Welcome to the Quality and Safety Nursing Education Module
In 2001, the Institute of Medicine (IOM) issued a landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century, was produced by the Institute of Medicine (IOM) and articulated quality and safety problems with the U.S. health care system. A subsequent IOM report, Health Professions Education: A Bridge to Quality, presented a core set of competencies for health professions education. Using the IOM competencies, the Quality and Safety Education for Nurses (QSEN) Project defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency. The overall vision is for nurses to continuously improve the quality and safety of the healthcare systems in which they work.
How to Use This Module
Provide’s Nursing Education Curriculum is designed for a flipped classroom model to incorporate unintended pregnancy prevention and care into existing curricula.
Students are encouraged to complete the Pre-Assessment below and then work through the module. Definitions and Orienting Facts provide context for the Patient Situations, which are clinical scenarios designed to raise critical issues and questions to put unintended pregnancy prevention and care in the context of Quality and Safety. Students may complete the Recommended Reading at any time while going through the Patient Situations. Please complete the Post-Assessment after finishing the module.
Faculty are encouraged to open the Faculty Guide tab below to access teaching tips, exercises and handouts for incorporating module content into the classroom, and to learn more about obtaining a “Site Code” to download and access students’ Pre- and Post-Assessment data.
Please complete the Pre- and Post-Assessments. A new window will open to a Survey Monkey Pre-Assessment and the window must remain open while you work with the module. Once you have completed the module you will return to the Survey Monkey window to complete the Post-Assessment. If your faculty requires completion of this module as a course requirement, please check with them about due dates and credit allocations.
- Understand concepts of population health and integrate into the care of the individual patient.
- Understand the intersection of quality and safety and how it relates to unintended pregnancy prevention and care.
- Understand the unique challenges of providing sexual health information to people from different backgrounds.
- Analyze systemic barriers to family planning/pregnancy prevention for vulnerable populations.
- Develop skills in providing effective referrals for unintended pregnancy prevention and care health services.
Relevant UPPC Essential Competencies
Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education (Hewitt, C. and Cappiello, J., 2015) 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education which provide a framework for curricular development in an important area of nursing education. The following competencies are relevant to this nursing education module.
- Demonstrate ability to recognize unique reproductive health needs of women from vulnerable and special populations (e.g. adolescents, women with mental or physical disabilities, survivors of violence) affected by many factors (e.g. relationship status, sexual orientation).
- Demonstrate knowledge of current state-specific laws regulating minors’ access to reproductive care for the state(s) in which nurse practices (including contraceptive access and abortion care).
- Demonstrate knowledge of confidentiality regulations specific to unintended pregnancy prevention and care.
- Demonstrate understanding of how contraceptive methods work (e.g. hormonal methods, post‐partum and emergency contraception, lactational and fertility methods, IUD, barrier methods, sterilization), risks, benefits, alternatives, effectiveness, and eligibility.
- Demonstrate knowledge of current evidenced‐based guidelines for primary prevention of unintended pregnancy.
- Demonstrate proficiency in providing pregnancy test results in patient-centered manner.
- Demonstrate proficiency in obtaining a complete health history (inclusive of sexual and reproductive history, sexual orientation, partner preference, and appropriate to the developmental level of client).
- Demonstrate proficiency in referring clients with unintended pregnancy to area providers and support services.
- Demonstrate ability to participate effectively in interprofessional, team‐based care for unintended pregnancy prevention and care.
- Demonstrate proficiency in evaluating outcomes of plan of care and referrals for women with unintended pregnancies.
- Demonstrate ability to obtain or refer for appropriate laboratory tests specific to unintended pregnancy prevention and care.
Each of the QSEN competencies defined below are closely linked with essential knowledge, skills, and attitudes (KSA) for pre-licensure nursing students.
Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making.
Patient Centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Quality Improvement (QI): Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Teamwork and Collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
In addition to the QSEN competencies, there are key words and concepts integrated throughout the module.
Cognitive Stacking: An invisible, decision-making process that nurses engage in as they re-organize and re-set priorities while caring for patients.
Early Pregnancy Decision-Making: Refers to the decision-making process that a woman engages in when faced with an unintended pregnancy. Pregnancy options include continuing the pregnancy with the intention to parent, continuing the pregnancy with the intention to adopt, or choosing abortion care.
Induced or Therapeutic Abortion (commonly referred to as “abortion”): An abortion that is brought about intentionally, also called a therapeutic abortion. Medical terminology refers to induced and spontaneous abortion (commonly referred to as a miscarriage).
Long-Acting Reversible Contraceptives: LARCs refer to methods of contraception that can last for several years. Examples are intrauterine devices (which range from 3-10 years) or a hormonal implant called Nexplanon (3 years). Some people also consider the Depo-provera injection (which lasts for 3 months) to be a LARC.
Unintended Pregnancy: An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception.
In 2005, the Robert Wood Johnson Foundation funded a national study to develop the knowledge, skills, and attitudes needed to educate nursing students on patient safety and healthcare quality. Using the IOM competencies for quality and safety, the Quality and Safety Education for Nurses (QSEN) faculty and a National Advisory Board defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes for pre-licensure nursing programs for each competency. The study identified six areas for nursing:
- Evidenced based practice
- Patient centered care
- Team work/collaboration
- Quality improvement
- The American Nurse Association Code of Ethics (2015) states in Provision 3.4 that it is the nurse’s ethical professional responsibility to promote a culture of safety.
- According to Finer and Zolna (2014) half of pregnancies among American women are unintended, and four in 10 of these are terminated by abortion. On a global scale unsafe abortion is a major determinant of women’s reproductive mortality and morbidity. Unsafe abortions are the third largest cause of maternal mortality worldwide.
- The Guttmacher Institute reports that “the average American woman spends about five years pregnant, postpartum or trying to become pregnant, and three decades—more than three-quarters of her reproductive life—trying to avoid an unintended pregnancy.” Guttmacher’s Fact Sheet on Induced Abortion in the United States indicates the likelihood of having an abortion rises over the course of a lifetime: 1 in 10 women will have an abortion by age 20, and 1 in 3 will have an abortion by age 45.
- The Guttmacher Institute also reports that births resulting from unintended or closely spaced pregnancies are associated with adverse maternal and child health outcomes such as delayed prenatal care, premature birth and negative physical and mental health effects for children.
The reduction of unintended pregnancy has been a key feature of the Healthy People goals since 1990, and sexual and reproductive health is one of the areas that has been identified by the Surgeon General as key to the delivery of preventive health services. These modules were formulated to include the UPPC competencies in clinical scenarios that reinforce the QSEN competencies.
Each scenario described in this module is broken into sections to enable self-guided learning. Detailed information is provided on the patient and the setting in addition to the patient scenario that deals with the complex and often controversial nature of unintended pregnancy prevention and care.
Destiny’s Care (Patient Situation #1)
Destiny is a 17 year-old girl who was admitted to the orthopedic floor post-surgery for the pinning of a nondisplaced hip fracture status after a fall from a horse. She is scheduled for discharge today. The discharge planning process began this morning but it is now later in the afternoon. Destiny is expected to leave in the next hour or two.
A large hospital. Today the unit is very busy and the nurses have heavy caseloads.
As the nurse reviews discharge instructions, including a medication plan for pain relief at home, Destiny sheepishly tells the nurse that when she was asked in the emergency room about medication use and was specifically asked about hormonal contraceptive methods, she said was not honest about the fact that she uses birth control pills.
Destiny has now been off the pill for 5 days and needs to resume birth control use. She was on her last month of pills and has only a few pills left in the pack. She is not sure how she will get her refills at her local clinic during her recovery at home. Although she is not anticipating that she will be sexually active in the near future due to her recovery from surgery, the birth control pills lessen the amount of her menstrual flow and decrease cramping for her. For this reason Destiny would like to resume her birth control pills right away so that she does not have a heavy period while she is recuperating.Are oral contraceptives contraindicated for Destiny?
Destiny’s parents were with her when the nurse on the day shift reviewed medication information with all three of them. When Destiny’s discharge was delayed, her parents had to leave the hospital to care for their other children. Destiny’s revelation about taking oral contraceptives was a surprise to the nurse currently on duty who expected a straightforward session of discharge planning to be finalized when Destiny’s father returns to take Destiny home.Can Destiny receive contraception without a parent’s consent?
Given that Destiny has already received contraception from a clinic that provided her with confidential services, this patient scenario takes place in a state that allows for minors to obtain contraceptive services without parent consent or notification.
To provide patient-centered care and adhere to evidence-based practice the nurse works with Destiny to meet her contraceptive needs. The nurse knows that the Centers for Disease Control and Prevention (CDC) state that healthy adolescents may safely use any form of highly effective contraceptives, including long acting reversible contraceptives (LARC), and it is important to be sure teens who are having sex know about all methods of contraception. Importantly, the 2006–2010 National Survey of Family Growth (NSFG) revealed that less than one-third of 15- to 19-year-old female subjects consistently used contraceptive methods at last intercourse.
In the American Academy of Pediatrics policy statement Addendum-Adolescent Pregnancy: Current Trends and Issues (2014) it is noted that there has been a trend of decreasing sexual activity and teen births and pregnancies since 1991, except between the years of 2005 and 2007, when there was a 5% increase in birth rates. Currently, teen birth rates in the United States are at a record low secondary to increased use of contraception at first intercourse and use of dual methods of condoms and hormonal contraception among sexually active teenagers (Hamilton and Ventura, 2012). Despite these data, the United Nations Statistic Division reports that United States continues to lead other industrialized countries in having unacceptably high rates of adolescent pregnancy, with over 700,000 pregnancies per year, the direct health consequence of unprotected intercourse.
The Triple Aim framework, developed by the Institute for Healthcare Improvement, describes an approach to optimizing health system performance based on three aims: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. The framework helps organizations and communities transition from a focus on health care to a focus of optimizing health for individuals and populations.
In this situation, the nurse can improve Destiny’s patient experience by meeting her needs. Ultimately, meeting Destiny’s needs has the potential to decrease health care costs by preventing unintended pregnancy. In Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program the Guttmacher Institute found that for every $1 the U.S. government spent in 2010 on funding family planning programs, over $7 was saved in Medicaid and other public expenditures associated with unintended pregnancy related care.
After Destiny’s question the nurse thinks about the list of patient care tasks he must perform. How will he re-adjust his work plan, create time to address Destiny’s needs, and attend to nursing tasks in a timely manner? This process of reorganizing and re-setting work plan priorities is called cognitive stacking.Cognitive stacking and patient-centered care
When the number of nursing activities reaches a high cognitive stacking load, the nurse’s ability to focus so as to maintain information about the stacked activities in an active, quickly retrievable state may be lessened. Conceivably a high cognitive stacking load may override the nurse’s ability to appropriately attend to a given patient’s priorities. A high stacking load may lead to errors or omissions. Researchers have found numerous work patterns that add to the complexity of nurses’ work including disorganized supply sources, missing supplies, and frequent interruptions. In addition, Ebright et al. (2000) and Potter et al. (2005) found nurses making tradeoffs in an effort to balance the often conflicting goals of maintaining patient safety, avoiding increasing complexity, preventing getting behind, and maintaining patient and family satisfaction. The authors suggest that research can no longer focus solely on the impact of working conditions on patient safety but must study the impact of the work environment on nurses’ complex clinical decision-making.
To meet Destiny’s needs, the nurse calls the medical consult team on the floor, engaging the hospitalist and the pharmacist. The team is able to provide Destiny with one pack of pills prior to discharge. An OB/GYN consult is ordered. The team is able to provide Destiny with one pack of pills prior to discharge.Providing interprofessional, team-based care
Many hospital systems have adopted TeamSTEPPS as an evidence-based teamwork system to improve communication and teamwork skills among health care professionals. TeamSTEPPS (safe, timely, effective, efficient, patient centered) was developed by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. The goal of the system is to produce effective teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients, increase team awareness, clarify team roles and responsibilities, resolve conflicts, improve information sharing, and eliminate barriers to quality and safety. In this scenario, the nurse used a team-based approach to meet Destiny’s contraceptive and confidentiality needs.
This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.What if Destiny needed a different contraceptive method?
Taking a Sexual History
Many patients are uncomfortable providing private information about their sexual history and behaviors. In A Guide to Taking a Sexual History the CDC provides recommendations for skills building in this area, which is essential to unintended pregnancy prevention care. It is important to acknowledge the nature of the questions, assure confidentiality, and explain that understanding this part of the patient’s life will help guide discussion on choosing the contraceptive method that will work best for the individual.
Bright Futures provides professional guidelines that recommend all teens have their first reproductive health visit between ages 11 and 15 years, with regular reproductive health visits throughout the adolescent years. Some discussions, such as sexual history taking and counseling, may best be had privately between the teen and the provider. Other times during the visit it may be important to include the teen’s parents or guardians. The Bright Futures textbook and online resource provides detailed information on well-child care for health care practitioners. It is considered the gold standard of pediatric care, including adolescent care.
Reproductive Life Plan Assessment
Assessing and helping a patient understand his or her reproductive life plan is a way for clinicians to provide preconception care and to work with patients to develop a contraceptive plan that will work best for the patient. In Preconception Health and Health Care: Information for Health Professionals the CDC provides information on the evidence-based effectiveness of preconception interventions, how to incorporate them into clinical practice, and links to other resources such as “Clinical Content for Women” and “Reproductive Life Plan Tool.”
Before, Between, & Beyond Pregnancy also describes how to assess a patient’s reproductive life plan, provides some key questions that will help solidify the plan, and makes recommendations on integrating reproductive life plan assessments into clinic operations.
After discussing Destiny’s experiences with various forms of birth control to understand her reactions and preferences, the nurse can use a tiered approach to contraceptive counseling, which involves presenting the most effective methods first. In 2014, the CDC released Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office Of Population Affairs, which offers guidance on providing high quality family planning and related preventive health services, including recommendations to use a tiered approach to contraceptive counseling and management. The CDC’s Selected Practice Recommendations for Contraceptive Use, 2013 and the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provide evidenced-based counseling and management recommendations for various contraception methods.
A useful way to think about the efficacy of reversible contraceptive methods is to use the terminology devised by the authors of Contraceptive Technology.
- Tier One: IUDs and implants. Failure rates >1%.
- Tier Two: injections, oral contraceptives, patches and rings. Failure rates 6 –12%.
- Tier Three: diaphragms, male and female condom, fertility awareness, spermicides and withdrawal. Failure rates >12%.
This interactive website, Method Match, from the Association of Reproductive Health Professionals (ARHP) provides fact sheets on different methods of contraception that includes information on efficacy, how each method works, benefits and contraindications of each. In addition, this Counseling Session video from LARC First is available in English and in Spanish, and provides a demonstration of high quality, non-directive counseling on contraception options.
Eva’s Care (Patient Situation #2)
Eva is a 23-year old woman who came to the emergency room during a manic episode. She was diagnosed with Type I Bipolar Disorder and is now stable. Her discharge medications include Lamictal 25 mg for two weeks, then 50 mg for two weeks with an expected daily dose of 100 mg per day.
A busy emergency room in an acute care hospital.
As the nurse reviews Eva’s chart for results of a pregnancy test, STI screening and for a contraception plan, she notices that the result of a pregnancy test, although ordered at admission, is not in the chart. After confirming that the test was not performed, the nurse has Eva collect a urine specimen and ensures that the specimen is sent to the lab. Eva’s discharge is delayed pending test results.Could Eva continue her medications if she were pregnant?
Until recently the FDA used five categories to indicate the potential of a drug to cause birth defects if used during pregnancy. The categories were determined by the reliability of documentation and the risk to benefit ratio. They do not take into account any risks from pharmaceutical agents or their metabolites in breast milk. The categories are:
- Category A: Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
- Category B: Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
- Category C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Lamictal is in this category.
- Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
- Category X: Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
The article Recent Changes in Pregnancy and Lactation Labeling: Retirement of Risk Categories (Ramoz and Patel-Shori, 2014) reviews and summarizes the FDA’s new pregnancy and lactation labeling rule, which will replace these five categories. The new rule is being implemented in response to decades of criticism to improve the risk vs. benefit of drugs used by pregnant and nursing mothers.
Using the older FDA labeling system, Lamotrigine is a Category C and should be monitored before, during, and after pregnancy. Women should be advised to notify their health care provider if they plan to start or stop use of oral contraceptives or other female hormonal preparations. Physiological changes during pregnancy may affect lamotrigine concentrations and/or therapeutic effect. Decreased lamotrigine concentrations during pregnancy and restoration of prepartum concentrations after delivery have been reported. Dosage adjustments may be necessary to maintain clinical response.
Researchers working with the North American Antiepileptic Drug (NAAED) Pregnancy Registry reported an unexpectedly high prevalence of isolated, non-syndromic, cleft palate and/or cleft lip in infants exposed to lamotrigine monotherapy during the first trimester of pregnancy. In the NAAED registry, 564 pregnant women were treated with lamotrigine monotherapy, and 5 oral cleft cases (2 isolated cleft lip, 3 isolated cleft palate) occurred (total prevalence of 8.9 per 1000). Prevalence of non-syndromic oral clefts among infants of nonepileptic mothers not taking lamotrigine from 0.50 to 2.16 per 1000 in studies from the U.S., Australia and Europe.
In addition, animal studies have revealed maternal toxicity and secondary fetal toxicity producing reduced fetal weight, delayed ossification, and fetal death. Animal studies have also reported that lamotrigine has decreased fetal folate concentrations, an effect known to be associated with teratogenesis in humans. There are no controlled data in human pregnancy.
Lamotrigine serum concentrations in a newborn child comparable to those usually achieved in active treatment have been reported. Pregnancy increases lamotrigine clearance by over 50%. This effect occurs early in pregnancy and reverts quickly after delivery.
Providers are advised to recommend that pregnant patients taking lamotrigine enroll in the NAAED Pregnancy Registry. This can be done by calling the toll free number 1-888-233-2334, and must be done by patients themselves. Information on the registry can also be found here.
The results of Eva’s pregnancy test are negative. The nurse discusses Eva’s reproductive life plan so that she can make an appropriate referral: if Eva does not want to be pregnant in the near future she will need reliable contraception and a referral to a gynecology/women’s health provider post discharge; if she is interested in planning a pregnancy soon, Eva needs a referral to a gynecology/women’s health expert for close management.What are Eva’s contraceptive options?
Following guidance from Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office Of Population Affairs, the nurse offers Eva information on the most effective contraceptive methods first, long-acting reversible contraceptives (LARCs): the hormonal implant (Nexplanon), which would last up to 3 years, and IUDs. Current IUDs are FDA approved for up to 3, 5, or 10 years. Pelvic inflammatory Disease (PID) was once thought to be higher in IUD users and thus IUD use was contraindicated in young women to preserve their fertility. Current research from Grimes (2000) suggests that PID and infertility are no more likely to occur with IUDs than with any other method of contraception. The presence of STIs, usually chlamydia, and not IUD use causes PID, therefore all adolescents should be screened for STIs at the time of insertion of an IUD to reduce the risk of PID. In addition, a 2001 study conducted by Hubacher et al. (2001) concluded that “tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use.”
Many myths exist about IUDs. The presentation IUD’s – Dispelling the Myths from the Reproductive Health Access Project, uses case studies to present factual information about intrauterine devices and their mechanisms, compares different types, and side effects including non-contraceptive advantages. In addition, LARC FIRST is a comprehensive website that not only provides information on long-acting reversible contraceptive methods, but also includes videos, counseling tips, training and preceptoring information, quality management, and patient resources.
If Eva did not want a LARC method, she could start oral contraceptives that day, in which case dose adjustments are necessary with lamotrigine (Lamictal). Ideally both medications would be started at the same time to allow for ease of titration. Estrogen-containing oral contraceptives have been shown to increase the clearance of lamotrigine. In women not taking other anti-seizure medications, the maintenance dose of lamotrigine will likely need increasing by 2-fold over the recommended dosing to maintain consistent plasma levels. The dose increases should begin at the same time that the oral contraceptive is started and continue at 50 to 100 mg/day every week. Gradual transient increases in lamotrigine plasma levels may occur during the pill free week; monitoring for side effects is needed. If stopping oral contraceptives, the dose of Lamictal will likely need decreasing by as much as 50. The effect of other hormonal contraceptive preparations on the pharmacokinetics of lamotrigine has not been systematically evaluated. Progestin-only pills had no effect on lamotrigine plasma levels. The FDA requires detailed prescribing information for each medication that is approved in the U.S.
Eva states that she is not ready to be pregnant and parent any time soon, is sexually active, and would like a referral to a gynecology/women’s health provider to discuss her contraceptive options. Unfortunately, many health care systems lack processes and infrastructure to track referrals and follow-up. If Eva does not make or keep her appointment, her health care provider or system of care may not be aware of this fact if they are not tracking referrals and follow-up. Eva may continue to be at risk for unintended pregnancy and not get the care she needs.Providing effective referrals to community based care
The process of transferring responsibility for care is referred to as the “handoff,” with the term “signout” used to refer to the act of transmitting information about the patient. Handoffs and signouts occur in the context of transfers of care during hospitalization and related to discharge and follow-up in the community. This is often done via electronic medical records using informatics to provide quality patient care.
In a hospital setting, no provider can work around the clock, so shifts in staffing inherently create a discontinuity of care. The Agency for Healthcare Research and Quality notes that “[t]his discontinuity creates opportunities for error when clinical information is not accurately transferred between providers.” In nursing, the SBAR method (Situation-Background-Assessment-Recommendation) has become widely accepted not only as a signout tool but also as a structured method for all communications between providers.
The Joint Commission requires all health care providers to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions” (2006 National Patient Safety Goal 2E). The Joint Commission National Patient Safety Goal also contains specific guidelines for the handoff process and preventing “adverse events” after discharge. For Eva, an “adverse event” could be barriers that prevent her from keeping a contraceptive appointment. Common barriers include the cost of care, transportation difficulties, limited ability to take time off of work, lack of childcare or language difficulties. Delays in initiating a contraceptive method could lead to an unintended pregnancy. If pregnant, barriers to accessing care could lead to late entry for prenatal care or delay in accessing an abortion.
To provide effective referrals, it is essential for nurses to be aware of other providers in the area.
- Find a Nurse Practitioner is a resource from the American Association of Nurse Practitioners. The interactive map will help a consumer find a NP in their geographic area.
- DoctorFinder is a resource from the American Medical Association that provides professional information on almost every licensed physician in the United States and can be used to locate doctors who specialize in prenatal care.
- The Association of Reproductive Health Professionals maintains a database of providers of long-term reversible contraceptive methods (implants and IUDs). The interactive map will help a consumer find a LARC provider in their geographic area.
This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.What if the pregnancy test was positive?
The nurse recognizes that this patient’s care requires a team approach to meet all of Eva’s needs. The nurse contacts the hospitalist or provider on call. The hospitalist orders a gynecology consult prior to discharge as well as a social work consult. However, when Eva learns of the test result, she is likely to begin talking with the nurse, the care provider at her bedside. The nurse is prepared to discuss pregnancy test results in a nonjudgmental manner. The nurse knows that hearing the results of a pregnancy test can be a life changing moment for patients, and may be difficult for Eva.
When giving pregnancy test results it is important for nurses to understand that the results belong to the patient and it is the nurse’s responsibility to provide the results and what they mean without bias. Hearing the results of a pregnancy test can be a life changing moment; women may be delighted, regretful, anxious, and sometimes ambivalent about the being pregnant. Since it is difficult to predict how someone will feel when receiving the results, it is important not to congratulate the patient and allow time for the information to “sink in” before asking if she would like more information.
This presentation, Giving Pregnancy Test Results: A Primer for Nursing Students, from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and an overview of laboratory pregnancy tests is provided. Recommendations are given on specific questions to ask and counseling language to use when providing negative and positive test results, and working with a patient who is ambivalent about the test results.
After giving Eva the results of the pregnancy test, the nurse will determine how far pregnant Eva is. Pregnancy wheels are commonly used to determine the due date or estimated date of confinement (EDC). Wheels are based on Naegele’s rule which estimates the EDC by adding one year, subtracting three months, and adding seven days to the first day of a woman’s LMP. The result is approximately 280 days (40 weeks) from the LMP. Wheels may vary by a day or two or it is easy for a health care provider to misread a wheel by a day or two. Electronic calculation is considered more accurate.
Depending on Eva’s reaction to the test results, and with her permission, the nurse would discuss Eva’s options in a non-directive, patient-centered manner. Eva’s options include a first trimester abortion with medication or an aspiration procedure, continue with the pregnancy, or she could make an adoption plan. Options Counseling for Unintended Pregnancy is a presentation from Provide’s ROE (Reproductive Options Education) Consortium was designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.
Truly non-directive options counseling can be difficult because of one’s own beliefs, especially if we have a strong feeling that we know what the best option is for a woman. In Options Counseling: Techniques for Caring for Women with Unintended Pregnancies Singer provides guidance for clinicians to examine their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy. A set of exercises in The Abortion Option from the National Abortion Federation supports health care workers to identify their values and define their boundaries related to options counseling, abortion care, adoption care, pregnancy care and the role of health care workers in providing options counseling.
While options counseling is a critical component to high quality health care, not all health care workers have the knowledge and skill to provide effective options counseling. Simmonds and Likis address the conflicts that nurses may experience when providing unintended pregnancy prevention and care, and examine the intersection of personal values with professional responsibilities in their 2005 article Providing Options Counseling for Women with Unintended Pregnancies. The article also provides epidemiological data on unintended pregnancy and strategies for providing options counseling.
First Trimester Abortion
These nursing education modules use the term “aspiration” abortion when discussing first trimester abortion care because it more accurately depicts a first trimester abortion than does “surgical” abortion. According to Weitz et al. (2004) surgical “implies incision, excision and suturing and is associated with the physician subpopulation of surgeons.”
The First Trimester Abortion: A Comparison of Procedures from the National Abortion Federation (NAF) shows a side-by-side comparison of three types of abortion procedures, how they work, advantages and disadvantages to each. NAF also publishes Clinical Policy Guidelines, which are evidence-based guidelines and standards on abortion care. They include clinical practices on patient care and counseling and different types of abortions. These guidelines, which are revised annually, are based on rigorous review of medical literature and known patient outcomes to support and educate providers on the most current information, standards, and recommendations. The following modules are specific to this competency:
- Module 5: Limited Sonography in Abortion Care
- Module 6: Early Medication Abortion
- Module 7: First-Trimester Aspiration Abortion
A 2014 Guttmacher Institute reports on the many barriers that exist for access to abortion care. The barriers are based on state specific restrictions such as mandatory waiting periods, doctor and clinic restrictions, lack of abortion providers, and limits on insurance coverage. Often such delays mean the woman is more advanced in pregnancy when she is able to access care. The nurse may need to coordinate with other providers to ensure Eva gets the care she needs, when she needs it, if she decides to terminate the pregnancy.
Making an Adoption Plan
If Eva decided to continue the pregnancy and make an adoption plan, she would likely place the baby for adoption shortly after birth. In a domestic infant adoption there are several options for how the process could work for Eva and the adoptive family. A social worker can work with Eva to find an optimal good match in an adoptive family. Eva could choose to have an open adoption, where identifying information is shared between families with an agreed-upon level of contact, or she could opt for a closed adoption with no shared identifying information. The Basics of Adoption Practices: A Bulletin for Professionals from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway, details types of adoption, family and child assessments, birth parent involvement, and how the placement and adoption process works including post-adoption services.
The nurse could also direct Eva to view Open Adoption: Could Open Adoption be the Best Choice for You and Your Baby? a resource from the U.S. Department of Health and Human Services’ Administration for Children and Families for expectant parents. There is a specific section on open adoption that details how it works, the benefits, legalities and action steps for this type of adoption.
With the choice to make an adoption plan, Eva commits to continuing the pregnancy, which requires intensive management of Lamotrigine.
Continuing the Pregnancy and Parenting
In addition to managing Eva’s Lamotrigine doses and response during her pregnancy and postpartum, Eva will need a plan that involves additional psychological support after the baby is born. Viguera et al. (2011) found that the risk of postpartum depression increases from 15% in the general population, to 50% in women with bipolar disorder (30% for women in unipolar disorder). Eva may benefit from home nurse visits. A recent study by Horowitz et al. (2013) found that when nurses visited new mothers diagnosed with postpartum depression to teach them how to bond with their babies, symptoms of depression decreased and interaction between mother and baby improved.
Quality and Safety Education for Nurses (Cronenwett, L., et al., 2007)
This article details how QSEN faculty used the IOM competencies to develop specific competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics). Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be developed during pre-licensure nursing education.
Crossing the Quality Chasm: A New Health System for the 21st Century
This report was produced by the IOM and articulated quality and safety problems with the U.S. health care system.
Health Professions Education: A Bridge to Quality
Using IOM competencies, the QSEN project defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency.
Keeping Patients Safe: Transforming the Work Environment for Nurses (National Research Council, 2004)
This publication details a study conducted by the IOM to identify key aspects of health care work environments that are likely to impact patient safety and recommend improvements in working conditions to improve patient safety.
An Analysis of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors (Potter P., et al., 2005)
This article presents a new approach to looking at how workflow in acute care hospital setting impacts nurses’ ability to make critical decisions about patient care. Having an improved understanding of the cognitive work of nurses may provide insight into the origins of medical errors.
Understanding the Complexity of Registered Nurse Work in Acute Care Settings (Ebright, P.R., et al., 2003)
In response to nursing shortages and the need for improved patient safety this article reports on a study that explored factors affecting registered nurse performance during work on acute care medical-surgical units.
The Complex Work of RNs: Implications for Healthy Work Environments (Ebright, P., 2010)
This article describes the complex work of registered nurses in today’s healthcare settings. The article addresses the complexity in delivering patient care by reviewing recent research on the work of nursing and explaining the concept of nurse cognitive stacking.
Core Competencies for Interprofessional Collaborative Practice
This 2001 report by an expert panel of educators from higher learning institutions presents interprofessional competencies to support the development of a workforce prepared to use effective teamwork and team-based care.
Core Principles & Values of Effective Team-Based Health Care
This discussion paper from the IOM provides common reference points for health care providers to improve coordinated collaboration and interprofessional team-based care. This resource highlights principles and values for effective team-based care, the importance of establishing clear roles, effective communication, and measureable process and outcomes of high-functioning health care teams.
Medical Teamwork and Patient Safety: The Evidence-based Relation (Baker, D.P., et al., 2011)
This publication from the Agency for Healthcare Research and Quality presents evidence to support the relation between team training and patient safety. The authors address the nature of effective teamwork, teamwork-related knowledge, skills, and attitudes, and contextual issues surrounding teamwork.
U.S. Selected Practice Recommendations for Contraceptive Use, 2013
These recommendations are designed as a companion guide to the MEC and are intended to help nurses and other health-care providers address issues related to use of contraceptives, including how to help a woman initiate use of a contraceptive method, which examinations and tests are needed before initiating use of a contraceptive method, what regular follow-up is needed, and how to address problems that often arise during use, including missed pills and side effects such as unscheduled bleeding. The document is based on the World Health Association’s (WHO) global health guide to contraception. Although many of the recommendations are the same as those provided by the WHO, they have been adapted to be more specific to U.S. practices or have been modified because of new evidence.
Recent Changes in Pregnancy and Lactation Labeling: Retirement of Risk Categories (Ramoz, L.L. and Patel-Shori, N.M., 2014)
This article provides a review and summarizes the FDA’s new pregnancy and lactation labeling rule replaces the five categories previously used. The new rule is being implemented in response to decades of criticism in an effort to improve the risk versus benefit of drugs used by pregnant and nursing mothers.
Recommendations to Improve Preconception Health and Health Care — United States
This report from Centers for Disease Control and Prevention (CDC) provides ten recommendations to improve preconception health that focus on changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps that, when implemented, can yield results within 2–5 years.
Preconception Care Clinical Toolkit
This extensive, interactive website was designed to help primary care providers and their practices incorporate preconception health into the routine care of women of childbearing age. The toolkit includes clinical guidance, patient resources, talking points, risk reduction strategies, and reproductive life planning assessments.
Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs
This set of guidelines for the provision of quality family planning and related preventive health services in primary care settings was released as a CDC Morbidity and Mortality Weekly Report (MMWR) in April 2014. The report details recommendations for the provision of contraceptive services, pregnancy testing and counseling, including effective options counseling.
Caring for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2011)
This article highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts.
A Guide to Taking a Sexual History
The Centers for Disease Control and Prevention provide recommendations for skills-building in this area which is essential to providing unintended pregnancy prevention care.
Contraceptive Options and Abortion
This presentation from the Reproductive Health Access Project uses case studies to determine the most appropriate contraceptive methods for different patients, detailing the risks, benefits, mechanisms of action, and other clinical considerations for each case.
Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy (ACOG, 2009)
This AGOG Committee Report recommends LARC methods be used as first-line contraceptive methods and encouraged for most women.
This interactive website from the Association of Reproductive Health Professionals (ARHP) provides fact sheets on different methods of contraception that includes information on efficacy, how each method works, benefits and contraindications to each.
IUD’s – Dispelling the Myths
This presentation from the Reproductive Health Access Project uses case studies to present factual information about intrauterine devices, their mechanisms, comparing different types, and side effects including non-contraceptive advantages.
This website not only provides information on long-acting reversible contraceptive methods, but also includes videos, counseling tips, training and preceptoring information, quality management, and patient resources.
The Counseling Session
This video from LARC FIRST is available in English and in Spanish, and provides a demonstration of high quality, non-directive counseling on contraception options.
Giving Pregnancy Test Results: A Primer for Nursing Students
This presentation from Provide serves as a guide for nursing students on giving pregnancy test results, identifying immediate health concerns, providing referrals, and gives an overview of laboratory pregnancy tests. Recommendations are given on specific questions to ask and counseling language to use when providing negative and positive test results, and working with a patient who is ambivalent about the test results.
Options Counseling: Techniques for Caring for Women with Unintended Pregnancies (Singer, J., 2004)
This article serves as a guide for clinicians to examine their own beliefs and values to improve their skills in providing nonjudgmental and nondirective options counseling for women experiencing unplanned pregnancy.
Providing Options Counseling for Women with Unintended Pregnancies (Simmonds, K. and Likis, F., 2005)
This article addresses the conflicts that nurses may experience when providing unintended pregnancy prevention and care, and examines the intersection of personal values with professional responsibilities. The article also provides epidemiological data on unintended pregnancy and strategies for providing options counseling.
Options Counseling for Unintended Pregnancy
This presentation from Provide’s ROE (Reproductive Options Education) Consortium was designed to give nurses and APRNs information on attitude, skills, and knowledge needed to provide options counseling to patients who experience unintended pregnancy.
The Abortion Option: A Values Clarification Guide for Health Care Professionals
These exercises from the National Abortion Federation are designed to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are presented to identify and examine potential biases.
“Medical” and “Surgical” Abortion: Rethinking the Modifiers (Weitz, T.A., et al., 2004)
Two descriptors, “medical” and “surgical,” have become the most commonly used modifiers for abortion. While these modifiers are comprehensible to most professionals active in the abortion field, the phrases “medical abortion” and “surgical abortion” are confusing for health service providers outside the abortion field, policymakers and the public. The authors suggest that the term “medication” abortion is clearer that the term “medical” and that “aspiration” abortion more accurately describe first trimester procedures.
National Abortion Federation 2015 Clinical Policy Guidelines
These evidence-based guidelines and standards on abortion care from the National Abortion Federation include clinical practices on patient care, counseling, and different types of abortions. These guidelines are revised annually and are based on rigorous review of medical literature and known patient outcomes to support and educate providers on the most current information, standards, and recommendations.
First Trimester Abortion: A Comparison of Procedures
This chart from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures and how they work as well as advantages and disadvantages to each.
A Surge of State Abortion Restrictions Puts Providers—and the Women They Serve—in the Crosshairs (Guttmacher Institute, 2014)
This report highlights the many barriers that exist to access to abortion care based on state restrictions including mandatory waiting periods, doctor and clinic restrictions, and limits on insurance coverage. The report also looks at the lack of abortion providers in the United States.
The Basics of Adoption Practices: A Bulletin for Professionals
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway details types of adoption, family and child assessments, birth parent involvement, and how the placement and adoption process works including post-adoption services.
Consent to Adoption
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway addresses issues related to consenting to adoption including who is involved and when and how it can take place.
Open Adoption: Could Open Adoption be the Best Choice for You and Your Baby?
This resource from the U.S. Department of Health and Human Services’ Administration for Children and Families via the Child Welfare information Getaway is designed for expectant parents and details open adoption, how it works, the benefits, legalities, and action steps.
This resource has an interactive United States map that provides links to adoption-related organizations in each state. There is also a search feature, and various adoption-related categories to find information on adoption agencies, home studies, foster care, counseling, embryo adoption, medical evaluation, etc.
Providing Effective Referrals
Caring for Women with Unintended Pregnancies (Simmonds, K. and Likis, F.E., 2011)
This article highlights the nurse’s professional responsibilities in providing care to women with unintended pregnancies which includes appropriate assessment, options counseling, referrals and care coordination, and prevention efforts.
Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers
This curriculum from Provide includes six modules with training tips, materials, role plays, and other exercises to support health care and social service professionals to provide effective referrals for high quality abortion care.
Referral-making in the Current Landscape of Abortion Access (Zurek, M., et al., 2014)
This article highlights the increasing importance of providing effective referrals for abortion care as clinic closures further limit women’s access to these services.
National Abortion Federation Find a Provider
This web page from the National Abortion Federation includes an interactive map that gives state-specific information on abortion services and clinic contact information for each state.
Find a Nurse Practitioner
This resource from the American Association of Nurse Practitioners uses an interactive map to help a consumer find a nurse practitioner in their geographic area.
This resource from the American Medical Association provides professional information on almost every licensed physician in the United States and can be used to locate doctors who specialize in prenatal care.
Minors and Teen Pregnancy
Addendum-Adolescent Pregnancy: Current Trends and Issues (American Academy of Pediatrics, 2014)
This addendum serves as an update for pediatricians and other professionals on recent research and data regarding adolescent sexuality, contraceptive use, and childbearing since publication of the original 2005 clinical report, “Adolescent Pregnancy: Current Trends and Issues.”
Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups (Hamilton, B.E. and Ventura, S.J., 2012)
This article identifies trends in U.S. teen birth rates and analyzes the possible factors influencing the continued decline in teen birth rates including strong prevention messaging and increased use of contraception.
Minor’s Rights Versus Parental Rights: Review of Legal Issues in Adolescent Health Care (Maradiegue, A., 2003)
This article gives a detailed historical overview of privacy and confidentiality laws for minors obtaining contraception and abortion, and discusses the clinical implications for practice.
An Overview of Minors’ Consent Law
This Guttmacher Institute brief provides background information and includes a chart with laws by state on minors’ right to consent without parental permission to contraception, STI treatment, abortion, prenatal care, and medical care for minor’s child.
This module addresses quality and safety in the context of unintended pregnancy prevention and care. Nurses work with patients in many different contexts, and providing safe, patient-centered care often means addressing a patient’s reproductive health concerns in addition to the primary reason the patient initially sought medical care. This gives nurses the unique opportunity to support patients in developing and achieving their reproductive life plan through patient-centered contraceptive management and options counseling.
These modules are designed to use with a flipped classroom model in which students are directed to complete the module as homework, including the Pre- and Post-Assessments. Once students have completed the module in its entirety, including the recommended reading, faculty can use the Teaching Tips document and materials from the Exercises and Handouts section below to integrate concepts from the module into the classroom or group setting.
Exercises and Handouts
These materials can be used to enhance classroom learning. The Teaching Tips document provides recommendations on how to incorporate these materials into a classroom or group setting.
Quality and Safety Patient Scenario: This handout from Provide describes a detailed patient scenario about Ana, a sexually active 17-year old who would like help managing her acne problems. The Teaching Tips document for this module provides guidance on facilitating classroom discussion related to the scenario.
Contraception Counseling: Provider Tips and Patient Questions: This handout from CORE (Curricula Organizer for Reproductive Health Education) identifies specific questions for providers to consider and use when supporting patients in choosing a contraception method.
Patient Education and Risk Reduction Messages: This exercise from CORE (Curricula Organizer for Reproductive Health Education) is designed for nursing faculty to use in class. The activity uses interactive case studies, role-play with scenarios, and group discussion questions.
Sexual History Taking Role Play: This exercise from CORE (Curricula Organizer for Reproductive Health Education) is designed to help health care professionals improve their knowledge, skills, and comfort with sexual history taking and risk assessments. The worksheet includes questions to ask when taking a sexual history, specifically when working with LGBTQ patients.
The Abortion Option: A Values Clarification Guide for Health Care Professionals: These exercises from the National Abortion Federation include tools that can be used in class for clarifying values related to abortion and discussing the role of health care providers.
HOW to Refer: Use materials in Module 2 of Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers from Provide to present referrals as part of services provision, identify general barriers to accessing abortion care, and demonstrate best practices for referrals.
Quality and Safety In-Class Presentation
For a more traditional approach to classroom learning, content from the Quality and Safety online module was used to develop this 15 – 20 minute presentation. Faculty can use this presentation in the classroom as a substitute for students completing the module independently. The Teaching Tips document and exercises and handouts that are provided as part of the module can be used to supplement this presentation and incorporate student participation in class.
Accessing Student Pre- and Post-Assessment Data
Pre- and Post-Assessments are designed to measure students’ satisfaction with the module as well as what they have learned. To be able to complete the Assessments students will need to enter a “Site Code” prior to working through the online module. Faculty will use this Site Code to download and review students’ Pre- and Post-Assessment data. To obtain a Site Code your institution must e-mail Provide. In the text of the email, please include your name (as instructor), the name of the institution, and the module(s) for which you would like to access data. Provide will send you 1) a Site Code for your students to enter at the beginning of the assessment, 2) a web link to access the results from each module, and 3) an “answer key” to help grade your students’ responses. You may also assign a unique Student Code to each student that you would like to assess on an individual basis. Students must enter the correct Site Code for faculty to be able to access their data.