Improving Communications for Perinatal Safety

June 2013Martha Ross

As a clinical nurse specialist in labor and delivery, Audrey Lyndon was called to consult on those unusual but rapidly unfolding cases where a mother’s or baby’s health was in jeopardy.

It gave her a broad view of how a team of nurses, physicians and midwives responded to sudden and potentially dire situations. Sometimes they would effectively share information and work well together to save the mother and baby. But there were times when things didn’t go so well.

Audrey Lyndon “We’d see cases where someone would recognize a problem, but for whatever reason opportunities for a rescue were missed,” says Lyndon, who, on June 16, in recognition of her body of research and public service, will receive a highly coveted Distinguished Professional Service Award from the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Lyndon is best known for her work demonstrating how communication failures contribute to preventable adverse events in perinatal care – and for developing strategies to improve safety on labor and delivery units.

Not Always the Most Natural Thing in the World

Most women come to hospitals expecting to safely deliver a healthy baby. After all, birth is one of the most natural things in the world and “usually works best if we let it evolve and not get in the way,” Lyndon says.

Nevertheless, when the unpredictable happens – the mother’s blood pressure spikes, infection sets in, or the baby goes into distress – missed opportunities can lead to devastating consequences.

Lyndon wanted to understand why some teams respond well to the unpredictable and others don’t. “That was really the genesis of what I’m interested in as a researcher,” she says.

Seeking Answers

After graduating from UCSF School of Nursing’s Master’s Entry Program in Nursing in 1994, Lyndon returned to earn her doctorate in 2007.

“Audrey is the epitome of what we teach in research methods – the question drives the method,” says Kathryn Lee, associate dean for research at UCSF School of Nursing and a frequent collaborator.

“I was really astounded by the work she has done statewide and nationally,” says Yvonne Dobbenga-Rhodes, a clinical nurse specialist at Washington Hospital Healthcare System in Fremont, who also serves on AWHONN’s board of directors. “In labor and delivery…you always hope for the best but expect the worst. That’s where Lyndon’s research on safety and improving communications has been invaluable.”

The Patient Advocate

Lyndon’s interest in nursing and women’s advocacy dates to her undergraduate days at UC Santa Cruz, where she majored in both biology and women’s studies. A postgraduate job as a medical assistant in a San Francisco OB-GYN office brought her face to face with the emotional trauma suffered by families when a pregnancy ends in death. In response, she developed a program to support mothers and fathers dealing with such horrific outcomes.

Her advocacy for patient care continued after she received her master’s degree, when her husband’s work took the couple to the Washington, DC, area. As a clinical nurse specialist at Anne Arundel Medical Center in Annapolis, Maryland, she developed an interdisciplinary program – including physicians, nurses, social workers and physical therapists – focused on addressing the psychological and medical needs of pregnant women who had to be hospitalized before birth, sometimes for weeks or longer.

The Failure to Communicate

As her career progressed, Lyndon found herself circling back to communication issues among team members in labor and delivery. Eventually, she became intrigued by approaches to safety that “high-reliability organizations” use, such as the airline and nuclear energy industries or the military.

One important lesson these organizations teach is that “there must be collective responsibility for identifying and managing continuously evolving threats,” Lyndon has written. “Safety is understood as a social, individual and collective responsibility, belonging to all team members.”

Accepting the possibility of disaster makes organizations better able to respond to the unexpected, Lyndon says. “The thing about human beings is that they are complex physiological systems, and can be unpredictable about how they respond to interventions. Medicine is not a production line. It’s dynamic, it’s complicated, and we need to be adaptive.”

To help teams adapt, Lyndon became the first to document the perspectives of maternity care nurses, physicians and midwives on communication issues and the first investigator to report a startling fact: clinicians across the professional spectrum acknowledge that they don’t speak up every time they recognize safety problems (BMJ Quality & Safety).

She has also found that communication breaks down for many complex reasons, including traditional hierarchical roles, lack of administrative support, resource issues, fatigue and stress among team members and personality differences.

“We’d all like to believe it’s very straightforward, but it’s a socially complex situation,” she says.

For example, in a hypothetical case Lyndon describes in an article published in the American Journal of Obstetrics and Gynecology, a nurse worries that a physician’s orders to induce labor will lead to a cesarean section when the patient, “Ms. B,” wants a natural childbirth.

But the nurse doesn’t speak up, because she doesn’t believe the doctor, who was brusque with her earlier, will listen. Meanwhile, the doctor, rushing from patient to patient on a busy shift, doesn’t share his concerns that a protracted labor for this particular patient could lead to hypertension and even stillbirth.

“Sometimes people just aren’t speaking the same language,” Lyndon says, and this is not restricted to nurses and doctors; it can include many other members of the team, including residents and attending physicians.

Lyndon’s work is also influenced by what is known as “situational awareness.” Michael Fox, a former perinatal outreach coordinator at UCSF who is now the clinical program director at UCSF’s Center for the Health Professions, introduced Lyndon to the concept.

She has come to believe that situational awareness is fundamental to the dynamic reasoning and decisionmaking health care providers need when facing evolving clinical circumstances. A nurse, typically the gatekeeper who manages a patient’s labor, needs to be constantly aware of the patient’s situation, as well as her own ways of interacting with other staff and the patient’s family.

Growing Concerns About the US Record

Lyndon’s research has coincided with a time when US health care providers have become keenly aware that this country lags in maternal safety. In 2008, there were 17 maternal deaths per 100,000 live births in the United States, lower than many developing nations in Africa and Central Asia, but higher than many industrialized countries around the world, according to an Institute for Health Metrics and Evaluation study.

In 2011, the United Nations placed the United States 50th in the world for maternal mortality rates, with the leading causes of US maternal deaths being hemorrhage, pregnancy-related hypertensive disorders, infection, thrombotic pulmonary embolism, cardiomyopathy and cardiovascular conditions.

“We could be doing a lot better, considering the resources we have,” Lyndon says.

Next Steps

Lyndon currently teaches and mentors doctoral students while consulting for organizations at the state and national levels on obstetric nursing.

As for her research, she wants to start gathering patients’ perspectives on perinatal safety and is seeking support for a study on helping parents maintain safety for their babies in neonatal intensive care units.

In addition, much work remains in terms of helping clinicians across disciplines be more assertive communicators – and better listeners. “Another area where we haven’t done enough work is that we need to build listening skills.”

In the case of “Ms. B,” Lyndon outlines how the nurse and doctor can help the patient. The doctor might recognize that the nurse is genuinely worried about increasing the dose of oxytocin to speed up the labor and ask, “Is there something else going on?” This would allow each to state what’s truly worrying them, which turns out to be the same thing: the possibility of an unnecessary cesarean section. Together they could work out a plan to avoid that if possible.

Lyndon would also like to focus on dissecting cases where team members work well together. “One of my interests is how we can study what works as opposed to what goes wrong,” she says. “There are many, many cases being resolved beautifully every day.”