Modified Delphi Study on Nursing Practice and Science in Fetal Care

ObjectiveTo identify essential structures, processes, outcomes, and challenges of nursing practice in fetal care and to identify research priorities for nurses in fetal care.DesignWe used a modified Delphi method to achieve consensus.SettingA secure online survey platform.ParticipantsThe expert panel included nurses from the Fetal Therapy Nurse Network. In addition, a multidisciplinary research jury included members of the North American Fetal Therapy Network (NAFTNet).MethodsWe collected data in three consecutive rounds with online questionnaires that were e-mailed to panelists. We used content analysis to generate statements from an initial round of open-ended questions. Statements met consensus if 75% of the panelists ranked it as greater than or equal to 6 on a 1-to-7 Likert scale.ResultsThe 48 nurse panelists and 11 multidisciplinary jury members described a range of nursing processes. Consensus was reached on 96 statements related to the structure, processes, outcomes, and research priorities of nurses in fetal care.ConclusionThe participants agreed that an expert fetal care nursing team is necessary to provide care to women and families during fetal diagnosis and treatment. Ideally, these nurses should coordinate care and provide direct clinical care (e.g., patient counseling) in outpatient prenatal settings and inpatient settings when fetal surgery is involved. Nurses should be supported to take on leadership roles in program development, research, quality improvement, and professional development with relevant professional organizations.     

Assessment Tool for Total Laparoscopic Hysterectomy: A Delphi Consensus Survey Among International Experts

ObjectiveTo achieve consensus among experts on the essentials steps to include in an assessment tool for total laparoscopic hysterectomy.MethodsUsing a Delphi consensus process, an initial survey was created based on the current literature and local expertise in laparoscopic surgery and sent to international experts in laparoscopic gynaecology. Experts were selected according to specific criteria. A second survey was formulated based on the answers and comments from the first round and sent to all experts who participated in the first round. Consensus was defined as a Cronbach alpha ≥ 0.80. A rate of agreement ≥ 0.70 was used to define which substeps to keep in the final tool.ResultsFrom the 85 experts invited to participate, 53 (62%) agreed to participate, and 51 of these participated in both rounds. The final instrument to assess total laparoscopic hysterectomy was created using the items with a high level of agreement after two rounds. This final tool showed good internal consistency among the experts, with a Cronbach alpha of 0.90.ConclusionUsing a Delphi methodology, we achieved international consensus among experts in laparoscopic gynaecology within a short time frame and with minimal costs. The resulting evaluation tool for total laparoscopic hysterectomy may serve in the assessment of surgical skills in the future, and would be a valuable adjunct to postgraduate training and continuing medical education programs. This tool will now undergo a validation process, comparing the rating scores of novices and experts surgeons.     

Identification of Essential Steps in Outlet Forceps-Assisted Vaginal Delivery: A Delphi Study

ObjectiveTo achieve expert consensus using the Delphi methodology on the sub-steps considered essential in an outlet forceps-assisted vaginal delivery (FAVD). The purpose of this work is to help inform a framework for standardized training and objective assessment in the procedure.MethodsA Delphi survey was conducted with an international panel of experts in FAVD. Using an online platform, experts rated sub-steps of FAVD on a 5-point Likert scale to indicate whether they considered them essential. Responses were returned to the panel until consensus was reached (Cronbach α ≥ 0.80) with an intraclass correlation coefficient ≥0.75. All sub-steps with a rate of agreement ≥80% are proposed to be included in a future evaluation instrument.ResultsAfter the first iteration of the Delphi procedure, a response rate of 42% was reached (n = 21); the second iteration was only sent to those who had participated in the initial iteration, reaching a response rate of 100%. Of 42 sub-steps rated in the first round, 24 (57.1%) achieved consensus, 8 (19%) were rejected, and 10 (23.8%) were re-rated in the second round. After 2 iterations, 28 sub-steps were agreed upon by the experts to be essential in FAVD.ConclusionsA panel of experts identified a total of 28 sub-steps essential to FAVD. This list could inform the development of an objective assessment framework and evaluation tool for this procedure. Further research should focus on the standardization, applicability, validation, and introduction of this tool in medical training, with a focus on real-life, high-fidelity simulation and online educational tools.     

Low Levels of Knowledge and Preventive Practices Regarding Vertical Hepatitis B Transmission among Perinatal Nurses

ObjectiveTo evaluate current levels of hepatitis‐B‐related knowledge and clinical practice among perinatal nurses.DesignCross‐sectional study.SettingSanta Clara County, California, home to one of the largest U.S. populations at risk of perinatal hepatitis B transmission.ParticipantsPerinatal nurses (N = 518) from eight birthing hospitals.MethodsIn 2008–2010, nurses completed a baseline survey evaluating existing hepatitis‐B‐related knowledge and preventive clinical practices, participated in an educational seminar, received instructional materials about hepatitis B, and completed a follow‐up knowledge survey.ResultsEighty percent of perinatal nurses had provided health care to a pregnant woman with chronic hepatitis B, but only 51% routinely provided patients with educational information about hepatitis B. While 75% routinely informed patients about effective methods to prevent mother‐to‐child transmission, only a small minority (17–34%) educated infected women about standard recommendations for protecting themselves and household members. One fourth or fewer nurses correctly answered most questions about hepatitis B prevalence, risks, and symptoms. After the educational seminar, knowledge increased statistically significantly.ConclusionExisting knowledge about hepatitis B is limited, and nationally recommended preventive clinical practices are commonly overlooked by perinatal nurses. This lack of knowledge and preventive care represents a noteworthy gap and an opportunity for targeted training and education to improve perinatal hepatitis B prevention and medical management of infected mothers.     

What should a website dedicated to the postnatal period contain? A Delphi survey among parents and professionals

ObjectivesMothers have a great need for information during the postnatal period. Trying to meet this need, mothers are increasingly turning to the Internet. Nevertheless, many women have stated that they often or always found that the information that they found on the Internet was incomplete or wrong. Many women therefore believe that health professionals should suggest reliable Internet websites for new mothers. The aim of this study was therefore to find a consensus on the content of a reliable and centralized website dedicated to mothers from the end of pregnancy to 1 year after childbirth.DesignTwo rounds of an online Delphi survey were used in this study.Setting and participantsThe panel of participants involved in the survey included parents (both mothers and fathers) and professionals (health professionals and professionals of early childhood for mothers of children aged 0 to 2 years).FindingsNinety-six parents and professionals participated in the first round (37.7 ± 9.76 years; 84.4% of women) and 78 in the second round. The majority of participants (94.6%) thought that a centralized website could help mothers from pregnancy to one year after childbirth. The content that the experts would like to find on a website were themed into five categories: “infants’ information”, “parents’ information”, “administrative information”, “professionals’ information” and “type of resources”. In each category, experts highlighted the key words that they found important and should be reported on the website. The most important items highlighted by participants were baby’s feeding/breastfeeding (92.8%), babies’ needs (84.1%), baby blues (77.9%), postpartum depression (72.1%), management of the couple’s relationship (72.1%), women's right to postnatal care (83.6%), links to reliable documents (63.9%) and a list of useful contacts (52.5%).ConclusionsThis study helped to understand the questions that mothers ask themselves during the postpartum period and provided priorities to respond to their questions in the process of developing a website.     

Expert Consensus Building using e‐Delphi for Necrotizing Enterocolitis Risk Assessment

ObjectiveTo confirm content validity of GutCheck^NEC, a risk index for necrotizing enterocolitis (NEC) and to determine the level of agreement among experts about NEC risk factors in premature infants.DesignElectronic Delphi method (e‐Delphi).SettingOnline electronic surveys and e‐mail communication supported by an interactive study website.ParticipantsNurses and physicians (N = 35) from four countries and across the United States who rated themselves as at least moderately expert about NEC risk.Methodse‐Delphi involved three rounds of surveys and qualitative thematic analysis of experts’ comments. Surveys continued until criteria for consensus and/or stability were met.ResultsOf 64 initial items, 43 were retained representing 33 risk factors (final GutCheck^NEC Content Validity Index [CVI] = .77). Two broad themes about NEC risk emerged from 242 comments: the impact of individual physiologic vulnerability and variation in neonatal intensive care unit (NICU) clinicians’ practices. Controversy arose over the impact of treatments on NEC, including probiotics, packed red blood cell (PRBC) transfusions, and patent ductus arteriosus (PDA) management using indomethacin.ConclusionGutCheck^NEC achieved borderline content validity for a new scale. The e‐Delphi process yielded a broad perspective on areas in which experts share and lack consensus on NEC risk. Future testing is underway to reduce the number of risk items to the most parsimonious set for a clinically useful risk tool and test reliability.     

Guideline-based quality indicators for early pregnancy assessment units

Research questionWhat valid guideline-based quality indicators can measure quality of care in early pregnancy assessment units (EPAU)?DesignThe systematic RAND-modified Delphi method was used to develop an indicator set from four evidence-based guidelines. An international expert panel was assembled to extract recommendations from these guidelines to establish quality indicators.ResultsA total of 119 recommendations were extracted. Eleven recommendations received a high median score and top five score above the 75th percentile and were selected as key recommendations. The expert panel reassessed 15 high score recommendations and top five score between the 50th and 75th percentile as well as one high score recommendation without consensus. Eight of these 16 recommendations were selected in the second round as key recommendations. The key recommendations were formulated into a set of 19 quality indicators, summarized as follows: women referred to an EPAU could be seen within 24 h and receive a clear explanation on treatment options; designated senior staff members could be responsible for the unit and staff could have had ultrasound training; protocols could be available for daily practice covering all treatment options for miscarriage and ectopic pregnancy; and an EPAU could have access to urine pregnancy testing and serum HCG assays.ConclusionsNineteen quality indicators to measure early pregnancy care provided by EPAU were identified.     

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

ObjectiveTo reach consensus for words used by nurses to document elements of a perinatal failure to rescue process measurement tool.DesignExploratory study with mixed methods.SettingVirtual. Participants were recruited through an online perinatal nursing discussion list and completed Internet-based electronic surveys.ParticipantsTwenty-nine (29) labor and delivery nurses with at least 5 years of bedside nursing experience and additional expertise in fetal heart monitoring.MethodsModified 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%.ResultsTwenty-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.ConclusionAchieving 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.     

Factors Associated with Unwanted Pregnancy among Adolescents in Russia

Study ObjectiveTo identify social and behavioral factors associated with unintended pregnancy among adolescents in Russia.DesignCross-sectional.Setting and ParticipantsThe investigation group consisted of 145 adolescents aged 15-19 years admitted to a youth-friendly clinic for induced abortion. The control group consisted of 77 sexually active never pregnant adolescent girls of similar age admitted for other reasons.InterventionsBoth groups completed a self-administered questionnaire about their occupation, educational level of their mother, family structure and socioeconomic status, relationship with their mother, sexual behavior, and substance use.Main Outcome MeasuresFactors associated with unintended pregnancy.ResultsIn the bivariate analysis pregnant adolescents tended to have a lower educational level, to live in a nonintact family, to prefer stronger alcohol drinks, and to have a younger age at sexual debut and more frequent sexual intercourse. In the log-linear model six factors appeared to be directly linked to pregnancy: mother's lower education, alcohol consumption, nonintact family structure, low academic grades, higher frequency of sexual intercourse, and lower age at sexual debut.ConclusionAlthough the issue of unwanted pregnancy and possible ways to prevent it should be kept in mind in the psychosocial assessment of any adolescent, the results of our study suggest that some adolescents are at increased risk of unwanted pregnancy. This group includes adolescent girls with low educational attainment, living in a disrupted family, and reporting other risk behaviors. These adolescents might specially benefit from specific preventive programs to reduce the number of adverse outcomes.     

Pilot Evaluation of an Internet‐Based Natural Family Planning Education and Service Program

ObjectiveTo evaluate the efficacy, knowledge of fertility, and acceptability of a web‐based natural family planning (NFP) education and service program.DesignA 6‐month repeated measure longitudinal evaluation pilot study.SettingA university based online website.ParticipantsThe website was piloted with 468 volunteer women seeking NFP services. Of these participants, 222 used the automatic online fertility charting system to avoid pregnancy. The 222 charting participants had a mean age of 29.9 years (SD=5.6), 2.2 children (SD=1.9), 37% were postpartum, and 47% had regular menstrual cycle lengths.InterventionNurse‐managed web‐based NFP education and service program.OutcomesPregnancies were confirmed by an online self‐assessed pregnancy evaluation form. A 10‐item fertility quiz and 10‐item acceptability survey was administered online.ResultsAmong the 222 users avoiding pregnancy, at 6 months of use, there were two correct‐use unintended pregnancies that provided a pregnancy rate of 2% and seven total unintended pregnancies providing a typical use pregnancy rate of 7%. Mean knowledge of fertility increased significantly from time of registration (8.96, SD=1.10) to 1 month of use (9.46, SD=.10), t=4.60, p<.001). Acceptability increased nonsignificantly from 1 month of use (45.6; SD=8.98) to 6 months of use (48.4; SD=8.77).ConclusionThe nurse‐managed online NFP system seems to provide adequate knowledge of fertility and help participants meet pregnancy intentions. Acceptability of such a system of NFP is still in question.     

Hospital‐Based Perinatal Nurses Identify the Need to Improve Nursing Care of Adolescent Mothers

ObjectiveTo determine whether hospital‐based perinatal nurses with expertise in adolescent mother‐friendly care identify a need to improve inpatient nursing care of adolescent mothers and how well perinatal units support nurses’ capacity to provide adolescent mother‐friendly care. Design/Setting/Participants: A key informant survey of nurses from eight perinatal units at three hospitals (four separate sites) in a Canadian city.MethodsPerinatal nurses expert in the care of adolescent mothers were identified by their managers and colleagues. These nurses and all perinatal clinical educators were invited to participate. Twenty‐seven of 34 potential key informants completed the survey.ResultsKey informants rated their own skill in caring for adolescent mothers higher (median 8.0) than they rated the skill of other nurses (median 6.0) on their units. They attributed their expertise working with adolescent mothers to their clinical and life experiences and their ability to develop rapport with adolescents. A common reason for the assigned lower peer‐group ratings was the judgmental manner in which some nurses care for adolescent mothers. Key informants also identified that hospital‐based perinatal nurses lack adequate knowledge of community‐based resources for adolescent mothers, educational programs related to adolescent mother‐friendly care were insufficient, and policies to inform the nursing care of adolescent mothers were not available or known to them.ConclusionA minority of perinatal nurses have expertise in adolescent mother‐friendly care. There is a need for perinatal unit‐level interventions to support the development of nurses’ skills in caring for adolescent mothers and their knowledge of community‐based resources. Peer mentoring and self‐reflective practice are promising strategies.     

Spousal violence and receipt of skilled maternity care during and after pregnancy in Nepal

Objectivesa substantial number of Nepali women experience spousal violence, which affects their health in many ways, including during and after pregnancy. This study aimed to examine associations between women's experiences of spousal violence and their receipt of skilled maternity care, using two indicators: (1) receiving skilled maternity care across a continuum from pregnancy to the early postnatal period and (2) receiving any skilled maternity care in pregnancy, childbirth, or postpartum.Methodsdata were analysed for married women aged 15–49 from the 2011 Nepal Demographic and Health Survey. Data were included on women who completed an interview on spousal violence as part of the survey and had given birth within the five years preceding the survey (weighted n=1375). Logistic regression models were developed for analyses.Resultsthe proportion of women who received skilled maternity care across the pregnancy continuum and those who received any skilled maternity care was 24.1% and 53.7%, respectively. Logistic regression analyses showed that spousal violence was statistically significantly associated with receiving low levels of skilled maternity care, after adjusting for accessibility of health care. However, after controlling for women's sociodemographic backgrounds (age, number of children born, educational level, husband's education level, husband's occupation, region of residence, urban/rural residence, wealth index), these significant associations disappeared. Better-educated women, women whose husbands were professionals or skilled workers and women from well-off households were more likely to receive skilled maternity care either across the pregnancy continuum or at recommended points during or after pregnancy.Conclusionspousal violence and low uptake of skilled maternity care are deeply embedded in a society in which gender inequality prevails. Factors affecting the receipt of skilled maternity care are multidimensional; simply expanding geographical access to maternity services may not be sufficient to ensure that all women receive skilled maternity care.     

Attitudes on fertility issues in breast cancer patients: an Italian survey

Abstract

Background: Fertility issues should be discussed with young women before the start of any anticancer treatment. The study is aimed to investigate the attitude on fertility among Italian oncologists and breast surgeons dealing with BCa, and to report the consensus achieved on specific statements.

Methods: One hundred and sixty-two panelists anonymously expressed an opinion through a web-based platform on 19 statements based on the Delphi method.

Results: Ninety-one percent of oncologists considered important to discuss with patients about fertility issues and 83% believed estrogens could stimulate the growth of hidden cancer cells in ER⁺ tumors. Difficulties in accessing fertility preservation procedures were mainly due to patients’ reluctance, but also to lack of coordination with the assisted reproduction specialists. No full consensus was reached on the prognostic role of pregnancy after BCa. Fifty-four percent of oncologists declared that pregnancy does not affect oncologic prognosis. Treatment with GnRHa during chemotherapy was considered the only mean for preserving ovarian function.

Conclusions: Fertility preservation in BCa patients is a well-accepted practice among Italian oncologists. A poor knowledge of this specific issue emerged from the survey, even if a certain degree of agreement was observed on most fertility-related issues.     

A modified Delphi method to create a scoring system for assessing team performance during maternal cardiopulmonary arrest

Background: Maternal cardiopulmonary arrest is a rare but often fatal emergency. The authors used a modified Delphi method to create a checklist of tasks for practitioners. Methods: Within each round, experts ranked tasks on a scale from zero through five. Consensus was defined a priori as 80% exact agreement. Results: Three rounds were required to achieve consensus resulting in a checklist of 45 tasks. Round One results revealed five tasks, Round Two included 25 tasks, and Round Three resulted in 29 tasks with 80% exact agreement. Conclusions: The modified Delphi method resulted in a weighted scoring system that can be used to objectively assess team performance.     

Narrative Inquiry Into Nursing Care of Pregnant Women and Families in Specialized Fetal Diagnosis and Treatment Settings

ObjectiveTo examine how nurses describe caring for women and families in specialized fetal diagnosis and treatment settings.DesignWe used narrative inquiry.SettingA secure online survey platform.ParticipantsWe recruited 26 nurses from the Fetal Therapy Nurse Network as a subsample from a prior Delphi study on the essential structures, processes, outcomes, and challenges of nursing practice in the emerging field of fetal diagnosis and treatment.MethodsWe used narrative inquiry and Clandinin’s three-dimensional space narrative analysis to interpret the stories provided by participants to illustrate their practice and the relationship between their practice and care quality and health outcomes.ResultsParticipants described three primary types of fetal diagnoses and management scenarios: prenatal intervention (maternal–fetal surgery to treat a fetal anomaly), postnatal intervention (neonatal surgery), and perinatal palliative care (continuation of a pregnancy after a life-limiting fetal diagnosis). We identified three overarching themes related to nursing processes: A Sounding Board: Counseling the Pregnant Woman and Family, A Care Coordinator: Orchestrating a Complex Journey, and A Constant Presence: Being With the Pregnant Woman and Family. We also identified specific outcomes related to nursing care.ConclusionWe used narrative inquiry to expand on prior research and advance the conceptualization of a model of nursing practice in fetal diagnosis and treatment settings. Our results provide a basis to begin to test theories that connect nursing practice to care quality and outcomes in clinical practice settings. To comprehensively evaluate and enhance care as it evolves and expands, the immediate and long-term effects of nursing practice must be identified.