Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK.
School of Nursing and Healthcare Professions, Federation University, Ballarat, Australia.
BMC Pregnancy Childbirth. 2019 Sep 9;19(1):331. doi: 10.1186/s12884-019-2487-0.
In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman's care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres?
Focus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach.
Factors influencing midwives' care escalation decisions included the care environment, a woman's diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used 'workarounds' to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable.
Findings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.
在英国，助产士将与多学科团队讨论，他们是否可以在分娩室提供产科高度依赖护理（OHDC），还是应该将女性的护理升级到重症监护团队。本研究旨在探讨以下问题：哪些因素会影响助产士提供 OHDC，或要求将护理从远离三级转诊中心的医院产科单位升级？
在英格兰的三个产科单位进行了焦点小组讨论，这些单位的年度出生率在每个产科单位的 1500 至 5000 人之间，在地区综合医院中进行。使用三个视频短片交接场景作为焦点小组的触发因素。情景 1：严重子痫前期，生理不稳定；2：产后大出血需要侵入性监测；3：最近入院的胸痛妇女，接受面部吸氧，需要连续心电图（ECG）监测。每个产科单位进行了两个焦点小组，由经验丰富的助产士参加。使用定性框架方法对数据进行分析。
影响助产士护理升级决策的因素包括护理环境、女性的诊断和胎儿或新生儿因素。整体护理计划，包括需要 ECG 和侵入性监测，也是影响因素。最小的产科单位的助产士没有提供 OHDC 的设施。较大的产科单位的助产士提供 OHDC，但确定了不同程度的技能，有时会使用“权宜之计”来促进护理的提供。助产士人员配置水平、技能组合和工作量也是影响因素。在同一个产科单位工作的助产士之间存在一些意见分歧，例如是否可以提供 OHDC，以及他们将寻求哪些支持来帮助他们提供护理。对临床指南的依赖似乎存在差异。
研究结果表明，在当地一级可能存在不公平的 OHDC 供应。需要建立组织上健全的系统，以促进安全、公平的 OHDC 护理，包括为助产士提供技能发展和精确的升级指南，以尽量减少权宜之计。对助产士的培训必须包括防止技能衰退的策略。
