by Rebecca Cypher, MSN, PNNP
You may remember that I shared the first part of my recent white paper with you not too long ago. It examined how healthcare technology as evolved as a result of perinatal nursing needs and changes in standards. Now it’s time to look at the flip side: How nursing as changed as a result of technology, specifically systems that help us monitor FHR.
Clinical Acumen and Care
While the fundamental technology in standard fetal monitoring equipment has changed little in recent decades, clinical behavior in response to FHR monitoring has changed considerably. Clearly defined nomenclature, 10, 11 standardized clinical guidelines, 12-16 and structured communication techniques are now part of obstetric care. Moreover, published nursing position statements and other resources have highlighted that skilled clinicians are essential to ensure maternal and fetal well-being when fetal monitoring is utilized. Additional publications focus on HIT’s vital healthcare role in terms of enhancing opportunities for reducing error in perinatal settings. 3, 11, 17, 18
There is increased awareness that environmental and human factors can impair clinical judgment resulting in delayed intervention and birth-related injury. To address some of these issues healthcare professionals have:
- Legislation that limits working hours
- Updated recommendations on nurse-patient ratios
- Stricter and more frequent credentialing
- Chain of command procedures
- In-house coverage rather than on-call at home
Despite these measures, assessing a clinical situation is still challenging. Nurses must often project what will happen in the future. Furthermore, these same nurses prefer to avoid allowing patients to deteriorate to a suboptimal status because, once changes have occurred, safe recovery may be impossible. To make decisions, the clinical mind must focus on what is important and disregard the irrelevant. The human brain is vulnerable to well described biases in this task.
Recent “vivid” experiences affect individual’s perception of risk. The psychological phenomenon of “Tunnel Vision” refers to a tendency to perceive and confirm only the information that aligns with a particular viewpoint and discard contradicting information. 19 Variations of this phenomenon include “Wishful thinking.” For example, a belief that a patient will deliver soon or not deteriorate on a shift can lead to poor FHR tracing assessments which is inconsistent under the best of conditions. Occasionally, humans get tired, distracted, have memory lapses, take risky shortcuts, or get diverted by competing interests. Furthermore, inadequate training or clinical experience can compound problems at the bedside. The objective, unbiased, statistical methods offered by HIT can counter these types of human bias, reduce information overload and assist novice and seasoned nurses to make more confident decisions. 20, 21, 22
Another attractive HIT feature for perinatal leaders is the ability to collect and organize outcome and performance data such as the number of cesarean births or elective inductions. Instead of hand counting data from multiple sources, which takes up valuable nursing time and resources, HIT can collect this data and provide written reports on a regular basis. Performance can be compared over time, to other unit level quality improvement goals or datasets of core measure such as those established by the Joint Commission and the National Perinatal Information Center. Policies and procedures can then be further refined based on benchmarked data in order to provide safer care to patients. 18, 23
The divisions between fetal monitoring technologies, technologies in healthcare information and modern nursing care have been become increasingly blurred. Monitors contain software. Systems in HIT employ clinical algorithms. Clinical algorithms are often based on research using huge datasets derived from HIT systems. Clinicians make decisions on monitoring data and research findings. A brief comparison of strengths and weakness related to computer and human faculties is outlined in Figure 2. Both are fallible but each one has strengths in specific areas. The strengths of one counter weaknesses of the others. Computers crunch numbers well. Let the computers apply that capacity to analyze, organize and display critical information without bias so that nurses can be empowered to use technology and focus on higher order clinical reasoning, collaborative dialogue with colleagues and compassionate quality care. Surely valuable nursing time should not be consumed by the repetitive, manual labor of measuring, counting and calculating. On the other hand, nurses are essential to seek out and integrate information from additional sources, see exceptions to the general rule, cue in to unspoken patient fears, and even make do with missing data. Nurses communicate, reason, educate, encourage and empathize with patients and families. The profession makes a profound difference as hands-on patient contact, visual interpretation at the bedside and having an underlying basic foundation in obstetric care is absolutely necessary to validate HIT information. The perception that technology will take over nursing responsibilities, such as FHR interpretation, leaving all data to be interpreted, documented and managed by artificial intelligence is not only incorrect but illogical. However, given what is known about human error, surely one could not advocate for one approach without the other i.e., nurses without equipment or equipment without nurses.
As HIT related to antepartum and intrapartum fetal surveillance techniques evolve, the profession is often concerned with how to integrate them without challenging or devaluing the role of nursing. This is where an understanding of HIT strengths is important so that they can insist on HIT functionality that is truly helpful allowing nurses to have more time with patients. Perinatal nurses must continue to be involved in the design of state-of-the art systems at the bedside that optimize time for hands-on patient care and streamlined workflow and patient safety. 18, 24 Additionally, nurses play an important role in collaboratively developing and utilizing a variety of quality improvement and risk reductions strategies with the aid of HIT to improve patient care, reduce adverse perinatal and neonatal outcomes (e.g. emergent cesarean section or neonatal intensive care unit admission) and potentially reduce liability. 13,25-28 These include but are not limited to
Developing clear fetal monitoring guidelines that include multidisciplinary protocols for interpretation, intervention, and documentation
Educating nurses, residents, nurse midwives, and physicians on fundamentals of fetal monitoring using standardized fetal monitoring nomenclature
Applying HIT to patient care by using high quality up to date decision aids, bundles and toolkits
Implementing peer reviewed evidence based information, such as clinical protocols, checklists (i.e. oxytocin), and guidelines in a high reliability organization to reduce clinician practice variation