For Expert_Researcher

JOGNN R E S E A R C H Women’s Satisfaction With Obstetric Triage Services Marilyn K. Evans, Nancy Watts, and Robert Gratton

Correspondence Marilyn K. Evans, RN, PhD, Arthur Labatt Family School of Nursing, Health Sciences Addition, Room H35, Western University, London, Ontario, Canada. [email protected]

Keywords obstetric triage patient satisfaction pregnancy perinatal nursing labor

ABSTRACT

Objective: To determine the satisfaction of pregnant women who presented at a triage unit in an obstetric birthing care unit with obstetric triage services.

Design: Qualitative descriptive with conventional content analysis.

Setting: Individual audio recorded telephone interviews with women after discharge from a tertiary care hospital’s obstetric triage unit.

Participants: Purposive sample of 19 pregnant women who had received obstetric triage services.

Methods: A semi-structured interview guide was used for data collection. All interviews were audio-taped and tran- scribed verbatim. Data analysis was consistent with qualitative content analysis with open coding to categorize and

develop themes to describe women’s satisfaction with triage services and care.

Results: Five themes, Triage Unit Environment, Triage Staff Attitude and Behavior, Triage Team Function, Nursing Care Received in Triage and Time Spent in Triage, illustrated the women’s recent triage experiences. Overall the women were

very satisfied with the triage services. Women appreciated a caring approach from triage nurses, being informed about

the well-being of themselves and their fetuses, being closely monitored, and effective teamwork among the members

of the health care team.

Conclusions: The results indicated that a humanizing, caring approach by the inter-professional team offering obstetric triage services contributed to women’s satisfaction and woman-centered care.

JOGNN, 44, 693-700; 2015. DOI: 10.1111/1552-6909.12759 Accepted August 2015

Marilyn K. Evans, RN, PhD, is an associate professor, Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada.

Nancy Watts, RN, MN, PNC(C), is a clinical nurse specialist, Women’s and Infant’s Health Program, Mount Sinai Hospital, Toronto, Ontario, Canada.

Robert Gratton, MD, is Chief of Obstetrics and an associate professor, Western University, London Health Sciences Center, London, Ontario, Canada.

T riage, in the context of health care, involvesthe process of determining the priority of pa- tient care according to the urgency of their need for treatment and is often associated with emer- gency and disaster services (McBrien, 2009). Triage concepts have become part of obstetric practice to improve utilization of bed capacity, in- crease immediate and appropriate response to obstetric emergencies, decrease wait times, pre- vent unnecessary admissions, and standardize assessment (Angelini & Howard, 2014). Obstet- ric triage is defined as the ability to appropriately prioritize and assess pregnant women in a timely manner, to improve patient flow, and enhance pa- tient safety (Paisley, Wallace, & DuRant, 2011). An increased complexity and acuity as well as volume of pregnant women being seen in obstetric units and specifically in triage require that the perinatal nurse as the first person who meets and assesses the woman presenting for care be able to deter- mine who needs to be seen immediately and who can safely wait.

Background and Significance In a recent systematic review of literature on ob- stetric triage published from 1998 to 2013, the au- thors identified quality improvement strategies that track acuity, length of stay, and patient satisfaction as important components of best practice (An- gelini & Howard, 2014). The obstetric triage unit functions uniquely as an outpatient assessment center in an inpatient unit in most hospitals. In an effort to improve the quality of obstetrical care and patient flow, the perinatal program team at an ur- ban tertiary care hospital in Southwestern Ontario developed and implemented a 5-category Obstet- ric Triage Acuity Scale (OTAS) in 2012 (Smithson et al., 2013). The OTAS tool was adapted from the Canadian Triage and Acuity Scale (CTAS) im- plemented across Canada in emergency depart- ments for use with obstetric patients (Canadian Association of Emergency Physicians, 2015). To ensure patient safety and consistency of care, women are assessed by experienced perinatal nurses within 5–10 minutes of their arrival, are

The authors report no con- flict of interest or relevant financial relationships.

http://jognn.awhonn.org C© 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 693

R E S E A R C H Women’s Satisfaction With Obstetric Triage Services

Further research regarding obstetric triage in clinical practice settings is needed to improve patient care, flow, and safety.

asked consistent questions (primary assessment), are assigned OTAS scores, and receive care fol- lowing a more thorough assessment (secondary assessment) based on acuity level (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014). The OTAS scores range from 1 (resuscitative) and 2 (emergent) to 5 (nonurgent) with guidelines for time of health care provider ini- tial and nursing reassessment. The obstetrician, family doctor, or midwife collaborate to determine need for transfer to the labor and birth area or antenatal unit, or discharge home based on the OTAS assessment, plan of care, and required in- terventions.

In an evaluative study conducted by Smithson et al. (2013), the OTAS demonstrated acceptable interrater reliability when used by triage nurses to assess obstetric acuity. Collaboration between triage nurses and obstetricians was critical to the initial modification of the tool as was independent testing to ensure the validity on multiple occa- sions. Triage nurses challenged with an unpre- dictable flow of patients who present with various complaints can use the tool to prioritize acuity for pregnant women. Perinatal nurses who provide care in triage struggle with numbers of patients who present simultaneously in their desire to pro- vide competent nursing care to all. The volume of obstetric triage patient visits has been estimated as ranging from a ratio of 1.2 to 1.5 to the overall birth volume (Paisley et al., 2011). Data collection at the study hospital supports volume of obstetric triage patients at the ratio 1.5 or greater to overall birth volume with little or no predictability.

Patient satisfaction has become an increasingly important and commonly used indicator for evalu- ating the quality of health care (Wen & Schulman, 2014). Furthermore, patient satisfaction measures are often used by hospital administration to in- form planning and development of health care services at various levels (Britton, 2012). Women’s satisfaction with obstetric care is recognized as a key component in assessing and monitoring the quality of maternal and newborn health care ser- vices being provided (World Health Organization [WHO], 2013). Although women’s satisfaction with care they received throughout labor and birth is shown to be related to overall maternal health, well-being, and positive transition to postpartum,

the concept is poorly understood and defined (Sawyer et al., 2013).

Obstetric triage has been implemented in prac- tice over the past decade and its effect on length of stay, efficiency, and patient flow has been pos- itive, yet little is known about pregnant women’s satisfaction with receiving triage services. Obstet- ric triage services have been shown to increase patient satisfaction through having access to ap- propriate health providers and shortened length of stay (Molloy & Mitchell, 2010; Paul, Jordan, Duty, & Engstrom, 2013).The process improve- ments within the Triage unit have been evaluated with various data measures, including length of stay and time to health care provider. In order to continually enhance and provide quality and safe obstetric care to pregnant women, eliciting their satisfaction with triage medical and nursing care is needed. The purpose of this study was to de- termine women’s satisfaction with obstetric triage services from the perspective of pregnant women presenting at a Triage Unit within an Obstetric Birthing Care Unit. Research questions included: What aspects of triage care do pregnant women consider valuable? What components of obstetric triage require improvement? Greater understand- ing of women’s satisfaction with obstetric services is an effective means to ensure implementation of obstetric triage services align with woman- and family-centered care.

Methods Study Design and Sampling A qualitative descriptive design with semi- structured interviews was considered the most appropriate approach to gain insight regarding pregnant women’s satisfaction with the obstetric triage experience. Qualitative inquiry serves to in- crease understanding of the individual’s health ex- periences and behaviors (Patton, 2015). The local research ethics board granted ethical approval for this study prior to commencement of data collec- tion.

Using purposive sampling (Morse, 1999), a sam- ple of 39 pregnant women who met the inclusion criteria was initially approached and recruited by two research assistants directly from the triage unit in the obstetric birthing care unit after the women had been initially assessed by triage staff using the 5-level OTAS scale. This sampling tech- nique was used to ensure the participants had experienced obstetric triage services and would have knowledge related to the research questions.

694 JOGNN, 44, 693-700; 2015. DOI: 10.1111/1552-6909.12759 http://jognn.awhonn.org

Evans, M. K., Watts, N., and Gratton, R. R E S E A R C H

None of the 39 women approached declined to participate in the study. Eligibility criteria included women who were at >20 weeks gestation at the time of enrollment and > 18 years of age, as- sessed in the triage unit, and could communicate in English. Women who were identified as hav- ing experienced an adverse event while in triage or prior to arrival, such as suspected intrauterine death or development of a clinical condition requir- ing emergency interventions, were not eligible to participate. The decision to exclude these women was to avoid creating any additional stress. All participants were recruited during May and June, 2014.

Data Collection Eligible women initially assessed in the triage unit were identified by the triage nurses and then ap- proached by the research assistants and informed about the study. Written informed consent and contact information was obtained from interested and eligible women while they were in the triage unit. One-on-one telephone interviews were con- ducted with the women within two weeks after they were discharged from the triage unit at a time convenient to the women. All interviews were conducted by telephone for the convenience of participants and lasted approximately 20 minutes. Consent was reconfirmed at the time of the tele- phone contact and prior to conducting interviews. A semi-structured interview guide was adapted, with permission, from a previously published pa- tient obstetric triage satisfaction questionnaire to include more open ended questions (Paul et al., 2013). Guiding interview questions pertained to topics such as why the women came to the triage unit, their expectations of triage and initial impres- sions, satisfaction with information and care re- ceived from staff, time spent in triage, what was most helpful about the care received, and how could triage services be improved. Some of the questions include the following: What happened when you first arrived at triage? What were your first impressions of the triage unit? What made you phone or come to the hospital? How did you feel about the care you received during triage?

All the interviews were audio taped with the par- ticipants’ permission and transcribed verbatim by one of the researcher assistants. Data collection was terminated after the 19th interview when the research team determined that data saturation had been reached; that is no new information or themes emerged from the interviews and data analysis (O’Reilly & Parker, 2013).

Data Analysis Data collection and analysis occurred con- currently throughout the research process. All transcripts were initially read while listening to the audio tapes to ensure accuracy. Data were subsequently analyzed consistent with conventional, qualitative content analysis (Hsieh & Shannon, 2005) to identify patterns and themes from the text.Transcripts were read in their entirety by research team members to gain a sense of what the women were saying. Next, line by line open coding of the transcribed interviews was conducted by the two research assistants to independently develop a preliminary descriptive code chart of terms within the transcripts. To enhance interrater reliability of coding, transcripts were subsequently coded independently by two other research team members using the initial coding guide. Using an inductive, iterative pro- cess, the researchers compared codes, focused on key terms and recurring phrases within each interview, and refined the initial coding chart. Open coding continued, and then as patterns were identified, the codes were grouped into categories which in turn were developed into final themes. Discrepancies in the coding and the development of categories and themes were resolved through collective reflection and open dialogue among the research team members until consensus was reached on the final themes.

Results Study Sample The final sample included 19 women, and the majority (n = 11) reported being referred to the triage unit by their physicians or midwives or hav- ing scheduled appointments. Two women men- tioned having contacted telehealth (confidential telephone health service provided by registered nurses) and were advised to go to triage. Other women (n = 6) self-referred to triage for con- ditions such as headache, minor motor vehi- cle collision, or contractions. The majority of the women were assigned OTAS scores that were less urgent, OTAS = 4 (n = 6), and non-urgent, OTAS = 5 (n = 8) categories, and none were scored as emergent. The eligibility criteria used for recruitment likely contributed to these results. The average perceived time women reported as spent in triage was approximately 2.5 hours (range 5 minutes to14 hours).

Themes Five themes emerged from the data that described the participants’ satisfaction with obstetric triage

JOGNN 2015; Vol. 44, Issue 6 695

R E S E A R C H Women’s Satisfaction With Obstetric Triage Services

Participants expressed that being closely monitored and receiving information was comforting and valuable.

services and the care they received: Triage Unit Environment, Triage Staff Attitude and Behavior, Triage Team Function, Nursing Care Received in Triage, and Time Spent in Triage. Although presented separately, the five themes together demonstrated that the participants were satisfied with their recent triage experiences.

Triage Unit Environment. Many participants noted the physical characteristics and overall atmo- sphere of the triage unit when they first arrived and throughout their stays and described it as “warm,” “comfortable,” and “welcoming.” Most participants described being met by “friendly” staff. Some participants explained that although the unit appeared very busy, they were greeted right away. One participant commented that the overall environment “was very calming . . . and quiet when it needed to be.”

Interestingly many participants expected the triage unit to be similar to an emergency depart- ment, crowded and highly emotional, and that they would have to wait to be seen. They were pleased that this was not the case: “I kinda thought it would be like an emerg type thing where tons of people are sitting around crying and waiting.”

It is important to disclose that the hospital was implementing a major change in the computerized infrastructure system at the same time this study was being conducted, and all medical and nursing staff was learning a new software system. One participant mentioned being aware of this change and its potential effect on wait times, but she was understanding of the implications on care:

I know there’s a new software system they were telling me they were all trying to get used to. They just kept apologizing pro- fusely because things seem to take a little bit longer than what they expected. . . . I am sure once that is up and running smoothly it will be a fantastic flow.

In addition, the unit itself was fairly new and had only been open for three years; many participants commented that it was “beautiful” compared to other hospital units they experienced.

Triage Staff Attitude and Behavior. The triage staff was described as showing respect, kindness, and understanding of the concerns participants had about themselves and their fetuses. Participants commented on feeling valued and acknowledged by nursing staff: “They didn’t make it seem like it wasn’t a big deal . . . and wanting to just get to the bottom and see why I was feeling the way I was feeling.” The participants indicated that staff mem- bers were “personable,” accommodating, gen- uine, and attentive to their needs: “It felt more human. It felt more, ‘Okay how can we help you’ rather than “what are you doing here.’” Another woman described she felt being looked after as an individual and not “thrown with a bunch of peo- ple in the waiting room.” Participants described a caring approach used by the triage nurses: “It was just her approach with me and the way she han- dled me, the way she grabbed my arm. The way she was, ‘Don’t worry, we’ll find out what’s wrong or what’s going on.’’

The participants felt that the nursing staff under- stood the amount of pain they were experiencing and their support needs, particularly if they were first time mothers. The participants described hav- ing their questions answered and not made to feel “silly” or that they should know the answers.

Triage Team Function. While receiving care in the triage unit, the participants observed the staff go- ing about their tasks and noted how they appeared to work together effectively as a team. Many par- ticipants commented on how well the nurses and physicians communicated with each other and kept them informed about treatments, test results, and what was happening. One woman stated, “I actually had like the same nurse there that was there the day before. So I didn’t have her but she communicated with the nurse that was seeing me what was going on.” Others appreciated that their regular physicians or obstetricians external to the triage unit were made aware of their test results by the triage staff:

They did some blood work and they were able to give me the results for that, but I can’t remember exactly what it was. But when they took my blood pressure they were able to tell me what it was. They told me that they were reporting back to my physician every time to make sure that she was updated with that as well.

Another woman was in the triage unit during shift change and was impressed by the “seamless”

696 JOGNN, 44, 693-700; 2015. DOI: 10.1111/1552-6909.12759 http://jognn.awhonn.org

Evans, M. K., Watts, N., and Gratton, R. R E S E A R C H

transition between the day nurse and physician and the night nurse and physician.

Care Received in Triage. Most participants had their immediate needs promptly met by the nurs- ing triage staff and were made to feel comfortable throughout their stays: “They made sure I had ev- erything that I needed, that I was comfortable.” Others described the simple actions performed by the nurses, such as offering them a warm blan- ket, a drink of water, or a pillow. One woman ex- pressed that being made to feel comfortable was vital to her ability to understand what was hap- pening: “It was the comfort I would say, because if you don’t have that then it doesn’t mat’er the in- formation that you get ’cause you’re not going to process it.”

Being closely monitored and informed about their own well-being and the well-being of their fetuses was very reassuring and helpful for the partici- pants. They indicated that staff shared test results and answered their questions in a timely manner, so they were not “deprived of any information.” One woman described being continually moni- tored: “The most helpful would be probably just the monitoring, like the nurse I would say, the nurses coming in and out explaining . . . where my contractions were and how the baby was doing.” The participants commented on the availability of staff to answer any questions they had in a timely manner and mentioned that being in triage was a stressful situation. Knowing everything was fine kept their anxiety from “escalating.”

Time Spent in Triage. The perceived length of time the participants spent in triage varied, but they were initially seen and assessed by a triage nurse quite quickly upon their arrival to the unit. Although some participants commented on having to wait to be seen again by the triage staff after the initial assessment, many attributed this to the unit being busy:

I know that waiting time is a problem. Like you sometimes wait for a long time to see a nurse and then she does see you. You wait a long time to see her again because they are so busy.

A few participants commented that having to wait to be seen by triage staff after their initial assess- ments was likely due to the fact that other women had more urgent needs. Some participants felt their situations were not emergencies. However,

some participants described lengthy wait times between initial screening and being seen by a nurse again and then the physician. The partici- pants also commented that the length of time staff spent with them seemed short, and some would have appreciated more time with the physician. However, participants were satisfied with the qual- ity of the time spent with staff and did not feel “rushed.” They also appreciated being told the reasons for the wait.

Discussion Our results were encouraging and indicated that overall the participants in this study were very sat- isfied with their triage experiences, the informa- tion provided about the fetus and their own well- being, and the overall care they received from triage nursing staff. The caring, holistic approach demonstrated by nursing triage staff was a key contributor to the participants’ satisfaction with ob- stetric triage care. Encountering genuine, caring, and attentive staff was highly valued by all the par- ticipants. The actual presence of nursing staff was therapeutic for the participants and helped to di- minish any anxiety associated with uncertainties they had about the well-being of their fetuses and themselves.

Similar to previous research regarding patient sat- isfaction with maternity care, our results indicated that emotional and informational support from nurses and physicians is significant for women when receiving obstetric triage services (Britton, 2012; Jenkins, Ford, Morris, & Roberts, 2014). Providing physical comfort, addressing emotional needs, and ensuring positive patient-health care provider interactions are supportive strategies for women in labor (Bowers, 2002; Paul et al., 2013). Comfort measures and having their con- cerns heard in a triage environment contributed to women’s satisfaction during latent labor (Hosek, Faucher, Lankford, & Alexander, 2014). Simple caring actions, such as providing a pillow or offer- ing a glass of water, contributed significantly to the women’s feelings of satisfaction. Larkin, Begley, and Devane (2009) proposed that implementing a social model of care rather than a medical model of care embodies the notion of being with woman and facilitates individual, emotional, physical, spir- itual, and psychological presence/support by the caregiver. Others advocated humanistic perinatal care, such as the provision of emotional support, information about progress, advice, comfort mea- sures, and advocacy (Hodnett, Gates, Hofmeyr, Sakala, & Weston, 2011).

JOGNN 2015; Vol. 44, Issue 6 697

R E S E A R C H Women’s Satisfaction With Obstetric Triage Services

Collaboration among triage team members and using a holistic, caring approach contributed to women’s satisfaction with triage

services.

Lack of communication with triage nursing staff is a major source of patient dissatisfaction (Nielson, 2004). In our study, the participants’ satisfaction with triage care was associated with being kept informed about what was going on and why, knowing about the health status of the fetus, hav- ing questions answered by staff, and having tests results readily shared with them. An explanation of why they are waiting was important to the participants. These findings concur with previous findings that having access to and exchange of information, support, and a trusting relationship with caregivers contributed to women’s satisfac- tion with their childbirth experiences (Madejic, Milicevic, Vasic, & Djikanovic, 2014; Meyer, 2013). Providing opportunities for women to ask questions and receive explanations about their care was critical to a positive prenatal experi- ence (Novick, 2009).Although the women were impressed with the physical characteristics of the triage unit, positive interactions with staff were the most comforting. Similarly, findings from a study conducted with laboring women from a range of settings in Australia indicated that women were more concerned with their interactions with staff than the physical environment (Jenkins et al., 2014).

An effective relationship between a woman and her health care providers is fundamental for the quality of care provided throughout pregnancy, childbirth, and the postpartum period (Aston, Saulnier, & Robb, 2010). Health care providers need to devote time to their patients and show genuine concern for their well-being to positively influence patient satisfaction (Senić & Marinković, 2013). Relational continuity or process and the quality of patient-health provider relationships are critical for a positive pregnancy and childbirth ex- perience and patient empowerment (Dahlberg & Aune, 2013).

Our results suggest ensuring effective and ongo- ing communication between health care providers and patients is imperative within the triage setting to enhance patient satisfaction. The concept of team collaboration has been clearly identified in the literature as an integral component of a health care environment that produces optimal birth out- comes and patient satisfaction (Kapov, Wright,

& Kean, 2014; Putnam, Ikeler, Raup, & Cantu, 2014). Furthermore, inter-professional collabora- tion improves patient care outcomes, promotes patient centeredness, and assists continuity of care (Posthumus et al., 2013; Raab, Brown-Will, Richards, & O’Mara, 2013). Results of our study also suggest that effective communication and collaboration between triage health team mem- bers and community-based health providers con- tributes to women’s satisfaction and should be supported and encouraged. Our findings align with evidence pertaining to inter-professional col- laboration and woman-centered care.

Our results also illustrate the importance of com- municating with health care professionals ex- ternal to the triage department, as needed, to ensure continuity of care. Ensuring continuity of care and consistency in sharing information have been identified as essential to quality care provi- sion in obstetric triage (Molloy & Mitchell, 2010).

Implications for Practice and Fur ther Research Our study findings contribute to the understand- ing of women’s satisfaction with obstetric triage and serves to inform quality intrapartum care. While care is provided by an interdisciplinary team throughout a triage visit, the nurse the eyes and ears of the team and provides ongoing as- sessment, intervention, and communication that is critical to the woman’s care (Behling & Re- naud, 2015). Timely assessment and close moni- toring are integral parts of the OTAS scoring sys- tem and are current quality measures for triage (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014). Our results indicated that nurses, despite experiencing in- creased volumes in the triage unit, still find time to develop therapeutic relationships and provide patient-centered care. Quality measures currently being used to measure outcomes such as the pro- cesses related to OTAS do not commonly mea- sure communication, documentation, and team- work but they are critical to the success and perceived patient satisfaction (Howard & Jolles, 2015).

Interestingly, the women initially expected to find that the triage unit would be similar to an emer- gency department and were pleased to find the unit, although at times busy, was calm and quiet. Further research is needed on how environmen- tal characteristics of an emergency department that offers obstetric triage services influence preg- nant women’s satisfaction. Further research is also

698 JOGNN, 44, 693-700; 2015. DOI: 10.1111/1552-6909.12759 http://jognn.awhonn.org

Evans, M. K., Watts, N., and Gratton, R. R E S E A R C H

warranted to explore satisfaction with triage care from the perspective of women whose initial as- sessment places them in a more acute OTAS category. In addition, it would be interesting to determine how women’s satisfaction of care re- lates to their specific OTAS score. As the OTAS tool is implemented in other obstetric triage set- tings, such as small non tertiary care hospitals offering maternity services and in emergency de- partments within hospitals, determining women’s satisfaction within these other practice settings is warranted.

Effective interprofessional collaboration within the obstetric triage unit contributes to women’s satis- faction. Our findings support triage staff embrac- ing a caring and inter-professional approach for providing care to women admitted to a triage unit. More research is warranted to determine what aspects of interprofessional practice relate to patient’s satisfaction of triage care.

Strengths and Limitations To our knowledge this is the first strictly qualitative study to determine pregnant women’s satisfaction with obstetric triage service. Open ended inter- viewing allowed the women’s voices to be heard and enhanced our understanding of their satis- faction with the care they received. In addition, our results provided some insight about the role inter-professional team work may play to enhance patient satisfaction.

Limitations to this study included a small sam- ple that was recruited from one large urban ter- tiary care setting offering obstetric triage services. Smaller facilities or those in nonurban settings of- fering maternity services might implement triage operations in a different and unique manner. In addition, most of the women included in the study had less urgent or nonurgent triage acuity scores. Women who are assessed as urgent, emergent or resuscitative may have provided different re- sponses regarding satisfaction. The study was also retrospective in nature and asking women to recall a past event invites the potential for recall bias. Since all the women needed to be English-speaking, applicability of the results to non-English-speaking women is limited. Finally, our findings are largely limited, as demographic characteristics of the participants are unknown, leaving our results open to bias. Our study would have benefited from including more descriptors about the sample.

Conclusion Obstetric triage offers a health service whereby pregnant women can be assessed and treated by qualified health professionals for labor and non-labor related conditions in a timely and safe manner. Our results indicated the significance of implementing a humanizing approach in obstet- ric triage services. Women’s satisfaction of care received while in triage involved an initial and on- going caring approach from nursing staff and the interdisciplinary team. Although obstetric triage involves effective time management and prompt assessment, nurses, physicians and other team members are capable of exhibiting a holistic car- ing approach and effective communication. Such behaviors contributed to women’s satisfaction and fortunately have not been lost.

REFERENCES Angelini, D., & Howard, E. (2014). Obstetric triage: A system-

atic review of the past fifteen years: 1998–2013. Ameri-

can Journal of Maternal Child Nursing, 39(5), 284–297. doi:

10.1097/NMC.0000000000000069

Association of Women’s Health, Obstetric and Neonatal Nurses.

(2014). Women’s health and perinatal nursing care quality draft

measures specifications. Washington, DC: Author. Retrieved

from https://www.awhonn.org/awhonn/content.do?name=02_ PracticeResources/02_perinatalqualitymeasures.htm

Aston, M., Saulnier, C., & Robb, K. (2010). Not just another delivery:

Women’s maternity care experiences of provider client relation-

ships. Women’s Health & Urban Life, 9(1), 32–49.

Behling, D., & Renaud, M. (2015). Development of an obstetric vital

sign alert to improve outcomes in acute care obstetrics, Nurs-

ing for Women’s Health, 19 (2), 128–141. doi: 10.1111/1751-

486X.12185

Bowers, B. (2002). Mothers’ experiences of labor support: Ex-

ploration of qualitative research. Journal of Obstetrics, Gy-

necologic, and Neonatal Nursing, 31(6), 742–752. doi:

10.1177/0884217502239218

Britton, J. R. (2012). The assessment of satisfaction with care in the

perinatal period. Journal of Psychosomatic Obstetrics and Gy-

naecology, 33(2), 37–44. doi: 10.3109/0167482X.2012.658464

Canadian Association of Emergency Physicians. (2015). Canadian

triage and acuity scale. (CTAS). Ottawa, Ontario, Canada: Au-

thor. Retrieved from http://caep.ca/resources/ctas

Dahlberg, U., & Aune, I. (2013). The woman’s birth experience: The

effect of interpersonal relationships and continuity of care. Mid-

wifery, 29 (40), 407–416. doi: 10.1016/j.midw.2012.09.006

Hodnett, E. D., Gates, S., Hofmeyr, G. J., Sakala, C., & Weston,

J. (2011). Continuous support for women during childbirth

(Review). The Cochrane Library, 2, 1–100. Retrieved from

http://apps.who.int/rhl/reviews/CD003766.pdf

Hosek, C., Faucher, M., Lankford, J., & Alexander, J. (2014). Per-

ceptions of care in women sent home in latent labor. Amer-

ican Journal of Maternal Child Nursing, 39(2), 115–121. doi:

10.1097/NMC.0000000000000015

Howard, E., & Jolles, D. (2015). Navigating the perinatal quality land-

scape. Journal of Perinatal and Neonatal Nursing, 29(2), 116–

129. doi: 10.1097/JPN.0000000000000092

JOGNN 2015; Vol. 44, Issue 6 699

R E S E A R C H Women’s Satisfaction With Obstetric Triage Services

Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualita-

tive content analysis. Qualitative Health Research, 15(9), 1277–

1288. doi: 10.1177/1049732305276687

Jenkins, M., Ford, J., Morris, J., & Roberts, C. (2014). Women’s expec-

tations and experiences of maternity care in NSW: What women

highlight as most important. Women and Birth, 27(3), 214–219.

doi.org/10.1016/j.wombi.2014.03.002

Kapov, D., Wright, G., & Kean, L. (2014). Prioritization in the labor suite.

Obstetrics, Gynaecology & Reproductive Medicine, 24(6), 157–

161.

Larkin, P., Begley, C., & Devane, D. (2009). Women’s experience of

labor and delivery: An evolutionary concept analysis. Midwifery,

25(2), e49–e59. doi:10.1016/j.midw.2007.07.010

Madejic, B., Milicevic, M., Vasic, V., & Djikanovic, B. (2014).

Maternal satisfaction with organized perinatal care in Ser-

bia. BMC Pregnancy Childbirth, 14(14), 1–9. Retrieved from

http://www.biomedcentral.com/1471-2393/14/14

McBrien, B. (2009). Translating change: The development of

a person-centered triage training programme for emer-

gency nurses. International Emergency Nursing, 17(1), 31–37.

doi:10.1016/j.ienj.2008.07.010

Meyer, S. (2013). Control in childbirth: A concept analysis and syn-

thesis. Journal of Advanced Nursing, 69(1), 218–228. doi:

10.1111/j.1365-2648.2012.06051.x

Molloy, C., & Mitchell, T. (2010). Improving practice: Women’s views

of a maternity triage service. British Journal of Midwifery, 18(3),

186–191.

Morse, J. (1999). Strategies for sampling. In J. Morse (Ed.), Qualitative

health research: A contemporary dialogue (2nd ed., pp. 127–

145). Newbury Park: Sage Publications.

Nielson, D. (2004). Improving ED patient satisfaction when triage

nurses routinely communicate with patients as to reasons for

waits: One rural hospital’s experience. Journal of Emergency

Nursing, 30(4), 336–338. doi:10.1016/j.jen.2004.06.015

Novick, G. (2009). Women’s experience of prenatal care: An integrative

review. Journal of Midwifery & Women’s Health, 54(3), 226–237.

doi:10.1016/j.jmwh.2009.02.003

O’Reilly, M., & Parker, N. (2013). “Unsatisfactory saturation”: A

critical exploration of the notion of saturated sample sizes

in qualitative research. Qualitative Research, 13(2),190–197.

doi:10.1177/1468794112446106

Paisley, K., Wallace, R., & DuRant, P. (2011). The develop-

ment of an obstetric triage acuity tool. American Jour-

nal of Maternal Child Nursing, 36(5), 290–296. doi:

10.1097/NMC.0b013e318226609c

Patton, M. (2015). Qualitative research & evaluation methods integrat-

ing theory and practice. (4th ed.). Thousand Oaks: Sage Publi-

cations.

Paul, J., Jordan, R., Duty, S., & Engstrom, J. (2013). Improving sat-

isfaction with care and reducing length of stay in an ob-

stetric triage unit using a nurse-midwife managed model of

care. Journal of Midwifery and Women’s Health, 58, 175–181.

doi:10.1111/j.1542-2011.2012.00239.x

Posthumus, A. G., Scholmerich, V. L., Waelput, A. J., Vos, A. A., De

Jong-Potjer, L. C., Bakker, R., & . . . Denktas, S. (2013). Bridging

between professionals in perinatal care: Towards shared care in

The Netherlands. Maternal Child Health Journal, 17(10), 1981–

1989. doi:10.1007/s10995-012-1207-4

Putnam, J., Ikeler, S., Raup, G., & Cantu, K. (2014). There’s

no “I” in team: Evaluating nurse-physician collaboration.

Nursing Management, 45(1), 10–13. doi: 10.1097/01.NUMA.

0000440636.71636.ea

Raab, C., Brown-Will, S., Richards, S., & O’Mara, E. (2013). The

effect of collaboration on obstetric patient safety in three

academic facilities. Journal of Obstetrics, Gynecologic, and

Neonatal Nursing, 42(5), 606–616. doi: 10.1111/1552-6909.

12234

Sawyer, A., Ayers, S., Abbott, J., Gaye, G., Rabe, H., & Duley, L.

(2013). Measures of satisfaction with care during labour and

birth. BMC Pregnancy and Childbirth, 13, 108. Retrieved from

http://www.biomedcentral.com/1471-2393/13/108

Senić, V., & Marinković, V. (2013). Patient care, satisfaction and

service quality in health care. International Journal of Con-

sumer Studies, 37(3), 312–319. doi: 10.1111/j.1470-6431.2012.

01132.x

Smithson, D., Twohey, R., Rice, T., Watts, N., Fernandes, C., & Gratton,

R. (2013). Implementing an obstetric triage acuity scale: Inter-

rater reliability and patient flow analysis. American Journal of

Obstetrics & Gynecology, 209(4), 287–293. doi:10.1016/j.ajog.

2013.03.031

Wen, J., & Schulman, K. A. (2014). Can team-based care im-

prove patient satisfaction? A systematic review of random-

ized controlled trials. PLoS ONE, 9(7), e100603. doi:10.

1371/journal.pone.0100603 Retrieved from https://

archive.org/details/pubmed-PMC4094385

World Health Organization. (2013). Consultation on improving mea-

surement of the quality of maternal, newborn and child care

in health facilities. Geneva, CHE: Author. Retrieved from

http://apps.who.int/iris/bitstream/10665/128206/1/97892415074

17_eng.pdf

700 JOGNN, 44, 693-700; 2015. DOI: 10.1111/1552-6909.12759 http://jognn.awhonn.org

Copyright of JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.