. A content analysis was conducted for the qualitative data. RESULTS: Unemployment rate was high among the respondents: 39.4% for midwives and 59.4% for obstetric nurses. Most of these unemployed nurses and midwives are working, but unpaid. About 80% of the employed midwives were working in urban facilities compared to 64.52% for obstetric nurses. Midwives were employed in community health centers (CSCom) (43%), referral health centers (CSRef) (20%), and private clinics and non-governmental organizations (NGO) (15%). The majority of midwives and obstetric nurses were working in the public sector (75.35%) and as civil servants (65.5%). The employment status of midwives and obstetric nurses evolved from private to public sector, from rural to urban areas, and from volunteer/unpaid to civil servants through recruitment competitions. Qualitative data supported the finding that midwives and obstetric nurses prefer to work as civil servant and preferably in urban areas and CSRef. CONCLUSION: The current mobility pattern of midwives and obstetric nurses that brings them from rural to urban areas and towards a civil servant status in CSRef shows that it is not likely to increase their numbers in the short term in places where qualified midwives are most needed.

Listeriosis in Pregnancy: Practitioners' Food Safety Counselling Practices to Pregnant Women.

OBJECTIVE: The relative risk of invasive listeriosis in pregnant women is approximately 20 times greater than the general population, and listeriosis during pregnancy can have negative consequences for pregnant women, their fetuses, and their newborns. Health care providers are valuable sources of information, but published data suggest that most providers are unaware of the risk factors for listeriosis or its propensity for pregnant women, and they do not counsel their pregnant patients about risks. The objective of this study was to determine knowledge and practices of Canadian perinatal care providers on food safety counselling to pregnant women. METHODS: An anonymous bilingual online questionnaire that sought information about awareness, knowledge of risk factors, practices for counselling pregnant women, and practitioners' learning needs with regard to listeriosis was sent to 3199 nurses, midwives, family physicians, and obstetrician/gynaecologists in Canada, with a response rate of 24.4%. RESULTS: Most respondents had heard of listeriosis, provided prenatal care, and attended deliveries. Rates of awareness of listeriosis were the same among professions and were independent of years in practice, whether practice was urban or rural, and province. One third of the respondents (35.7%) were aware that listeriosis was more common in pregnant women; a minority (18.7%) correctly identified the incubation period for listeriosis and the stage in pregnancy in which women are at highest risk (30.4%). Those respondents who did not counsel women about the risks of listeriosis during pregnancy reported a lack of information or knowledge as the main reason. CONCLUSION: Advising pregnant women about behaviours and lifestyle habits to prevent infectious diseases remains important, and information about preventive practices needs to be complete and adequate. The health care providers who participated in this study did express a clear need for information related to food safety during pregnancy and listeriosis, as supported by their lack of knowledge in some areas. If that lack is remedied, the knowledge gained could improve counselling practices.

Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study.

BACKGROUND: Kenya has a maternal mortality ratio of 488 per 100,000 live births. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at delivery. Kenyan national statistics estimate that the proportion of births attended by a skilled health professional have remained below 50% for over a decade; currently at 44%, according to Kenya's demographic health survey 2008/09 against the national target of 65%. This study examines the association of mother's characteristics, access to reproductive health services, and the use of skilled birth attendants in Makueni County, Kenya. METHODS: We carried out secondary data analysis of a cross sectional cluster survey that was conducted in August 2012. Interviews were conducted with 1,205 eligible female respondents (15-49 years), who had children less than five years (0-59 months) at the time of the study. Data was analysed using SPSS version 17. Multicollinearity of the independent variables was assessed. Chi-square tests were used and results that were statistically significant with p-values, p < 0.25 were further included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were (95%) calculated. P value less than 0.05 were considered significant. RESULTS: Among the mothers who were interviewed, 40.3% (489) were delivered by a skilled birth attendant while 59.7% (723) were delivered by unskilled birth attendants. Mothers with tertiary/university education were more likely to use a skilled birth attendant during delivery, adjusted OR 8.657, 95% CI, (1.445- 51.853) compared to those with no education. A woman whose partner had secondary education was 2.9 times more likely to seek skilled delivery, adjusted odds ratio 2.913, 95% CI, (1.337- 6.348). Attending ANC was equally significant, adjusted OR 11.938, 95% CI, (4.086- 34.88). Living within a distance of 1- 5 kilometers from a facility increased the likelihood of skilled birth attendance, adjusted OR 95% CI, 1.594 (1.071- 2.371). CONCLUSIONS: The woman's level of education, her partner's level of education, attending ANC and living within 5kms from a health facility are associated with being assisted by skilled birth attendants. Health education and behaviour change communication strategies can be enhanced to increase demand for skilled delivery.

Maternity Nurses' Responses to Maternal Early Warning Criteria.

OBJECTIVE: The purpose of this study was to assess the influence of nursing care on implementing perinatal risk-appropriate care in the context of maternal early warning criteria. DESIGN: Medical record review and survey of maternity nurses in a three-hospital system in Wisconsin with two level I hospitals and 1 level III hospital. PARTICIPANTS: Seven maternity nurses from the level III hospital conducted the medical record reviews and all maternity staff nurses from two level I hospitals were invited to complete the survey. MEASUREMENTS: All medical records in 2017 that met these inclusion criteria: hypertension, sepsis, preeclampsia, hemorrhage, low Apgar scores, and transport were reviewed to assess identification and response time for maternal early warning signs using the Nurses Contribution to Maternal Mortality Worksheet. The survey included questions about influences on the nurses' confidence when interpreting early warning indicators. RESULTS: Thirty-two medical records met inclusion criteria and were reviewed. The number of maternal early warning signs recorded ranged from one to four, with a mean of 1.75 indicators. Eighty percent of records documented increased evaluation as a nursing response to the maternal early warning signs. Time-lapse between notifying a provider and bedside evaluation was less than 15 minutes in 54% of cases. Of the 31 eligible nurses, 18 completed the survey (58% response rate). Personal knowledge (90%) was reported by nurses as being the greatest influence on nursing confidence. Sixty-nine percent of nurses reported not receiving patient information from team members at the transporting hospital. CONCLUSION: A systematic record review by frontline nurses can monitor identification and response to maternal early warning signs. Feedback on patient transports can reinforce nurses' decision-making that has the potential to improve responsiveness to clinical warning signs.

Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda.

OBJECTIVE: To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC. STUDY DESIGN AND SETTING: This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio. RESULTS: On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates. CONCLUSION: The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.

Secondary Traumatic Stress Among Labor and Delivery Nurses.

PURPOSE: To describe the prevalence and severity of secondary traumatic stress (STS) among labor and delivery nurses within a Northeastern United States academic health system. STUDY DESIGN AND METHODS: Using a cross-sectional, descriptive correlational design, a convenience sample of labor and delivery nurses (288 nurses) were invited to complete Secondary Traumatic Stress Scale (STSS), a 17-item Likert-type instrument, that measures intrusion, avoidance, and the arousal symptoms associated with indirect exposure to traumatic events. Five additional questions about potential consequences of STS were also asked. RESULTS: N = 144 completed the survey (50% response rate). Average STSS score was 33.74 (SD, 11.8), with 35% of respondents meeting symptom severity scores associated with STS. STSS Scores ≥ 38 were significantly correlated with nurses considering leaving their jobs, calling out sick, or requesting an assignment change after witnessing a traumatic birth (p < 0.001). The majority of respondents (84.7%) reported witnessing a traumatic birth. After witnessing a traumatic birth, respondents used co-workers, family, and friends as sources of support. CLINICAL IMPLICATIONS: This study offers insight into the frequency and severity of STS among labor and delivery nurses, as well as the potential workforce-related consequences and provides a foundation for future work aimed at developing interventions to prevent or alleviate STS.

Interprofessional Simulation to Improve the Understanding of Obstetric Sepsis.

Sepsis parameters are not well defined for the obstetric population, which can result in delayed recognition. The escape room-based simulation sought to improve obstetric providers' and nurses' understanding, identification, and timely treatment of maternal sepsis. Participants expressed interest and enthusiasm in using this learning style to improve care of the sepsis patient. This intervention proved beneficial to staff development educators as an innovative and effective way to improve interprofessional engagement and promote knowledge of maternal sepsis.

'InUTERO': The effectiveness of an educational half day stillbirth awareness workshop for maternity care providers.

BACKGROUND: There is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women. OBJECTIVES: To gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice. DESIGN: A pre-post intervention study. SETTING: Maternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop. PARTICIPANTS: Maternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys. METHODS: A four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy. RESULTS: Stillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t 29 = 7.9, <0.001). Before the workshop, only 20% of participants responded that they "always" or usually" discussed the possibility stillbirth occurring with pregnant women in their care whereas, after the workshop, nearly all (88%) indicated that they planned to "always" discuss stillbirth with their pregnant clients. CONCLUSIONS: Attending a stillbirth awareness for prevention education workshop resulted in significant knowledge improvement and self-reported intention to change practice in a group of Australian maternity care providers. While these results are promising, further study is needed to determine the presence and extent of actual practice change following such education.

Quality of and barriers to routine childbirth care signal functions in primary level facilities of Tigray, Northern Ethiopia: Mixed method study.

BACKGROUND: Efforts to expand access to institutional delivery alone without quality of care do not guarantee better survival. However, little evidence documents the quality of childbirth care in Ethiopia, which limits our ability to improve quality. Therefore, this study assessed the quality of and barriers to routine childbirth care signal functions during intra-partum and immediate postpartum period. METHODS: A sequential explanatory mixed method study was conducted among 225 skilled birth attendants who attended 876 recently delivered women in primary level facilities. A multi stage sampling procedure was used for the quantitative phase whilst purposive sampling was used for the qualitative phase. The quantitative survey recruitment occurred in July to August 2018 and in April 2019 for the qualitative key informant interview and Focus Group Discussions (FGD). A validated quantitative tool from a previous validated measurement study was used to collect quantitative data, whereas an interview guide, informed by the literature and quantitative findings, was used to collect the qualitative data. Principal component analysis and a series of univariate and multivariate linear regression analysis were used to analyze the quantitative data. For the qualitative data, verbatim review of the data was iteratively followed by content analysis and triangulation with the quantitative results. RESULTS: This study showed that one out of five (20.7%, n = 181) mothers received high quality of care in primary level facilities. Primary hospitals (ß = 1.27, 95% CI:0.80,1.84, p = 0.001), facilities which had staff rotation policies (ß = 2.19, 95% CI:0.01,4.31, p = 0.019), maternal involvement in care decisions (ß = 0.92, 95% CI:0.38,1.47, p = 0.001), facilities with maternal and newborn health quality improvement initiatives (ß = 1.58, 95% CI:0.26, 3.43, p = 0.001), compassionate respectful maternity care training (ß = 0.08, 95% CI: 0.07,0.88, p = 0.021), client flow for delivery (ß = 0.19, 95% CI:-0.34, -0.04, p = 0.012), mentorship (ß = 0.02, 95% CI:0.01, 0.78, p = 0.049), and providers' satisfaction (ß = 0.16, 95% CI:0.03, 0.29, p = 0.013) were predictors of quality of care. This is complemented by qualitative research findings that poor quality of care during delivery and immediate postpartum related to: work related burnout, gap between providers' skill and knowledge, lack of enabling working environment, poor motivation scheme and issues related to retention, poor providers caring behavior, unable translate training into practice, mismatch between number of provider and facility client flow for delivery, and in availability of essential medicine and supplies. CONCLUSIONS: There is poor quality of childbirth care in primary level facilities of Tigray. Primary hospitals, facilities with staff rotation, maternal and newborn health quality improvement initiatives, maternal involvement in care decisions, training on compassionate respectful maternity care, mentorship, and high provider satisfaction were found to have significantly increased quality of care. However, client flow for delivery service is negatively associated with quality of care. Efforts must be made to improve the quality of care through catchment-based mentorship to increase providers' level of adherence to good practices and standards. More attention and thoughtful strategies are required to minimize providers' work-related burnout.

The completion of partograms: knowledge, attitudes and practices of midwives in a public health obstetric unit in Bloemfontein, South Africa.

INTRODUCTION: most maternal and 24.3% of infant deaths occur during childbirth. Interventions during childbirth may reduce maternal and neonatal deaths. The Guidelines for maternity care in South Africa (2015) stipulates that all observations during labour should be recorded on a partogram. The objective of this study was to assess the knowledge and attitudes of nursing personnel and to evaluate their practices of completing partograms at National District Hospital, South Africa. METHODS: a two-phase, quantitative, cross-sectional, descriptive study design was used. In phase 1, the knowledge and attitudes of midwives and nurses were evaluated. Midwives and nurses completed anonymous, self-administered questionnaires that assessed their knowledge and attitudes. In Phase 2, partogram practices were measured by assessing completed partograms using a data collection tick sheet. RESULTS: twelve of the 17 nursing personnel completed the questionnaires. More than 90% of participants answered basic partogram knowledge questions correctly, but only two thirds knew the criteria for obstructive labour and just more than half that for foetal distress. Participants displayed a positive attitude toward the use of partograms. Of the 171 randomly selected vaginal deliveries during the study period, only 57.1% delivered with a completed partogram. Most elements of foetal monitoring and progress of labour scored above 80%, however, for maternal monitoring scored poorly in 26.4% of cases. CONCLUSION: although 71.4% of partograms scored more than 75% for completion, the critical components that influence maternal and foetal death, like the identification of foetal distress, maternal wellbeing and progress of labour, were lacking.

Patient-level analysis of outcomes using structured labor and delivery data.

This paper presents methods for identifying and analyzing associations among nursing care processes, patient attributes, and patient outcomes using unit-level and patient-level representations of care derived from computerized nurse documentation. The retrospective, descriptive analysis included documented nursing events for 900 Labor and Delivery patients at three hospitals over the 2-month period of January and February 2006. Two models were used to produce quantified measurements of nursing care received by each patient. The first model considered only the hourly census of nurses and patients. The second model considered the size of nurses' patient loads as represented by computerized nurse-entered documentation. Significant relationships were identified between durations of labor and nursing care scores generated by the second model. In addition to the clinical associations identified, the study demonstrated an approach with global application for representing the amount of nursing care received at the individual patient level in analyses of patient outcomes.

Experiences Influencing upon the Significance of Obstetric Care in Mexican Nurses.

OBJECTIVES: This work sought to learn which and how are the professional experiences that influence upon significance processes of obstetric care in nurses working in toco-surgery rooms. METHODS: This was a qualitative study with grounded theory approach. Individual interviews were conducted with 16 nurses who work in two public hospitals in a border city in northern Mexico. Data analysis was performed according to that proposed by Strauss and Corbin. RESULTS: Four categories were identified that explain the relationship established among the professional experiences and the significance processes of obstetric care; these are: Dilution of borders and demand for interculturality, Modification in the scale of values associated to care, Institutional and public policy crises, and Violence endured within the work setting. Obstetric care is signified within an imaginary that recognizes the existence of a globalized context, which requests problematizing the worldview not of the "other" but of "many others", and not merely from those receiving care, but also from other professionals who participate in institutional care. CONCLUSIONS: Significance processes analyzed show how the socio-historical situation and current policy require new attitudinal skills and knowledge for nursing to participate efficiently in obstetric care.

Mapping midwifery and obstetric units in England.

OBJECTIVE: to describe the configuration of midwifery units, both alongside&free-standing, and obstetric units in England. DESIGN: national survey amongst Heads of Midwifery in English Maternity Services SETTING: National Health Service (NHS) in England PARTICIPANTS: English Maternity Services Measurements descriptive statistics of Alongside Midwifery Units and Free-standing Midwifery Units and Obstetric Units and their annual births/year in English Maternity Services FINDINGS: alongside midwifery units have nearly doubled since 2010 (n = 53-97); free-standing midwifery units have increased slightly (n = 58-61). There has been a significant reduction in maternity services without either an alongside or free-standing midwifery unit (75-32). The percentage of all births in midwifery units has trebled, now representing 14% of all births in England. This masks significant differences in percentage of all births in midwifery units between different maternity services with a spread of 4% to 31%. KEY CONCLUSIONS: In some areas of England, women have no access to a local midwifery unit, despite the National Institute for Health&Clinical Excellence (NICE) recommending them as an important place of birth option for low risk women. The numbers of midwifery units have increased significantly in England since 2010 but this growth is almost exclusively in alongside midwifery units. The percentage of women giving birth in midwifery units varies significantly between maternity services suggesting that many midwifery units are underutilised. IMPLICATIONS FOR PRACTICE: Both the availability and utilisation of midwifery units in England could be improved.

[Results of childbirth care at a birthing center in Belo Horizonte, Minas Gerais, Brazil]. / Resultados da assistência ao parto no Centro de Parto Normal Dr. David Capistrano da Costa Filho em Belo Horizonte, Minas Gerais, Brasil.

This was a descriptive and retrospective study of 2,117 deliveries from January 2002 to July 2003 at the Dr. David Capistrano da Costa Filho Birthing Center in Belo Horizonte, Minas Gerais, Brazil. Widespread questions have been raised concerning the quality of services provided at birthing centers by obstetric nurses. The results of the current study were: 11.4% maternal transfer rate; 2.2% cesarean sections; 1.2% neonatal ICU admissions; and 1% 5-minute Apgar scores below 7. Delivery dystocia and the request for epidural anesthesia were the main reasons for maternal transfer, and respiratory distress was the main cause of neonatal ICU admission. Corrected neonatal mortality was 2 per 1,000 live births. The results at this birthing center did not differ significantly from those in a review of the international literature. The most striking finding was the low cesarean rate. Comparative studies and more comprehensive national data on low-risk gestations are needed.

Multidisciplinary In Situ Simulation-Based Training as a Postpartum Hemorrhage Quality Improvement Project.

BACKGROUND: Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries, with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong teamwork and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemorrhage following our multidisciplinary in situ simulation training exercise. METHODS: This was a quality improvement project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services completed the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improvements. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to measure participant comfort. A paired t test was used to assess differences in participant responses before and after the simulation exercise. We also measured the time to prepare simulated blood products and followed the number of postpartum hemorrhage cases before and after the simulation exercise. RESULTS: We trained 113 health care professionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assistants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score was 4.14 compared to a pretraining mean score of 3.88 (p = 0.01, 95% confidence interval [CI] = 0.06-0.47). For shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 (p = 0.001, 95% CI = 0.41-0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining mean score of 3.86 (p = 0.001, 95% CI = 0.36-0.63). We also observed a decrease in the time to prepare simulated blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which continued after initiating the postpartum hemorrhage simulation exercise. DISCUSSION: Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex, the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as postpartum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to practice skills and improve systems processes in the health care setting.

Mapping the literature of maternal-child/gynecologic nursing.

OBJECTIVES: As part of a project to map the literature of nursing, sponsored by the Nursing and Allied Health Resources Section of the Medical Library Association, this study identifies core journals cited in maternal-child/gynecologic nursing and the indexing services that access the cited journals. METHODS: Three source journals were selected and subjected to a citation analysis of articles from 1996 to 1998. RESULTS: Journals were the most frequently cited format (74.1%), followed by books (19.7%), miscellaneous (4.2%), and government documents (1.9%). Bradford's Law of Scattering was applied to the results, ranking cited journal references in descending order. One-third of the citations were found in a core of 14 journal titles; one-third were dispersed among a middle zone of 100 titles; and the remaining third were scattered in a larger zone of 1,194 titles. Indexing coverage for the core titles was most comprehensive in PubMed/MEDLINE, followed by Science Citation Index and CINAHL. CONCLUSION: The core of journals cited in this nursing specialty revealed a large number of medical titles, thus, the biomedical databases provide the best access. The interdisciplinary nature of maternal-child/ gynecologic nursing topics dictates that social sciences databases are an important adjunct. The study results will assist librarians in collection development, provide end users with guidelines for selecting databases, and influence database producers to consider extending coverage to identified titles.