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The article presents the discussion on perspectives of women in Appalachian Kentucky on surviving severe maternal morbidity (SMM) and the social determinants influencing their experiences. Topics include intermediary determinants like access to healthcare and structural determinants such as bias and patient agency, highlighting the complexities of SMM experiences in underserved communities.

Purpose: To examine the effect of nurse staffing in varying work environments on missed breastfeeding teaching and support in inpatient maternity units in the United States. Background: Breast milk is the optimal food for newborns. Teaching and supporting women in breastfeeding are primarily a nurse's responsibility. Better maternity nurse staffing (fewer patients per nurse) is associated with less missed breastfeeding teaching and support and increased rates of breastfeeding. We examined the extent to which the nursing work environment, staffing, and nurse education were associated with missed breastfeeding care and how the work environment and staffing interacted to impact missed breastfeeding care. Methods: In this cross-sectional study using the 2015 National Database of Nursing Quality Indicator survey, maternity nurses in hospitals in 48 states and the District of Columbia responded about their workplace and breastfeeding care. Clustered logistic regression models with interactions were used to estimate the effects of the nursing work environment and staffing on missed breastfeeding care. Results: There were 19 486 registered nurses in 444 hospitals. Nearly 3 in 10 (28.2%) nurses reported missing breastfeeding care. In adjusted models, an additional patient per nurse was associated with a 39% increased odds of missed breastfeeding care. Furthermore, 1 standard deviation decrease in the work environment was associated with a 65% increased odds of missed breastfeeding care. In an interaction model, staffing only had a significant impact on missed breastfeeding care in poor work environments. Conclusions: We found that the work environment is more fundamental than staffing for ensuring that not only breastfeeding care is not missed but also breastfeeding care is sensitive to nurse staffing. Improvements to the work environment support the provision of breastfeeding care. Implications for Research and Practice: Both nurse staffing and the work environment are important for improving breastfeeding rates, but the work environment is foundational. [ABSTRACT FROM AUTHOR]

Background: We compared low‐risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low‐risk cesarean rates less than or equal to White women. Methods: In this cross‐sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low‐risk cesarean for Black and White women across hospital categories. Results: Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low‐risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low‐risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01–1.44) increase in the odds of having a low‐risk cesarean. Discussion: Black women had higher odds of a low‐risk cesarean than White women and were more likely to access care in hospitals with higher low‐risk cesarean rates. The existence of hospitals where low‐risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low‐risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system‐level policy efforts to improve equity and reduce cesarean birth rates. [ABSTRACT FROM AUTHOR]

Aims: To explore factors associated with nurses' moral distress during the first COVID-19 surge and their longer-term mental health. Design: Cross-sectional, correlational survey study. Methods: Registered nurses were surveyed in September 2020 about their experiences during the first peak month of COVID-19 using the new, validated, COVID-19 Moral Distress Scale for Nurses. Nurses' mental health was measured by recently experienced symptoms. Analyses included descriptive statistics and regression analysis. Outcome variables were moral distress and mental health. Explanatory variables were frequency of COVID-19 patients, leadership communication and personal protective equipment/cleaning supplies access. The sample comprised 307 nurses (43% response rate) from two academic medical centres. Results: Many respondents had difficulty accessing personal protective equipment. Most nurses reported that hospital leadership communication was transparent, effective and timely. The most distressing situations were the transmission risk to nurses' family members, caring for patients without family members present, and caring for patients dying without family or clergy present. These occurred occasionally with moderate distress. Nurses reported 2.5 days each in the past week of feeling anxiety, withdrawn and having difficulty sleeping. Moral distress decreased with effective communication and access to personal protective equipment. Moral distress was associated with longer-term mental health. Conclusion: Pandemic patient care situations are the greatest sources of nurses' moral distress. Effective leadership communication, fewer COVID-19 patients, and access to protective equipment decrease moral distress, which influences longer-term mental health. Impact: Little was known about the impact of COVID-19 on nurses' moral distress. We found that nurses' moral distress was associated with the volume of care for infected patients, access to personal protective equipment, and communication from leaders. We found that moral distress was associated with longer-term mental health. [ABSTRACT FROM AUTHOR]

Background: Birth is the most common reason for hospitalization in the United States. Hospital variation in maternal outcomes is an important indicator of health care quality. Spontaneous vaginal birth (SVB) is the most optimal birth outcome for the majority of mothers and newborns. The purpose of this study was to examine hospital‐level variation in SVB overall and among low‐risk women in a four‐state sample representing 25% of births in the United States in 2016. Methods: Women giving birth in California, Pennsylvania, New Jersey, and Florida were identified in 2016 state discharge abstracts. Patient data were merged with hospital data from the American Hospital Association's (AHA) 2016 Annual Survey. Overall and low‐risk SVB rates were calculated for each hospital in the sample and stratified by bed size, teaching status, rurality, birth volume, and state. Results: Our final sample included 869 681 women who gave birth in 494 hospitals. The mean overall SVB rate in the sample was 61.1%, ranging from 16.8% to 79.9%. The mean low‐risk SVB rate was 78% and ranged from 34.6% to 93.3%. Variation in SVB rates cut across all the hospital structural characteristic strata. Discussion: The wide variation in SVB rates indicates significant room for improvement in this maternal quality metric. Our finding, that hospitals of all types and locations had both low and high SVB rates, suggests that excellent maternal outcomes are possible in all hospital settings. The variation in SVB rates across hospitals warrants research into modifiable hospital factors that may be influencing SVB rates. [ABSTRACT FROM AUTHOR]

Aims and objectives: To evaluate differences in hospitals' proportion of specialty certified nurses and to determine whether and to what extent individual nurse characteristics and organisational hospital characteristics are associated with a nurse's likelihood of having specialty certification. Background: Prior research has shown that patients in hospitals with high proportions of specialty certified nurses have better outcomes including lower mortality and fewer adverse events, yet less is known about what motivates nurses to obtain specialty certification. Methods and design: Cross‐sectional study of paediatric nurses in 119 acute care hospitals. Multivariate logistic regression models were used to determine the association between individual nurse characteristics, organisational hospital characteristics and an individual nurses' likelihood of holding a specialty certification. STROBE was followed. Results: The proportion of certified nurses varies substantially among hospitals, with Magnet® hospitals being significantly more likely, on average, to have higher proportions of certified nurses. Nurses in children's hospitals were no more likely than paediatric nurses in general hospitals to be certified. A nurse's years of experience and bachelors‐preparation were significantly associated with higher odds of having certification. The strongest predictors of certification were favourable nurse work environments and Magnet®‐designation of the hospital. Conclusions: While individual attributes of the nurse were associated with a nurse's likelihood of having a specialty certification, the strongest predictors of certification were modifiable attributes of the hospital—a favourable nurse work environment and Magnet®‐designation. Relevance to clinical practice: Hospital administrators seeking to increase the proportion of specialty certified nurses in their organisation should look to improvements in the organisation's nurse work environment as a possible mechanism. [ABSTRACT FROM AUTHOR]

Introduction: To examine whether there is a threshold of oxytocin exposure at which the risk for primary cesarean increases among women who are nulliparous with a term, singleton, vertex fetus (NTSV) and how oxytocin interacts with other risk factors to contribute to this outcome. Methods: This was a secondary analysis of the Consortium on Safe Labor data set that used a retrospective cohort study design. Women who met the criteria for NTSV who were not admitted for a prelabor cesarean and for whom oxytocin data were available, were included in the sample. Robust logistic regression was used to examine the association of oxytocin exposure with primary cesarean birth, while controlling for demographic and clinical risk factors and clustering by provider. Results: The sample comprised 17,331 women who were exposed to oxytocin during labor. The women were predominantly white non‐Hispanic (59.2%) with an average (SD) gestational age of 39.4 (1.1) weeks and an 18.5% primary cesarean rate. Exposure to greater than 11,400‐milliunits (mU) of oxytocin resulted in 1.6 times increased odds of primary cesarean birth compared with less than 11,400 mU (95% CI 1.01‐2.6). Discussion: Exposure to greater than 11,400 mU of oxytocin in labor was associated with an increased odds of primary cesarean birth in NTSV women. [ABSTRACT FROM AUTHOR]

Objective:  While there are known racial disparities in cesarean delivery (CD) rates, the exact etiologies for these disparities are multifaceted. We aimed to determine if differences in induction of labor (IOL) management contribute to these disparities., Study Design:  This retrospective cohort study evaluated all nulliparous patients with an unfavorable cervix and intact membranes who underwent IOL of a term, singleton gestation at a single institution from October 1, 2018, to September 30, 2020. IOL management was at clinician discretion. Patients were classified as Black, Indigenous, and People of Color (BIPOC) or White based on self-report. Overall rates of CD were compared for BIPOC versus White race. Chart review then evaluated various IOL management strategies as possible contributors to differences in CD by race., Results:  Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White. BIPOC patients were more likely to be younger (26 years interquartile range (IQR): [22-30] vs. 32 years IQR: [30-35], p  < 0.001) and publicly insured (59.1 vs. 9.9%, p  < 0.001). Indication for IOL and modified Bishop score also differed by race ( p  < 0.001; p  = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling for confounders (30.7 vs. 21.7%, p  = 0.001; adjusted relative risk (aRR) = 1.41, 95% confidence interval (CI): [1.06-1.86]). Despite this difference in CD, there were no identifiable differences in IOL management prior to decision for CD by race. Specifically, there were no differences in choice of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo CD for fetal indications and failed IOL., Conclusion:  BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients within our institution. These data suggest that the disparity is not explained by differences in IOL management prior to cesarean, indicating that biases outside of induction management may be important to target to reduce CD disparities., Key Points: · The etiologies for racial disparities in cesarean are likely multifaceted.. · In this work, there were no differences by race in measures of labor induction management.. · Biases outside of induction management during labor may be targeted to reduce CD disparities.., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: To summarize how nursing resources and missed nursing care are associated with hospital breastfeeding outcomes, including human milk provision., Background: Nurses are the primary providers of breastfeeding support in the hospital. Nursing resources, eg, staffing and the work environment, enable nurses to carry out their work successfully. If resources are constrained, nurses may miss providing breastfeeding support. There is a gap in the literature about the relationships among nursing resources, missed nursing care, and breastfeeding outcomes., Methods: The Cumulative Index to Nursing and Allied Health Literature and PubMed were searched with keywords such as: "nurse staffing," "nurse work environment," "missed nursing care," "breastfeeding," "human milk," and "lactation." We included peer-reviewed studies of US samples in English published between 2014 and 2022., Results: Of 312 references, 8 met inclusion criteria: 5 quantitative and 3 qualitative. Better nurse staffing and breastfeeding support were associated with improved breastfeeding outcomes in the qualitative and quantitative literature. Missed care partially mediated the relationship between staffing and exclusive breast milk feeding rates. Better nurse work environments were associated with increased breastfeeding support and provision of human milk., Conclusions: Empirical evidence supports an association between the nurse work environment, nurse staffing, breastfeeding support, and outcomes. Implications for practice and research: Poor staffing may be associated with decreased breastfeeding support and outcomes. Hospital administrators and nurse managers may consider improving nurse staffing and the work environment to improve breastfeeding outcomes. Future research should simultaneously examine staffing and the work environment and address breastfeeding outcome disparities., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Local Problem: Variations in nursing practice were observed across our hospital, a 520-bed acute care teaching facility in the northeast United States, regarding the timing and frequency of insulin administration in adult patients with diabetes. Chart audits noted that RNs administered insulin more than one hour after blood glucose results were obtained 97% of the time. In addition, insulin was given at bedtime only 37% of the time., Purpose: The purpose of this quality improvement (QI) project was to improve the care of inpatients requiring insulin by implementing protocols and adjusting practice to align with best practice recommendations., Methods: The clinical nurse education specialist met with a team of staff nurses, providers, nurse leaders, and patient care technicians (PCTs) to formulate protocols and design interventions to ensure improvements in the quality of care for inpatients with diabetes. A sequence of education sessions and an online learning module were developed and assigned to nurses and PCTs to address knowledge gaps, specifically in the pharmacodynamics and safe administration of insulin, as well as how best to provide care to patients with diabetes. Monthly adherence data were disseminated to nurse leaders and educators and reviewed with clinical staff at daily safety huddles and staff meetings. Additional interventions to enhance nursing practice in caring for patients with diabetes included ensuring both bedtime insulin administration and timely insulin delivery. This project began in May 2017 and ended five years later., Results: Two weeks after initial education sessions began in May and June 2017, the frequency of giving bedtime insulin based on the order set and according to the patient's blood glucose levels rose from 37% to 82%, and adherence to best practice protocols continued until final chart audits were performed in May 2022. The frequency of giving insulin less than one hour after obtaining blood glucose results improved from 3% to 64% between October and December 2019, and increased to a sustained level above the project's 92% goal two years later., Conclusion: Protocol development, targeted education, and audits with feedback led to improved care delivery for patients requiring insulin and increased nursing confidence., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: This study aimed to determine the well-being outcomes and quality of work environment among emergency nurses compared with inpatient nurses working in Magnet hospitals and identify recommendations in emergency department work environments that hold promise for enhancing emergency nurses' well-being., Methods: This is a cross-sectional analysis of multicenter survey data collected in 2021 from 11,743 nurses practicing in 60 United States Magnet hospitals. Nurses report on burnout, job dissatisfaction, intent to leave, work environment, and recommendations to improve well-being., Results: Emergency nurses are significantly more likely to report high burnout (P = .04), job dissatisfaction (P < .001), and intent to leave (P < .001) than inpatient nurses working in the same Magnet hospitals. Emergency nurses are significantly more likely to report insufficient staffing (P = .001), an unfavorable work environment (P < .001), and lack confidence that management will act to resolve problems in patient care (P < .001) but did report significantly better working relationships with physicians (P < .001) than their inpatient counterparts. The 2 greatest recommendations to improve well-being included improving nurse staffing (91.4%) and the ability to take uninterrupted breaks (86.7%); the lowest-ranked recommendations were employing more advanced practice providers (25.9%) and appointing a wellness champion (21.2%)., Discussion: High burnout and other adverse nurse outcomes are common among emergency nurses in Magnet hospitals. Modifiable features of ED work environments including inadequate nurse staffing, inability of nurses to take uninterrupted breaks, and lack of responsiveness of management to persistent problems in patient care warrant high priority attention by Magnet hospital leaders., (Copyright © 2023 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Objective: To examine variation in nursing resources across three different types of maternity units in five regions of the United States., Design: Cross-sectional descriptive., Setting: Maternity units in hospitals in 48 states and the District of Columbia that participated in the 2016 National Database of Nursing Quality Indicator survey., Participants: Staff nurses (N = 19,486) who worked in 707 maternity units., Methods: We conducted a secondary analysis of survey data examining nursing resources (work environment, staffing, education, specialty certification) by type of maternity unit, including labor and delivery, labor/delivery/recovery/postpartum, and postpartum. We used descriptive statistics and analysis of variance., Results: Participants worked in 707 units (269 labor and delivery units, 164 labor/delivery/recovery/postpartum units, and 274 postpartum units) in 444 hospitals. The work environment was not significantly different across unit types (mean = 2.89-2.94, p = .27). Staffing, education, and specialty certification varied significantly across the unit types (p ≤ .001). In terms of staffing, postpartum units had, on average, almost twice the number of patients per nurse as labor and delivery units (7.51 patients/nurse vs. 4.01 patients/nurse, p ≤ .001) and 1.5 times more patients than labor/delivery/recovery/postpartum units (5.04 patients/nurse vs. 4.01 patients/nurse, p ≤ .001)., Conclusion: Nursing resources varied significantly across types of maternity units and regions of the United States. This variation suggests that improving nursing resources may be a system-level target for improving maternity care in the United States., Competing Interests: Conflict of Interest The authors report no conflicts of interest or relevant financial relationships., (Copyright © 2022 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)