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  • Writer's pictureJeanette Zocco

The Perinatal Safety Nurse Role: A key feature in a comprehensive perinatal safety program

Updated: Mar 23

Teamwork
Teamwork

A robust perinatal safety program is multifaceted and interdisciplinary, incorporating the following components: quality improvement methodologies, implementation and human factors science, data analysis, safety bundle/evidence-based protocols, safety event review and investigation, multidisciplinary simulation, and work around TeamSTEPPS, culture of safety, and health equity.  All of this work takes a village and requires ongoing collaboration between multidisciplinary frontline staff and hospital administration. Physician and nursing leadership face many barriers in getting this work accomplished. Staffing shortages, minimal administrative time for project work, competing priorities, and lack of personnel to do the work are all examples of these barriers. As such, there is a significant need for a dedicated nurse leader, whose sole focus is on patient quality and safety efforts in collaboration with a multidisciplinary team. This article discusses the main role responsibilities, areas of focus, and the value of a dedicated perinatal safety nurse as a key feature in a comprehensive perinatal safety program. 


Current State: Maternal Morbidity and Mortality

Data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System has shown that the risk of pregnancy-related death in the United States is unacceptably high. Complications in pregnancy resulting in death, impact approximately 700 women per year (Peterson et al., 2019). These may have occurred during the pregnancy, around the time of birth, and through the first year post-delivery. Further investigation conducted by statewide mortality review committees has shown that approximately sixty percent of patient deaths were preventable, with contributing factors identified in the following areas: community (transportation difficulties), hospital-specific (inexperience managing obstetric emergencies), patient (inadequate knowledge of maternal early warning signs), provider (failure to diagnose) and system-related (insufficient access to care) (Peterson et al., 2019).  


Severe maternal morbidity, defined as “unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a woman’s health” has also markedly increased in the United States (Kilpatrick & Ecker, 2016, para 2). It occurs more often than maternal mortality, has similar findings of high preventability, and is worthy of equal attention. Some cases of severe maternal morbidity can also be considered as near misses that could have led to maternal death, without appropriate recognition and treatment (Kilpatrick & Ecker, 2016). 


In addition, literature has shown racial and ethnic disparities are significant contributors to both severe maternal morbidity and mortality. Mortality data has demonstrated that non-Hispanic Black women and American Indian/Alaska Native women are 3.2 and 2.3 times more likely to die than their non-Hispanic White counterparts (Ahn et al., 2020).  Morbidity data has shown that women in every racial and ethnic minority classification have significantly higher delivery complications compared to non-Hispanic white women (Admon et al, 2018). 


Key takeaways from this data demonstrate (1) preventability as the prevailing theme, (2) the need for more concerted quality and safety efforts to be taken, and (3) programs aimed at reducing racial and ethnic disparities. In response, many acute care hospitals and healthcare systems have implemented comprehensive perinatal safety programs to reduce preventable harm and improve maternal and neonatal outcomes (Lyndon et al., 2015). The Perinatal Safety Nurse (PSN) Role has evolved as a salient feature of a robust perinatal safety program. 


Real-Time Surveillance: Boots on the Ground Approach

While role responsibilities may differ among organizations, depending on nurse leader team composition, areas of expertise, and hospital resources such as data support or project management, having a boots-on-the-ground approach is an essential aspect of the PSN position. 


This role can be described as having one foot in the administration suite and one foot on the unit, providing real-time support for quality initiatives, and overall patient safety. Real-time support involves overseeing initiative implementation and role modeling safety and advocacy behavior. In implementing a new process, the PSN provides prompting, serves as a resource, and can help troubleshoot any issues that arise on the spot. They also monitor processes through auditing, data analysis, and real-time observation to ensure initiative maintenance. 


On-going support for patient safety includes encouraging a safe environment for raising concerns, demonstrating effective communication, and facilitating open and respectful dialogue when team disagreements occur. This is also the responsibility of all administrators in promoting a culture of safety and effective communication (Lyndon 2015). However, “Organizations that dedicate personnel specifically to team training, patient-safety programs, and tracking outcomes in real-time are much more successful in implementing and sustaining team-focused patient-safety initiatives” (Lyndon et al., 2015, p. 346-347). 


Another aspect of unit presence involves regularly connecting with frontline staff, nurse, and physician leaders, which allows for identifying current and imminent threats. This could include attending unit huddles, team meetings, or safety walk rounds (Raab et al., 2011). Equally important is simply getting to know people, personally and professionally, and understanding what is important to them. Relationship building in this manner strengthens trust and encourages discussion of safety concerns. This boots-on-the-ground approach, with attention to quality and safety oversight, advocacy, and team support, helps to promote a culture of safety. 


Primary Driver: Quality Improvement Programs 

As a primary driver of quality improvement initiatives and national safety bundles, the PSN should have an understanding of different quality improvement methodologies including but not limited to Lean, Six Sigma, and the IHI Model for Improvement. Understanding these methodologies allows one to implement a project through all phases: engaging key stakeholders, systematically evaluating for gaps/opportunities, identifying viable solutions, initiating small-scale testing followed by large-scale implementation, and integrating sustainability plans. Using data to drive the work helps to determine if (1) processes have been integrated into practice (we are doing what we intended to do) and (2) the changes implemented have resulted in improvement. Inherent in this work is an understanding of change management and the dynamics of working with multidisciplinary teams. 


The PSN approach should include viewing quality improvement and safety work through the lens of human factors science. Human factors science evaluates human behavior, thinking, and physical abilities and limitations, and develops solutions to support these abilities and limitations. Factors studied include lighting, noise level, distractions, interruptions, equipment design, stress, fatigue, staffing, patient census/acuity, workarounds, technology, teamwork, and culture. Incorporating human factors science into quality improvement work, whether it’s applied to a new process change, or used in evaluation after a safety event or error has occurred, can help to design a workplace in which errors are reduced, work processes are improved, and systems of care become safer. Ultimately, this approach can help develop processes that make it easier for frontline staff to do the right thing. 


Data Monitoring

There are different aspects of data collection and analysis that the PSN may be involved with. Collecting and maintaining data related to root cause analyses or safety event investigations conducted, including identified themes and corrective action plans has been described as a responsibility of the PSN by Raab et al., (2011). 


Often data is collected from several sources, such as coded data provided by external organizations (National Perinatal Information Center, or Premier) and data collected from electronic medical records (EMR). Each has pros and cons. For instance, coded data is typically delayed because it takes time to code and export.  It is dependent on accurate provider documentation and coding. If opportunities for improvement are noted in these areas, they can be improved through collaboration with both coding and provider teams. Data from the EMR is dependent on staff inputting complete and accurate data. Teams must decide which data source to monitor. 


An essential component of the PSN role is ensuring accuracy of the data, and reviewing patient cases to understand the patients that compose the metric. Deep dives often reveal repeat themes and areas of opportunity. Next steps involve bringing this information to a multidisciplinary team, assessing strengths and opportunities, looking for trends, and benchmarking against national data and/or targets. This assists in understanding where hospitals may stand out as performing well or needing improvement, thus driving targeted improvement efforts.  


Facilitating  Multidisciplinary Team Training and Simulation Programs

A team training program, such as TeamSTEPPS, is foundational in building a culture of safety. TeamSTEPPS curriculum includes advocacy, conflict resolution, and daily communication events that facilitate effective communication, shared mental models, and risk-mitigation strategies. The PSN role is integral to this work, as a master trainer and in continued sustainment plans. For instance, threading this curriculum into other types of education and forums, such as multidisciplinary simulation, fetal heart monitoring strip reviews, weekly newsletters, and staff meetings helps to reinforce the concepts. 


Simulation training uses manikins, task trainers, or standardized patients in high-risk low-frequency type events. These drills allow team members to practice the necessary clinical skills and team communication to effectively manage these situations. Shoulder dystocia, maternal cardiac arrest, emergency cesarean delivery, eclamptic seizure, and obstetric hemorrhage are all examples of scenarios that can be practiced. In addition, simulation allows team members to apply muscle memory to a new process/workflow. The PSN role is to facilitate simulation training (Raab et al., 2011). 


In summary, all team members own a piece of quality and safety work. However, there is a need for a dedicated PSN role whose sole focus is on patient quality and safety efforts in collaboration with a multidisciplinary team. This decentralized quality model allows for a boots-on-the-ground approach with close surveillance and real-time support of the work. 


*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on Amazon, click below to access:



Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS


References


Admon L., Winkelman T., Zivin K.,Terplan M., Mhyre J., & Dalton V. (2018) Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012–2015. Obstetrics & Gynecology 132(5), 1158-1166. DOI: 10.1097/AOG.0000000000002937


Ahn R., Gonzalez G., Anderson B., Vladutiu C., Fowler E., & Manning L. (2020). Initiatives to Reduce Maternal Mortality and Severe Maternal Morbidity in the United States

Annals of Internal Medicine, https://doi.org/10.7326/M19-3258

Kilpatrick S., & Ecker J. (2016). Severe maternal morbidity: screening and review. American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, 215(3), B17-B22. https://doi.org/10.1016/j.ajog.2016.07.050.


Lyndon A., Johnson C., Bingham D., Napolitano P., Joseph G., Maxfield D., O’Keeffe D. (2015) Transforming Communication and Safety Culture in Intrapartum Care: AMulti-Organization Blueprint. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(3), 341-349. DOI: 10.1111/1552-6909.12575


Petersen EE, Davis NL, Goodman D, Cox S, Mayes N, Johnston E, Syverson C, Seed K, Shapiro-Mendoza CK, Callaghan WM, & Barfield W. (2019). Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017. Morbidity and Mortality Weekly Report, 68(18), 423-429. doi: 10.15585/mmwr.mm6818e1. 


Raab C., Palmer-Byfield R. (2011).The Perinatal Safety Nurse: Exemplar of Transformational Leadership. MCN, The American Journal of Maternal/Child Nursing, 36(5), 280-7. DOI:10.1097/NMC.0b013e31822631ec



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