Standardizing the Words Nurses Use to Document Elements of Perinatal Failure to Rescue

摘要

Objective: To reach consensus for words used by nurses to document elements of a perinatal failure to rescue process measurement tool. Design: Exploratory study with mixed methods. Setting: Virtual. Participants were recruited through an online perinatal nursing discussion list and completed Internet-based electronic surveys. Participants: Twenty-nine (29) labor and delivery nurses with at least 5 years of bedside nursing experience and additional expertise in fetal heart monitoring. Methods: Modified Delphi study with three rounds. Qualitative methods were used to analyze study results for round one. Rounds 2 and 3 were analyzed quantitatively with a desired level of consensus of 75%. Results: Twenty-seven of 29 participants completed all three study rounds. Seventy-six distinct data elements related to careful monitoring, timely identification of problems, appropriate intervention, and activation of a team response were defined by consensus. Because classification of maternal and fetal risk determines assessment frequency in labor, specific criteria for classifying a woman or fetus as high risk or low risk were included in the definitions for which participants reached consensus. Conclusion: Achieving consensus about the actual words used to document perinatal nursing elements provides the foundation for incorporating paper-based process measurement tools, such as perinatal failure to rescue (P-FTR) into electronic documentation systems. Standardizing the words perinatal nurses use in documentation facilitates data retrieval and analysis and increases the usefulness of process measurement tools such as perinatal failure to rescue. Further, building process measurement tools into electronic systems may facilitate real-time rather than retrospective recognition of process deficiencies and improve perinatal outcomes.