News: PQI Profiles

How One Nurse Scientist is Exploring Nurse-Level Cesarean Rates for Quality Improvement

Tuesday, June 16, 2020  
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By Siena Davis, MPH, Project Manager, PQI

This Q&A is a follow-up to the PQI Champions webinar titled “Using Nurse-Level Cesarean Rates for Quality Improvement” by Joyce K. Edmonds, PhD, MPH, RN.


Dr. Joyce Edmonds is an Associate Professor at Boston College's WF Connell School of Nursing. She has over fifteen years’ experience in nursing and public health practice and research focused on maternal health outcomes. Dr. Edmonds has a research appointment with the Munn Center for Nursing Research at Massachusetts General Hospital and is an Affiliate at Ariadne Labs leading the Nurse Impact Portfolio with the Delivery Decisions Initiative team. She teaches public health and population health courses at Boston College, is an Editorial Board Member of JOGNN, and is Chair-elect of the American Public Health Association Public Health Nursing Section.


Can you briefly describe your research related to using nurse-level cesarean rates for quality improvement?


“I have been investigating how to measure the influence of labor and delivery nurses on birth outcomes and factors that shape Registered Nurses’ practice patterns. The goals of my program of research is to support physiological childbirth to improve quality and equity of maternity care services.”


Why does measuring RN cesarean birth rates matter?


“Widespread variation in clinical practices are routinely observed in health care and obstetrics is no exception. We also know that nursing care is essential to ensuring patient safety and quality. As a self-governing profession, we need to monitor our practice in ways that are meaningful particularly in light of the increased demand from the public and payers for accountability and transparency about clinical processes that affect patient outcomes at the hospital-level. Nurse-level cesarean birth rates is a particularly meaningful metric because it aligns with national as well as provider unit level initiatives across the United States.”


What are the primary challenges of measuring RN cesarean birth rates?


“There are a few measurement considerations inherent in calculating and interpreting cesarean birth rates. The effort is dependent on hospital specific context such as the composition of the nursing staff, the model care delivery, birth volume and nurse documentation systems need to be considered.


Despite the challenges, it’s a worthwhile endeavor. While we do operate in a team environment, and that’s critical, nurses aren’t interchangeable. They have unique strengths and skill sets, even within a team. To have knowledge of the effect of each individual RN means you’re your care matters. This can be really empowering with the potential of impacting decisions about patient assignments, for example.”


What are the pros and cons of measuring RN cesarean birth rates?


“I think measuring RN practices can promote individual and team accountability and increase data literacy among nurses. I think there is the potential to stimulate engagement and inquiry into continuous quality improvement and it aligns nurses with national and department QI initiatives.


I think the information must be contextualized. While it’s important to think about the individual level practices of RNs, the goal is not only to target specific changes in individual practices but also to improve the systems that support high-quality safe nursing care. Measuring RN practices is a potential gateway to having additional insights into the broader context in which nurses are working. The practice environment or context is very influential on nursing behaviors. For example, environments that lack resources like adequate nurse staff and equipment will be faced with more stressors and less time to be with their patients.



The following questions were asked by participants during the Q&A session of the PQI Champions Webinar.


What criteria do you use to determine which nurse owns the outcome for a cesarean birth?


“Attribution is the method of assigning responsibility for patient outcomes to a specific health care provider. Across the board, in all specialties with all types of providers, this is a challenge. There have been several ways that we have approached attribution. The most readily accessible nurse identity timepoint in the labor and delivery is the nurse who supported the birth. But that is commonly criticized because it doesn’t reflect the complexity of patterns or intensity of nursing care over the course of a woman’s labor. The concern is that the nurse attributed to the mode of birth may not be the nurse who most influenced whether there was a cesarean or vaginal birth. An ideal standard for attribution would include length of nursing care and quality of care.


In the webinar, I presented a few studies. We looked at the nurse at admission, the nurse during labor management (defined as the nurse who spent the greatest amount of time with the patient – what they call the “majority of care rule”) and then, the nurse at the point of delivery. In the future, we would like to explore at multiple attributions.


When considering the tradeoffs of different attribution methods, it is important to remember that we are not suggesting that nurses are solely responsible. They are part of a much bigger picture. It’s really about bringing them into that conversation and empowering them with their own data to stimulate inquiry into practice. We are not establishing cause and effect.


In your research, are you using balancing measures, such as Apgar scores?


“Balancing measures are important in terms of maternal and fetal outcomes. Adverse events are rare so you can often cannot drill down to the individual level in any meaningful way. At the unit level you can look at the Joint Commission’s PC-06 Measure or Unexpected Complication in Term Newborns, which is the recommended balancing measure to PC-02. We have not yet looked at balancing measures. I think it’s an important next step.”


Would some nurses work for a vaginal birth in situations where a cesarean births might be indicated?


“Cesarean births are a critical lifesaving procedure. A very unintended consequence of working to reduce cesarean births would be that nurses would delay responding to a life-threatening situation or a difficult labor or fetal heart rate pattern because they didn’t want their cesarean birth rates to increase. I don’t see that happening. Within the context of really good leadership and management, that positive environment and management structure that’s really fostering a culture of continuous quality inquiry is what’s important.”


What impact does shift working have on cesarean birth rates? Some hospitals have fewer cesarean deliveries called at night than during day.


“That’s really interesting. That would be one dimension that you could look at. You could calculate individual-level nurse rates and aggregate them at the shift level to look at means, or the distribution, between day and night shift.”


During the webinar, you mentioned that physicians have said, “If the hospital is going to publish my cesarean rates, then I want to pick my nurses.” Could you give a reference for this quote?


“There’s anecdotal feedback from our physician colleagues that there are some nurses that are better at facilitating safe vaginal births in certain types of patients than others. Physicians are aware of the influence that nurses have and that some are better at supporting vaginal birth than others. Just like, nurses have insight into physician practice patterns.”


Is there anything else you would like to add?


“I would love to hear from hospital-leaders currently calculating nurse-level rates about their experience. I would also love to hear from hospital leaders who are interested in measuring RN cesarean birth levels for quality improvement purposes. I’ve been thinking about coming up with a one-page self-assessment questionnaire to determine hospital readiness to abstract and use the data needed for this metric for QI purposes.”

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