Patient
Situation 1
Quality and Safety
in Unintended Pregnancy
and Prevention Care
Destiny’s Care
(Patient Situation #1)
The Patient
Destiny is a 17 year-old girl who was
admitted to the orthopedic floor postsurgery 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.
The Setting
A large hospital. Today the unit is very busy
and the nurses have heavy caseloads.
What Happened
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 3 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.
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Are oral contraceptives contraindicated for
Destiny?
If Destiny is immobile for an extended period of time during recuperation from
surgery, she is at risk for deep vein thrombosis (DVT). In this case, a hormonal
method may compound her risk of DVTs. Destiny’s use of pills need to be
discussed with her orthopedist in light of her post-operative recovery activity
level.
Most patients are encouraged to ambulate beginning a few hours after surgery
and to gradually increase activity each post-op day. Since she will be ambulating,
her provider states that resuming low dose oral contraceptives upon discharge is
allowed.
Destiny’s revelation about taking oral contraceptives was a surprise to the nurse
on duty. The nurse expected a straightforward session of discharge planning to
be finalized when Destiny’s father returned to take her home.
Can Destiny receive contraception without a
parent’s consent?
In Minor’s Rights Versus Parental Rights: Review of Legal Issues in Adolescent
Health Care Maradiegue provides a detailed historical overview of privacy and
confidentiality laws for minors obtaining contraception, and discusses the clinical
implications for practice. Each state has different laws regarding a minor’s right
to consent to health care services without parental permission. The Guttmacher
Institute brief, An Overview of Minors’ Consent Law, provides background
information and includes a chart comparing state laws on minors’ right to consent
to contraception, sexually transmitted infection screening and treatment, abortion
services, prenatal care, and medical care for a minor’s child.
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 minors to obtain contraceptive services without parent consent.
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.
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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. This trend may be due 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.
To better address patient-centered care, 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 quality of care by meeting her
reproducitve health 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 on funding family planning programs, over $7
was saved in Medicaid and other public expenditures associated with unintended
pregnancy related care.
What Happened (continued)
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.
QUALITY AND SAFETY
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Destiny’s Care
(Patient Situation #1)
Cognitive stacking and
patient-centered care
Cognitive shifts occur in response to
patients’ needs, the organizational style of
the nurse, and environmental demands. For
example, a nurse will shift cognitively when
a patient’s condition changes, medications
need to be administered or, as in this
case, when a patient request requires
additional attention. Cognitive shifts occur
frequently throughout a nurse’s workday
and showcase the challenge a nurse has
in remembering and carrying out priorities
of care in conditions that are fast-paced
and unpredictable. The nurse uses the
organizational skill of stacking and restacking to determine which activities to
complete and which should remain on hold.
When the number of nursing activities reaches a high cognitive stacking load, the
nurse’s ability to focus in an active, quickly retrievable state may be lessened.
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 make 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.
What Happened (continued)
The product information instructions for oral contraceptives state that if three or
more pills are missed in a row, throw out the rest of the pill pack and start a new
pack the same day. Destiny will not be able to get to the clinic in the near future
to pick up pills since she cannot drive for a few weeks. How can the nurse help
assist in problem solving?
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If the hospital pharmacy stocked Destiny’s oral contraceptive, the the hospitalist
could write an order and the nurse would dispense the pack prior to discharge.
However, the pharmacy might not stock the medication. In this case. Destiny
needs to figure out if her clinic will allow a friend to pick up a pack of pills for
her given the circumstances. A call to the family planning clinic will answer this
question. If this strategy does not work, the hospitalist could write an order for
a pack of pills. A friend could pick up the prescription for Destiny the next day.
Fortunately Destiny is taking a low cost pill so that the pharmacy cost is not
significantly higher than the cost at the family planning clinic.
If Destiny were to be sexually active during this cycle, she should use a back up
method such as condoms.
Providing interprofessional, team-based care
The nurse is skilled in teamwork and collaboration and it is important to engage
members of the health care team to address patient concerns, to provide high
quality care, and to assure patient satisfaction. QSEN states teams should
function effectively within nursing and inter-professional teams, fostering open
communication, mutual respect, and shared decision-making to achieve quality
patient 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.
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What If...
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.
Destiny wants to change her contraceptive
method in three months?
If Destiny decides she is not
interested in continuing with depot
medroxyprogesterone acetate (DMPA),
the nurse in the outpatient clinic will
need to facilitate contraceptive decisionmaking. In the course of this discussion,
Destiny acknowledges that she had
difficulty remembering to take oral
contraceptive pills consistently. As part of
the health care team, this nurse has the
skill to take a sexual history, facilitate a
discussion of reproductive life planning,
provide information on contraceptive
options and convey all of this to Destiny’s
provider.
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.
Contraceptive Counseling
Contraceptive counseling should always
be patient centered, that is, provided in a
respectful manner that ensures that each
person is supported in identifying the
method that best meets his or her needs.
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• Tier One: IUDs and implants. Failure
rates >1%.
After discussing Destiny’s experiences
with various forms of birth control to
• Tier Two: injections, oral
understand her reactions and preferences,
contraceptives, patches and rings.
the nurse can use a tiered approach
Failure rates 6 –12%.
to contraceptive counseling, which
involves presenting the most effective
• Tier Three: diaphragms, male and
methods first. In 2016, the CDC released
female condom, fertility awareness,
Providing Quality Family Planning Services:
spermicides and withdrawal. Failure
Recommendations of CDC and the U.S.
rates >12%.
Office Of Population Affairs, which offers
guidance on providing high quality family
The interactive website, Method Match,
planning and related preventive health
from the Association of Reproductive
services, including recommendations to
Health Professionals (ARHP) provides
use a tiered approach to contraceptive
counseling and management. The CDC’s fact sheets on different methods of
Selected Practice Recommendations for contraception that includes information
on efficacy, how each method works,
Contraceptive Use and the U.S. Medical
benefits and contraindications of each.
Eligibility Criteria for Contraceptive Use
provide evidenced-based counseling and In addition, the Counseling Session video
from LARC First is available in English and
and management recommendations for
in Spanish, and provides a demonstration
various contraception methods.
of high quality, non-directive counseling on
A useful way to think about the efficacy of contraception options.
reversible contraceptive methods is to use
the terminology devised by the authors of
Contraceptive Technology.
References
Finer and Zola. (2014). Shifts in intended and unintended pregnancies in the
United States, 2001-2008. https://www.ncbi.nlm.nih.gov/pubmed/24354819
Guttmacher Institute. (2016). Fact sheet: unintended pregnancy in the United
States. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
Maradiegue, A. (2003). Minor’s rights versus parental rights: review of legal issues
in adolescent health care. http://onlinelibrary.wiley.com/doi/10.1016/S15269523(03)00070-9/abstract
Center for Disease Control and Prevention. (2011).Teenagers in the United
States: sexual activity, contraceptive use, and childbearing, 2006-2010 national
survey of family growth. http://www.cdc.gov/nchs/data/series/sr_23/sr23_031.pdf
American Academy of Pediatrics Policy Statement. (2014). Addendum—
adolescent pregnancy: current trends and issues. http://pediatrics.
aappublications.org/content/133/5/954.full.pdf+html
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Hamilton and Ventura. Centers for Disease Control and Prevention. (2012). Birth
rates for U.S. teenagers reach historic lows for all age and ethnic groups. http://
www.cdc.gov/nchs/data/databriefs/db89.htm
United Nations Statistic Division. (2011). Table 10: live births. http://unstats.un.org/
unsd/demographic/products/dyb/dyb2011/Table10.pdf
Guttmacher Institute. Frost et al. (2014). Return on investment: a Fuller
assessment of the benefits and cost savings for the US publicly funded family
planning program. https://www.guttmacher.org/sites/default/files/pdfs/pubs/
journals/MQ-Frost_1468-0009.12080.pdf
EBright et al. (2000). Understanding the complexity of registered nurse work in
acute care settings. https://www.ncbi.nlm.nih.gov/pubmed/14665827
Potter et al. (2005). An analysis of nurses’ cognitive work: a new perspective for
understanding medial errors. https://www.ncbi.nlm.nih.gov/books/NBK20475/
Center for Disease Control and Prevention. Guide to taking a sexual history. http://
www.cdc.gov/std/treatment/sexualhistory.pdf
Bright Futures Tool and Resource Kit. https://brightfutures.aap.org/materials-andtools/tool-and-resource-kit/Pages/default.aspx
Center for Disease Control and Prevention. (2014). Preconception health and
health care: information for health professionals recommendations. http://www.
cdc.gov/preconception/hcp/recommendations.html
Before, Between, and Beyond Pregnancy. http://beforeandbeyond.org/
Method Match. http://www.arhp.org/methodmatch/
LARC Counseling Session. http://www.larcfirst.com/sessions.html
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