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

Abstract

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. 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. 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? 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.