1. family and parenting
2. motherhood
3. pregnancy

PREECLAMPSIA: UNDERSTANDING AND IMPLEMENTING
THE CALIFORNIA MATERNAL QUALITY
CARE COLLABORATIVE TOOLKIT
A Project Presented to the Faculty
of
California State University, Stanislaus
In Partial Fulfillment
of the Requirements for the Degree
of Master of Science in Nursing
By
Jennifer Serratos
May 2015
CERTIFICATION OF APPROVAL
PREECLAMPSIA: UNDERSTANDING AND IMPLEMENTING
THE CALIFORNIA MATERNAL QUALITY
CARE COLLABORATIVE TOOLKIT
by
Jennifer Serratos
Signed Certification of Approval Page is on file with the University Library
Marla J. Seacrist, RN, PhD
Associate Professor of Nursing
Date
Beth Stephens-Hennessy, RNC, OB-EFM, MSN
Clinical Nurse Specialist
Date
Vicki Henry, RN, MSN/Ed
Clinical Nurse Educator
Date
© 2015
Jennifer Serratos
ALL RIGHTS RESERVED
DEDICATION
I would like to dedicate this project to all the women and children that will be
helped through the use of the evidence based best practice regarding preeclampsia.
iv
ACKNOWLEDGEMENTS
I would like to acknowledge my family and their sacrifices that assisted me to
reaching my goal of my master degree; Nicholas, Andrew, Allison, Kamarin, Ken,
Colleen, and Melissa. Also I would like to recognize my committee members and
chair for their countless hours to assist me with the multiple revisions to this project.
Each one of you brought a different expertise that help to refine this project. Marla
Seacrist as my chair, good friend, and mentor your guidance and many talks to help
me off the “ledge” and redirect me were invaluable. Vicki Henry you are one of the
smartest women I know and your input as an educator and non-obstetrics nurse made
sure that the information was relevant to a new learner. Beth Stephen-Hennessy you
were my content expert and your participation assisted me to insure the information I
was reading and interpreting for the end project was valid. Finally, I would like to
thank Wendy Matthew for all you have done in supporting me through this process of
getting our master’s degree; the endless texting, proofreading my papers and being
the exact opposite of me. Again thank you all, as it truly takes a village to raise a
child… or in this case complete an evidence based project that has the potential to
help many women and children.
v
TABLE OF CONTENTS
PAGE
Dedication ...............................................................................................................
iv
Acknowledgements .................................................................................................
v
Abstract ................................................................................................................... viii
Understanding and Implementing Elements of a Toolkit .......................................
1
Theoretical Frameworks .............................................................................
Preeclampsia .............................................................................................
Implementation of the Toolkit and Evaluation ...........................................
Summary of Culminating Experience Project ............................................
1
2
2
3
Background, Significance, and Theoretical Frameworks .......................................
4
Knowles Andragogical Model ....................................................................
Kolb’s Experiential Learning Theory .........................................................
Learning Styles ...........................................................................................
The Power of a Checklist ............................................................................
Change Theory ............................................................................................
6
7
8
14
16
Preeclampsia Literature Review .............................................................................
19
Definition of Hypertensive Disorder ..........................................................
Risk Factors for Preeclampsia ....................................................................
Historical Perspective of Preeclampsia .......................................................
Pathogenesis of Preeclampsia .....................................................................
Current Standard of Practice Prior to CMQCC Toolkit..............................
20
21
23
25
28
CMQCC Toolkit Implementation ...........................................................................
32
American College of Obstetricians and Gynecologists ..............................
California Pregnancy Associated Mortality Review...................................
California Maternal Quality Care Collaborative.........................................
Implementation ...........................................................................................
33
34
35
37
Evaluation ...............................................................................................................
41
Board of Registered Nursing ......................................................................
Evaluation Tools .........................................................................................
42
43
vi
Overall Conclusion of Project .....................................................................
44
References ...............................................................................................................
48
Appendices
A.
B.
C.
D.
E.
F.
G.
H.
I.
Summary of Articles from the CMQCC Toolkit ........................................
History and Pathophysiology of Preeclampsia ...........................................
California Maternal Quality Care Collaborative: Preeclampsia Education
Preeclampsia Early Recognition Tool ........................................................
Evaluation and Treatment of Antepartum & Postpartum Preeclampsia .....
Treatment for Severe Preeclampsia ............................................................
Eclampsia Checklist ....................................................................................
Online Module Evaluation Tool .................................................................
Simulation Evaluation.................................................................................
vii
61
64
70
77
78
79
80
81
82
ABSTRACT
The California Maternal Quality Care Collaborative (CMQCC) created a toolkit that
defined the best practices for hypertensive disorders in pregnancy. Knowledge gaps
exist in the understanding of pathophysiology, history, and treatment of preeclampsia.
According to the CMQCC, hypertensive disorders occur in 12-22% of pregnancies,
resulting in the leading cause of maternal mortality. The purpose of this culminating
project is to implement an adult learning program that includes both a didactic portion
and an experiential component focusing on preeclampsia. Various theoretical
frameworks, teaching strategies, and learning theories will be discussed to build the
background foundation. These theories include: Knowles Adult Learning theory,
Kolb’s Experiential Learning theory, Kotter’s Change theory, Online and Computer
based learning, and the power of the checklist in the field of healthcare. The aim of
this project is to assist staff nurses and providers who work in maternal health
departments. Key words include: Preeclampsia, adult learning theory, andragogical,
online and computer based learning, checklist in nursing, evaluation, and simulation.
The outcome of this project will be a computer based learning module, a team based
simulation scenario, and finally a best practice checklist and algorithms regarding the
history, pathophysiology and current treatment for preeclampsia, supported by the
elements from the CQMCC toolkit. The rewards of an evidence based learning
program for nurses, implications for future research and implications for nursing
practice regarding preeclampsia will be explored.
viii
UNDERSTANDING AND IMPLEMENTING ELEMENTS OF A TOOLKIT
Preeclampsia and its associated syndromes are one of the leading causes of fetal and
maternal morbidity (Druzin, Shields, Peterson, & Cape, 2013; Martin, 2013; Silasi, Cohen,
Karumanchi, & Rana, 2010). The syndrome of preeclampsia is diagnosed when a previously
normotensive preganat female develops a new onset of hypertension and has symptoms of
either proteinuria or end organ dysfunction (August, 2014; Sibai, 2012). Staff nurses at this
author’s hospital were surveyed, and readily admit to a knowledge gap in understanding
hypertensive disorders of pregnancy, specifically related to preeclampsia, the history of
preeclampsia, and the current treatment of preeclampsia.
Two separate expert task forces [California Maternal Quality Care Collaborative
(CMQCC) and The American College of Obstetricians and Gynecologist (ACOG)] convened
to investigate the management of hypertension in pregnancy and published their evidence
based recommendations (ACOG, 2013; Druzin, Shields et al., 2013). The purpose of this
culminating experience project is to develop an electronic learning (e-learning) module, a
simulation scenario, and a preeclampsia checklist using the CMQCC toolkit. The title of the
reference toolkit is Improving Health Care Response to Preeclampsia: A California Quality
Improvement Toolkit.
Theoretical Frameworks
Theoretical frameworks will be used to guide the development of this project.
Knowles’ (1989) andragogical models will be discussed in reltation to adult learning and
strategies. Kolb’s (1984) experiential learning theory will be used to guide the
implementation of the simulation scenario. Kotter’s (1996) change theory will be used to
guide the implementation of the CQMCC toolkit and evidence based practice changes.
1
2
Additionally three different learning styles will be explored to determine the best practice for
implantation of the e-learning, simulation, and checklist portions of this project.
Preeclampsia
In order to effectively use the CMQCC toolkit an extensive literature review was
conducted to gain knowledge about preeclampsia, its history, risk factors, prognosis, and
treatment. Preeclampsia affects 3% to 5% of all pregnancies, and has a perinatal and neonatal
mortality rate of 10% worldwide (Silasi et al., 2010). In California, preeclampsia is
responsible for 17% of all maternal deaths, in which all of were judged to be preventable to
some degree (Druzin, Walsh et al., 2013). The United States of America allocated between
18 to 22 billion dollars of direct healthcare cost to treat women with preeclampsia and their
neonates in 1992 (Shmueli, Meiri, & Gonen, 2012). It is important to look at the past
treatment and history of preeclampsia, to gain insight that will produce best practices and
tools, for future patients suffering from preeclampsia.
Implementation of the Toolkit and Evaluation
Many reasons can be attributed to errors occurring in healthcare. According to
Ennen and Satin (2014), patient safety is at risk due to human fallibility errors, complexity in
the medical field, and defensive barriers. Many strategies can be implemented to reduce
errors; such as individual education, simulation and drills, the development of evidence based
protocols, guidelines and checklists (Kohn, Corrigan, & Donaldson, 2000). The end product
for this culmination experience project will include an e-learning module, a checklist, and a
simulation scenario. The module content will include the history, risk factors, and current
treatment of preeclampsia. The checklist is to be used when a preeclampsia patient arrives to
a maternal child unit to direct the treatment and interventions of care the patient will receive.
Finally a simulation scenario for a preeclamptic patient experiencing an eclamptic seizure
3
will be drilled, on a maternal child unit, to educate the staff on the care that is expected to be
delivered. The creation and/or implementation of these items will be guided by the CMQCC
toolkit (Druzin, Shields et al., 2013).
Summary of Culminating Experience Project
The final section of this culminating experience project will be to identify the gaps
that still exist after the implementation of the e-learning, simulation, and checklist related to
the care of the preeclampsia patient. Despite the fulfillment of several areas of needed
education and implementation this project will complete, new areas of future research or
education will become evident after completion. Furthermore implications for future nursing
practice will be acknowledged and discussed, along with an overall evaluation of the
application of this culminating experience project.
Preeclampsia is one of the most common complications of pregnancy affecting both
the mother and fetus (Druzin, Shields et al., 2013). The treatment of preeclampsia is
currently a rescue perspective, as opposed to a preventable approach. Until the definitive
cause of preeclampsia is found, prevention remains elusive. However, with the development
of the CMQCC toolkit, a standard of interventions for best practice is now available for
providers, clinical staff, hospitals, and healthcare organizations (Druzin, Shields et al., 2013).
One would hope that with the implementation of evidence based practice interventions
regarding preeclampsia, there will be a decrease morbidity and mortality for mothers and
babies.
BACKGROUND, SIGNIFICANCE, AND THEORETICAL FRAMEWORKS
Nursing professionals are lifelong learners. The current emphasis for
treatment and care for their patient population is to apply evidence based best
practices. Learning opportunities should have a theory based foundation. Knowledge
regarding the various learning styles, theories, models, and frameworks ensure that
the education being delivered is appropriate to meet the learning goals. The reliable
models and theories, created by Knowles (1989) and Kolb (1984), are appropriate for
the implementation of adult active learning strategies. Some adult active learning
strategies include simulation, computer based learning, and standardization of care
through the use of a checklist. Changing the standard for practice to reflect evidence
based best practices within the field of nursing is a slow process.
With the emphasis in the medical field to create a culture of safety by
applying evidence-based best practice for better patient outcomes and safety, nurses
must continue to learn best practices. Nurses must have research-based knowledge
and apply it appropriately when caring for patients (Gawande, 2010). Nurses are
lifelong learners requiring continuing education for the renewal of their professional
licenses (Curran, 2014). It is imperative for nurses to be professionally accountable
with current education, skills, knowledge, and delivery of care that has been
supported by the best evidence (Bromley, 2010). Learning opportunities should be
accessible and convenient.
4
5
Challenges for nurses to keep up to date with their knowledge include staffing
problems that make it difficult for acute care facilities to allow staff to attend
conferences. Cost for extended education is expensive with the travel, course fees,
time off from work, and time away from their families (Bromley, 2010). The goal is
to make education obtainable for the staff nurse so that he/ she will continue to apply
critical thinking and clinical reasoning with evidence based best practices.
Adult learners are classified as being between the ages of 25 to 64 and
somehow involved in a learning experience for work or non-work purpose’s
(Promoting Adult Learning, 2005). Many adult learning theories can be referenced to
guide nursing education. Malcolm Knowles (1989) and his adult learning framework
along with David Kolb’s (1984) experiential learning theory will be the theatrical
frameworks applied in the development and implementation of this project. As with
adult theorists, many teaching strategies can be used to educate the adult learner. The
active teaching strategy that will be applied is computer based or electronic learning
(e-learning), along with simulation, and checklist development and usage. Change is
difficult for some people especially those in the nursing field that have been doing the
same thing the same way for years. Lastly, the application of a change theorist will
guide and assist with the concept and implementation of change for practicing nurses.
Currently there are two types of learning; passive and active. Passive learning
is when the learner is not required to be an active participant in the learning (Phillips,
2005). An example of passive learning is the traditional reading from the textbook,
watching videos, and attending lecture. The educator gives the information and the
6
learner recalls the ideas. According to Phillips (2005), fewer high level cognitive
skills are applied, and the learning is often at a lower level. Active learning strategies
engage the learner and demand an advanced level of thinking. The learner is required
to integrate, relate, and retain the knowledge. Educators’ roles change from a teacher
to facilitator; it is now the students’ responsibility to learn when using active learning
(Phillips, 2005).
Knowles Andragogical Model
Many different theories are embedded in nursing research that would serve to
provide a foundation for this project. Malcom Knowles (1989) is the adult learning
framework that will guide this cumulating project. According to Curran (2014),
Knowles coined the word andragogy to build his assumptions on adult learning
theory. Andragogy refers to scholarship that uses learner focused teaching, where the
student and educator use a collaborative approach (Bromley, 2010; Curran, 2014;
Phillips, 2005; Reeves & Reeves, 2008). Some examples of andragogical educational
strategies that promote active learning are: learners collaborating with their peers,
online discussion forums, web based tele conferencing, and instructive feedback from
instructors (Bromley, 2010). According to Knowles, (1989) his andragogical model
(adult learning framework) is comprised of six assumptions:
Adults need to know why they need to learn something before undertaking to
learn it. Adult have a self-concept of being responsible for their own lives.
Adults come into an educational activity with both a greater volume and a
different quality of experience from youths. Adults become ready to learn
7
those things they need to know or to be able to do in order to cope effectively
with their real-life situations. In contrast to children’s and youths’ subjectcentered orientation to learning (at least in school), adults are life centered (or
task centered or problem centered) in their orientation to learning. While
adults are responsive to some extrinsic motivators (better jobs promotions,
salary increases, and the like), the more potent motivators are intrinsic
motivators. (Knowles, 1989, pp. 83-84).
The application of Knowles andragogical model will be threaded into this project, as
all the learners are adults, self-directed, prefer active learning strategies, and create
their environment for the knowledge to meet their needs.
Kolb’s Experiential Learning Theory
After the learner gains the cognitive information presented in the learning
modules, they will have the ability to apply the knowledge in a simulated
environment. Kolb’s (1984) experiential learning theory is a learner-center approach
that focuses on the learner actively problem solving and contributing to the physical
experience (Curran, 2014; Lisko & O’Dell, 2010). Experiential learning is a
continuous process that changes the way a person reasons and performs by
transforming the experience into cognitive concepts (Lisko & O’Dell, 2010) The four
stages of an experiential learning cycle are concrete experience, reflective
observation, abstract conceptualization, and finally active experimentation (Stutsky &
Laschinger, 1995). According to Kolb (1984) experiential learning theory stages are:
8
An orientation toward concrete experience focuses on being involved in
experiences and dealing with immediate human situations in a personal way.
An orientation toward reflective observation focuses on understanding the
meaning of ideas and situations by carefully observing and impartially
describing them. An orientation toward abstract conceptualization focuses on
using logic, ideas, and concepts. An orientation toward active
experimentation focuses on actively influencing people and changing
situations (Kolb, 1984, pp. 68-69).
The application of Kolb’s experiential learning theory will be threaded into this
project, as all the learners will be asked to apply didactic cognitive skills into a
simulation scenario.
Learning Styles
According to Overview of Learning Styles (2013), there are seven different
ways that individuals can learn; visual, logical, verbal, physical, aural, social, and
solitary. The visual learning or spatial learner tend to prefer pictures, images, and can
use spatial references for understanding and tend to be fast-paced learners. The
logical learning style or mathematical learner prefers to use logic or reasoning for
understanding. The verbal learning or linguistic learner tends to use words, either in
writing or speech to gain an understanding. A physical learning style or kinesthetic
learner will use their body, hands and the sense of touch to gain knowledge. The
aural learning style or auditory-musical learner will use sound, song, or music to
increase knowledge. The social style or interpersonal learner prefers to learn in a
9
group setting with other people, whereas the solitary learning style or intrapersonal
learner tends to want to work alone. Most people tend to have a style that they prefer
to use and may use a combination of one or more styles (Overview of Learning
Styles, 2013). With the implementation of the California Maternal Quality Care
Collaborative (CMQCC) preeclampsia toolkit and simulation scenarios, it will be
imperative to build various learning styles into the curriculum that will meet the
learning style of the students.
Active learning strategies will be engaged in the project. Along with knowing
how different people learn, evaluate the assumptions the various generations of
learners hold in regards to their learning. According to Phillips, (2005), baby
boomers (aged 44-64 years) may have barriers against using an e-learning module as
they lack computer skills and are accustomed to passive learning. Generation X
(aged 24-44 years) are not as technological astute as generation Y, and might not
know where to find information (Phillips, 2005).This generation is highly
independent with problem solving, multitasking, and frequently challenge authority
(Clark, 2008). Generation Y (aged 24 years and younger) are easily assimilated into
e-learning as they are knowledgeable about current technology (Phillips, 2005). This
generation has the greatest cultural diversity, is self-reliant, question frequently,
expects respect from others, is the most technologically advanced, and is often
addicted to visual media (Clark, 2008).
10
Computer Based Learning
As technology improves, so does the way in which people are taught. No
longer are classroom lectures (passive learning) the only way instruction is
administered. Computer based learning (CBL) is becoming more conventional in
nursing as a quality way to promote higher order cognitive skills where the learner is
self-directed and independent (Blake, 2010; Bromley, 2010, Phillips, 2005). Using
only CBL compared to lecture has shown to have lower satisfaction and higher
dropout rates over the long term from students if the learning is only computer based
(Adams, 2004; Blake, 2010; Hahne, Benndorf, Frey, & Herzig, 2005; Smith & Reed,
2008). There are many studies that illustrate online courses are as effective of a
learning strategy as traditional lecture in a classroom settings (Blake, 2010; Bromley,
2010; Phillips, 2005; Reeves & Reeves, 2008; Smith & Reed, 2008). Technology
allows new ways to obtain continuing education. Learning segments for nurses’
development can be in the form of short modules or mandatory competencies
(Phillips, 2005). The learning segments are placed on institutions computer learning
systems that are available to the staff at any time and any day (Phillips, 2005).
Disadvantages occur with only using CBL education. It is important to
review what is currently published to understand why students do not like e-learning
prior to building a comprehensive learning module. Social isolation without human
contact or lack of immediate feedback (the ability to ask questions, or have
knowledge tested) have all contributed to CBL failures (Blake, 2010; Bromley, 2010).
Lack of computer literacy or competency in basic computer skills, along with
11
accessibility due to lack of connectivity of the internet, have been shown to be
frequent situations that create a non-optimal learning environment (Bromley, 2010).
Finally from the educators point of view, concerns are that computer based learning
can be labor- intensive, is costly since it requires the purchase of a learning system,
and the educator has the lack of human contact to provide immediate feedback or
knowledge testing (Blake, 2010; Bromley, 2010; Phillips, 2005).
The advantages of CBL are flexibility of learning, increased opportunities for
professional development, individually paced learning, and enhanced quality of
education (Blake, 2010; Reeve & Reeves, 2008). Online learning is a way to engage
learners into active learning strategies (Phillips, 2005). Online learning puts the
learner in charge of their own learning, by having them choose when to do the
learning. It allows them to repeat lessons to improve knowledge acquisition and,
finally, there is less cost as a result of less need to travel to seminars and learning
courses (Blake, 2010; Bromley, 2010; Smith & Reed, 2008). According to Reeves
and Reeves (2008), there are five rewards with online learning. Online course are
more affordable, with increased higher- order cognitive skills such as problem solving
and clinical reasoning. Secondly, learners have multiple venues to obtain knowledge,
instead of just a lecture and information from an outdated text book. Thirdly,
academic staff can reform the curriculum to align with professional agencies and
accreditation standards. The fourth reward is that educators can become renewed
professionally by using the new opportunities to teach. Lastly, the learner is prepared
for learning in the 21st century with the newest technologies (Reeves & Reeves,
12
2008). It is important to ensure that the educators are developing quality courses with
constructive feedback incorporated as a way of formative assessment of the students
(Adams, 2004).
Breaking lessons into small achievable steps, with short quizzes or test to
assess the knowledge from the learner, should be incorporated in CBL (Adams,
2004). The context of the learning modules should incorporate text, images, videos
with sound, and interactive learning (Adams, 2004). The CBL modules will give
didactic skills in conjunction to simulation which gives experiential skills through
role-play. As discussed previously, computer based learning should be paired with
hands on learning opportunities to gain the largest benefits for the learner.
Simulation
Simulation is used more often in nursing schools as a way to allow students to
have experience they may not be exposed to while in the clinical arena (Cant &
Cooper, 2010). Different kinds of high risk, low frequency procedures often happen
in the hospital setting. Simulation is one of best practice tools for developing a
culture of safety (Cant & Cooper, 2010). Simulation is discovery learning with a
group approach, in which role playing involves a case study that unfolds as the
learners perform tasks and processes in real time with well-defined constraints and
responsibilities (Adams, 2004; Clark, 2008; Kohn, Corrigan, & Donalson, 2000;
Rourke, Schmidt, & Garga, 2010). The goal for the simulation experience is to offer
learners an opportunity to apply contextual learning (Lisko & O’Dell, 2010). This is
achieved by problem solving, while using simulation models or confederates (actors),
13
in a safe and secure environment, where students receive feedback from simulation
champions, other team members, or through video recording (Cant & Cooper, 2010;
Kohn et al., 2000; Rourke et al., 2010). Research shows that cooperative learning, as
with simulation, leads to improved learning, and superior outcomes are produced as
the participants are motivated to actively engage in the learning process (Imel, 1999).
It is imperative to recognize that not all learners will see the significant aspects of the
simulation scenario, and the educator will need to draw out the missed learning
opportunities during a debrief (Adams, 2004). According to Cant and Cooper (2010),
there are four key elements that are accomplished with simulation, 1) the
development of psychomotor skills through repetition where technical proficiency is
achieved, 2) experts or champions of simulation, assist the learner and tailor the
scenario to meet the needs of the learner, 3) the learner is given a specific learning
objective to achieve, and 4) clinical reasoning is developed by the learner through the
application of the knowledge and skills (Cant & Cooper, 2010).
The effectiveness of simulation learning has been discussed in many articles.
In the systematic review of 12 studies, by Cant and Cooper (2010), statistical
improvement was gained in three areas during simulation. Knowledge and skills are
improved. Secondly, the learner reported having confidence in critical thinking skills
after participating in a simulated scenario increased. Finally, the results showed that
simulation is an effective strategy for learning, where participants expressed
satisfaction with the experience. Cant and Cooper (2010) discussed one of the
important implications for nursing practice was to pair practice guidelines to
14
simulation with manikins as an effective teaching and learning method. Current
literature shows that simulation has a significant advantage over other teaching
strategies, by empowering nurses to cultivate, synthesize, and then relate that
knowledge in a safe, real life experience (Cant & Cooper, 2010).
The Power of a Checklist
The aviation industry cannot afford to have planes fall from the sky due to
human error, just as nurses cannot afford to compromise patient care. According to
the Kohn et al. (2000), healthcare like the aviation industry should develop and use
tools whenever appropriate to reduce the reliance on memory. In healthcare, the goal
is to improve outcomes in complex activities, where to rely solely on memory from
even the most experienced staff sets up errors to occur (Gawande, 2010; Kohn et al.,
2000; McDowell & McComb, 2014; Tweedale & Reiss, 2010). A checklist guides
the user to select the next appropriate action or decision by giving structure to critical
tasks, thus it assists with the reduction of making an error (Gawande, 2010; Kohn et
al., 2000).
The process of developing a checklist to include all situations or critical paths
can be difficult. Checklists must be developed using evidence based practice to
provide a foundation. A well-developed checklist that is regularly used in high risk,
low frequency procedures addresses the human failure issue and allows the
professional to use their critical reasoning (Tweedale & Reiss, 2010). Standardizing
a process of a high risk, low frequency situation can reduce the reliance of memory
and improve outcomes (McDowell & McComb, 2014; Kohn et al., 2000).
15
Standardization gives individuals a simplified process to assist with problem solving
when dealing with unfamiliar complex processes. (Kohn et al., 2000).
The best constructed checklists are brief, clear, only include the critical steps
that promote communication and team work, and finally require all users to take
action (Gawande, 2010; Tweedale, Reiss 2010). If the checklist includes every step it
will be too detailed and difficult for the user to apply, thus it will not be viewed as
useful and not used. The only steps that should be included are the critical steps that
have been shown to produce bad outcomes, or are commonly missed steps. It is
important to debrief (a thorough careful analysis) the checklist after adverse outcomes
occur to identify weakness and make improvements (Gawande, 2010). According to
Kohn et al. (2000), crew resource management (team work and communication) leads
to fewer errors, as each member of the team is “looking out” for each another and
they know that individually they are responsible for all the members on the team as
well as the outcome of the situation. Effective communication is one of the most
powerful tools a clinician has to reduce errors (Tamura-Lis, 2013). Having a checklist
to guide the actions of the team gives members a sense of trust in the each other’s
judgment and directs the care being given (Kohn et al., 2000). According to Gawande
(2010), implementing a new checklist is a cultural change that can potentially shift
responsibility; expectations of the staff, and authority in applying evidence based
patient care. It is important that the leadership team support the staff during the
implementation of a checklist (Gawande, 2010).
16
Change Theory
With the implementation of change, such as creating a culture of safety, it is
important to look at a framework that will guide the transformation of change.
Although change frameworks will not guarantee success, it can simplify or direct the
process to help those that are affected by the change (Mitchell, 2013). John Kotter
(1996) recognized eight critical factors that help successfully implement change.
Kotter’s (1996) model is as follows: there must be (a) a sense of urgency for the
change; (b) an alliance must be formed with individuals who have power and can
work together to lead the change; (c) a vision to direct the change, and a strategy to
achieve the vision; (d) the change vision must be communicated constantly to the
employees; (e) obstacles must be identified and replaced with nontraditional ideas, or
activities; (f) short term wins need to be rewarded and celebrated; (g) continue to
assess the process of change that has occurred and implement additional visions for
change as needed; (h) and finally insure that the new behaviors that have occurred
with the change have created better performances (Kotter, 1996).
Applying Kotter’s (1996) model to the implementation of the CMQCC
preeclampsia toolkit could resemble the following:

Staff need to understand preeclampsia is one of the leading cause of
maternal and fetal morbidity and mortality (Druzin, Shields, Peterson,
& Cape, 2013).

Key staff must be identified to guide the change (formal and informal
leaders, such as nurse managers, charge nurses, providers, and staff
17
nurses) with the implementation of the CMQCC toolkit, simulation,
and checklist, which are evidence based and best practice.

The CMQCC has developed an evidence based approach, which is
methodical, and will standardize care for preeclampsia patients
(Druzin, Walsh, Shields, Morton, & Peterson, 2013). The toolkit will
be the foundation for the development of the online learning, scenario
in the simulation, and the checklist.

Online learning and simulation will be mandatory for all staff and
discussed at all staff meetings and supported by the leadership team.

Computer based learning and simulation are learning strategies that
can be employed for adult learners as an alternative of class lectures
and testing.

As staff complete the computer modules, simulation exercise, and are
appreciative of the knowledge; they will become early adopters and
can assist with promoting the education to other staff.

It will be important to make sure current evidence is always being
implemented in the care for the preeclampsia patient, research, and
checklist adaptation must be ongoing.

To insure the change is permanent it will be important to audit the
patient’s charts, with a diagnosis of preeclampsia, to insure the
checklist and toolkit were followed.
18
A theory based foundation will help provide learning opportunities for nursing
professionals. Being informed about the various learning styles, theories, models, and
frameworks ensure that the education being delivered is appropriate to meet the
learning goals. Knowles (1989) and Kolb (1984) have created reliable models and
theories for implementation of adult active learning strategies. Some of those
strategies include computer based learning, simulation, and standardization of care
through the use of a checklist. Change in current knowledge based evidence and
standards for practice within the field of nursing is frequently a slow process from
inception to adoption. The ultimate goal is to educate the staff nurses caring for their
patient population by creating a culture of safety through the use of best practices.
PREECLAMPSIA LITERATURE REVIEW
Hypertensive disorders, which includes preeclampsia, are some of the leading
medical complications that effect pregnant women (Druzin, Walsh, Shields, Morton,
& Peterson, 2013; Lowdermilk, Perry, Cashion, & Alden, 2012; Martin, 2013). The
discovery of preeclampsia occurred in the fourth century BC, yet there is still no
definitive cause or prevention for the disease (August, 2014; Bell, 2010). In the
United States, hypertensive disorders are responsible for 17% of all maternal deaths,
and tragically many of these deaths could have been avoided (Druzin, Shields,
Peterson, & Cape, 2013). In a review of the pregnancy related deaths in California,
50% of the deaths from preeclampsia had a strong to good chance and the other 50%
has some chance to alter the outcome (California Department of Public Health, 2012).
Hypertensive disorders of pregnancy comprise a significant number of complications
that affect both the mother, with end-organ dysfunction, and fetus with preterm
delivery related to hostile uterine environment (Lowdermilk et al., 2012).
Preeclampsia affects 3 to 5% of all pregnancies and has a neonatal mortality rate of
10% worldwide (Silasi, Cohen, Karumanchi, & Rana, 2010) and a maternal death rate
of 10% to 15% worldwide (August & Sibai, 2014; Lowdermilk et al., 2012). This
paper will explore the definitions of hypertensive disorders associated with
pregnancy, historical perspectives, risk factors and pathogenesis of preeclampsia, and
the current standard of care for preeclampsia patients. Insight to produce best
19
20
practices and standardized tools, for the future of patients suffering from
preeclampsia will be gained.
Definition of Hypertensive Disorders
Currently the American College of Obstetrician and Gynecologist (ACOG)
use a four category classification system for hypertension during pregnancy (2013).
The different categories include gestational hypertension, chronic hypertension (from
any origin), chronic hypertension with superimposed preeclampsia, and preeclampsiaeclampsia (ACOG, 2013; August & Sibai, 2014; Lowdermilk et al., 2012).
Hypertensive disorders of pregnancy are defined as having a systolic blood pressure
(BP) greater than 140 mm Hg, a diastolic BP greater than 90 mm Hg or both on two
occasions at least six hours apart (Druzin, 2013). Severe hypertension is defined as
having a systolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm
Hg.
Gestational hypertension is described as a new onset of elevated BP that
develops after 20 weeks of pregnancy with the absence of proteinuria. Chronic
hypertension is diagnosed when elevated BP is present prior to conception or noted
before 20 weeks of gestation and persist longer than 12 weeks postpartum. Chronic
hypertension with superimposed preeclampsia is defined as elevated BP prior to 20
weeks with proteinuria or end-organ dysfunction after 20 weeks gestation (ACOG,
2013; August & Sibai, 2014; Lowdermilk et al., 2012). According to Lowdermilk et
al., this form of hypertension is difficult to diagnose and is associated with adverse
maternal and fetal outcomes (2012).
21
Preeclampsia is a progressive multisystem disorder, unique to humans during
pregnancy (ACOG, 2013; Lowdermilk et al., 2012). Preeclampsia is classified, in
pregnant women, by hypertension occurring only after 20 weeks of pregnancy and
accompanied with proteinuria or end-organ dysfunction. (August & Sibai, 2014;
Lowdermilk et al., 2012). According to ACOG the observation of proteinuria
removed as an essential criteria for the diagnosis of preeclampsia (ACOG, 2013).
Additional signs and symptoms that have been noted to occur including: (a)
headaches, (b) visual disturbances, (c) epigastric pain, (d) thrombocytopenia, (e)
abnormal liver functions, (f) pulmonary edema, and (g) renal insufficiency (ACOG,
2013; August & Sibai, 2014; Druzin, 2013; Karumanchi, Lim, & August, 2014;
Lowdermilk et al., 2012; Preeclampsia Foundation, 2013a). Preeclampsia without
severe features or preeclampsia severe features can develop into eclampsia when the
patient starts to have grand mal seizures (ACOG, 2013; August & Sibai, 2014;
Lowdermilk et al., 2012). The placenta is thought to be the root cause of
preeclampsia, as the symptoms begin to resolve once the fetus and placenta are
expelled (Druzin, Walsh, et al., 2013; Lowdermilk et al., 2012). The risk factors for
developing preeclampsia and the co-morbidities related to this disorder are important
to recognize.
Risk Factors for Preeclampsia
Current literature shows that the following are risk factors of developing
preeclampsia

prim parity of the pregnancy;
22

carrying multiple fetuses;

extreme in maternal ages, less than 20 years old, and greater than 40 years old;

new paternity;

prolonged interval between pregnancies (greater than 10 years);

previous history of preeclampsia;

family history of preeclampsia (August et al., 2014; Lowdermilk et al., 2012;
Preeclampsia Foundation, 2013a; Silasi et al., 2010).
Many co-morbidities linked to an increase chance of developing preeclampsia include

chronic hypertension;

renal disease;

obesity;

rheumatoid arthritis or lupus;

diabetes mellitus, or gestational diabetes;

migraines,

hypercoagulable states (August, 2014; August & Sibai, 2014; Lowdermilk et al.
2012).
Preeclampsia also increases the patients risk for developing life threatening events
such as

acute renal failure;

cerebral hemorrhage;

placental abruption;

pulmonary edema;
23

disseminated intravascular coagulation (DIC);

hepatic failure or rupture;

progression to eclampsia or seizures; (August & Sibai, 2014).
All of the risk factors and complications listed above (August, 2014; August & Sibai,
2014; August & Sibai, 2014; Lowdermilk et al., 2012; Preeclampsia Foundation,
2013a; Silasi et al., 2010) can have significant negative consequences for both the
mother and the baby. The fetus is especially vulnerable and has an increase in
morbidity and mortality due to a greater risk of restricted fetal growth and preterm
birth (August & Sibai, 2014).
Historical Perspective of Preeclampsia
During ancient Grecian times, from the fifth to fourth century BC,
preeclampsia or eclampsia was not classified as a formal disorder of pregnancy (Bell,
2010; Lindheimer, 2013). In the face of the limited knowledge and technology the
concept of eclampsia was noted as a headache accompanied by heaviness and
convulsions during pregnancy (Bell, 2010; Lindheimer, 2013). From 400 to 1200
AD, medical and scientific progress came to a standstill due to the influence of
Christianity (Bell, 2010).
In the Renaissance period (1400-1600), the female reproduction tract was
accurately described (Bell, 2010). By the 17th century Francois Mauricea
scientifically described eclampsia and distinguished that primigravida was a risk
factor for convulsions (Bell, 2010; Lindheimer, 2013). Mauricea posited that
convulsions were caused by inflammation due to a dead fetus or abnormal lochial
24
flow (Bell, 2010). The suppressed vaginal flow resulted in pains in the head, which
cause convulsions, suffocation, or death. Treatment during this time period was
blood-letting, purging, or altering diets, as a way to decrease cerebral congestion thus
reduce the chance of convulsions (Bell, 2010; Preeclampsia Foundation, 2013a).
The 18th century differentiated eclampsia from epilepsy (Bell, 2010;
Preeclampsia Foundation, 2013a). Epilepsy was considered to be chronic as the
convulsions recurred over time. Eclampsia was classified a disease that was acute in
nature and resolved with the removal of the precipitating event (Bell, 2010;
Preeclampsia Foundation, 2013a). It was believed, at this time, that pregnancy was
not the only precipitating event. Hemorrhage, pain, and infection could also cause
eclampsia (Bell, 2010).
In the 19th century Dr. Thomas Denman recognized that more people in large
cities and towns had convulsions (Bell, 2010). Denman’s theory for convulsions
during pregnancy was linked to the uterus. When the uterus got larger, more pressure
was placed on the descending blood vessels. This caused an increase in pressure with
the regurgitation of blood backing up into the head and overloading the vessels of the
brain causing convulsions. The treatment included: bloodletting, opiate usage, warm
baths, inducing delivery, and splashing the face with cold water. Toward the end of
the 19th century, a connection was made between premonitory symptoms and
convulsions (Bell, 2010). The development of the mercury manometer in 1896, gave
the ability to measure BP which is what transformed preeclampsia into a hypertensive
disorder, as elevated blood pressures were linked with eclampsia (Druzin, Walsh et
25
al., 2013; Lindheimer, 2013; Preeclampsia Foundation, 2013b). During this time
period the term preeclampsia was introduced and defined as the time period to deliver
women to prevent the progression to eclampsia (Druzin, Walsh, et al., 2013). With
the defining of symptoms of hypertension, edema, proteinuria, and headaches,
physicians had tangible symptoms for the diagnosis for preeclampsia (Bell, 2010).
Physicians at the beginning of the 20th century continued to identify some of
the patho-physiological changes, but failed to uncover the cause and prevention of
preeclampsia (Bell, 2010). Research during the 1960’s focused on the placenta as the
cause of preeclampsia. The findings from examining the placenta beds revealed that
placental trophoblast cells did not adequately enter into the maternal arteries in the
uterus (Bell, 2010; Roberts & Escudero, 2012). The placental trophoblast cells are
responsible for converting maternal arteries from small, high resistant vessels, to
large low resistant vessels. The lack of conversion of the maternal arteries caused
restriction in blood flow to the placenta and fetus (Bell, 2010; Roberts & Escudero,
2012). An additional hypothesis posited a reduction in placental perfusion which
causes ischemia to the placenta, resulting in toxins being produced (Bell, 2010). The
toxins then damage the endothelial cells in the blood vessels and activate the
coagulation cascade. Considerable research related to preeclampsia has been
conducted, with the results reflecting an unclear etiology (Martin, 2013).
Pathogenesis of Preeclampsia
The cause of preeclampsia is unknown, however many studies have begun
looking at placenta tissues to develop hypothesis about the pathophysiological
26
mechanisms involved in preeclampsia (Lowdermilk et al., 2012; Townsend &
Drummond, 2011). According to Karumanchi et al., placental tissue is required in the
development of preeclampsia, not fetal tissue, and the cure always occurs after the
delivery of the placenta (2014). The maternal adaptation that occur in preeclampic
women, where the placental invasion to the uterine muscle occurs, does not correctly
remodel the uterine spiral arteries (August, 2014; Karumanchi et al., 2014;
Lowdermilk et al., 2012; Townsend & Drummond, 2011). This occurs at conception.
The placentation appears to be incomplete in preeclampic women. The uterine spiral
arteries do not remodel, which is necessary to increased blood and oxygen flow from
the mother to the placenta. Remodeling occurs when cytotrophoblast cells enter the
endothelium and musculature of the maternal uterine spiral arteries. This creates
vessels that are larger in capacity and have lower resistance. If the arteries fail to
remodel they become narrow vessels and cause hypoperfusion of the placenta.
Placental infarctions along with a decreased oxygen flow to the placenta causes
placental hypoxia (Karumanchi et al., 2014; Lowdermilk et al., 2012; Townsend &
Drummond, 2011).
The symptoms from the lack of remodeling can be described as a leaking
hose. Nancy Donoho (personal communication, March, 28, 2009) once used the
leaking hose analogy to describe the effects to preeclampsia on the cellular level.
When a hose is kinked the water behind the kink may build up, or shoot out of the
faucet connection, and eventually the hose will break down. In front of the kinked
area is a reduced volume of water coming out, but it is under a higher pressure.
27
Blood vessels are the hose and blood the water. When remodeling fails to occur, the
hose (or blood vessels) kinks and the red blood cells (RBC) collide with the vessel
walls. This collision damages the RBC’s and the endothelial tissue of the vessel wall.
Some RBC’s are destroyed (hemolyzed) as they strike the walls; some are hemolyzed
as they pass by the kink. The RBC’s and fluid that do not get the kink will start
backing up into the vascular and cellular beds.
Around 20 weeks the effects of the poor placentation process subsequently
causes clinical manifestations. Placental ischemia is believed to stimulate the release
of substances that are toxic to endothelial cells, thus causing endothelial cell
dysfunction (Lowdermilk et al., 2012). The cellular dysfunction then causes
vasospasm and decreased organ perfusion, intravascular coagulation, and increased
permeability and capillary leakage (Lowdermilk et al., 2012; Sibai, 2011; Townsend
& Drummond, 2011). An in-depths look at each of these three consequences and the
manifestation will follow.
Vasospasms result in poor tissue perfusion to all the organ systems
(Lowdermilk et al., 2012). Vasospasms in turn cause

hypertension;

uteroplacental spams that cause intrauterine growth restriction;

glomerular damage that causes increased plasma uric acid and creatinine; and
oliguria;

cortical brain spams that causes headaches, hyperreflexia, and seizure activity;

retinal arteriolar spams that cause blurred vision and scotoma;
28

hyperlipidemia;

liver ischemia that causes elevated liver enzymes, nausea, vomiting, epigastric
pain, and right upper quadrant pain.
Intravascular coagulation causes

hemolysis of red blood cells;

platelet adhesion as evidenced by low platelet counts due to platelet consumption;

disseminated vascular coagulation (Lowdermilk et al., 2012).
Finally, increased permeability and capillary leakage occur and cause

proteinuria;

generalized edema;

pulmonary edema that cause dyspnea;

hemoconcentration that results in intravascular dehydration as proteins and fluid
loss occur resulting in less plasma volume as evidenced by increased hematocrit
(Lowdermilk et al., 2012; Sibai, 2011; Townsend & Drummond, 2011).
Until the definitive cause of preeclampsia is found treatment will include treating the
symptoms of PE and keeping women pregnant as long as possible.
Current Standard of Practice Prior to CMQCC Toolkit
Once a diagnosis of preeclampsia occurs, the management of care is
hospitalization, frequent BP measurements, laboratory studies, 24 hour urine
collection, daily weights, and fetal monitoring (Bell, 2010). Laboratory studies
reviewed for the severity of preeclampsia are platelet counts, liver function, and the
evidence of hemolysis (Roberts & Escudero, 2012). The patient is confined to bed
rest and has frequent assessments for blurred vision, epigastric pain, persistent
headaches, and fetal surveillance for wellbeing (Bell, 2010; Hoedjes et al., 2011;
29
Lowdermilk et al., 2012). The only cure for preeclampsia is delivery (Bell, 2010).
The decision for the type and timing of delivery is dependent on the gestational age,
the conditions of the mother and child, and the severity of preeclampsia (Bell, 2010).
The current medical model for preeclampsia is to manage the symptoms with
intravenous magnesium sulfate and antihypertensive medication (hydralazine or
labetalol) for the mother (Bell, 2010; Lowdermilk et al., 2012; Townsend &
Drummond, 2011). Magnesium sulfate is given to prevent seizures. The medication
interferes with the release of acetylcholine at the synapses, thus decreasing the
neuromuscular irritability (Lowdermilk et al., 2012). Cardiac conduction is decreased
and magnesium sulfate decreases the central nervous system irritability (Lowdermilk
et al., 2012). The dose of magnesium sulfate differs in the literature. Magnesium
sulfate is given intravenously with a loading dose between four to six grams followed
by one to three grams an hour (Lowdermilk et al., 2012; Nguyen, Crowther,
Wilkinson, & Bain, 2013; Norwitz & Repke, 2014). Calcium gluconate is the antidote
for magnesium toxicity and must be available to be given, should an magnesium
sulfate overdose occur (Lowdermilk et al., 2012; Norwitz & Repke, 2014)
Antihypertensive medications are used when the BP is greater than 160/110 mm Hg
(Lowdermilk et al., 2012; Norwitz & Repke, 2014). The goals of antihypertensive
medications, such as labetalol or hydralazine, are to reduce the chance of maternal
stroke and maintain uteroplacental perfusion (Lowdermilk et al., 2012; Norwitz &
Repke, 2014; Townsend & Drummond, 2011). If the gestation is less than 34 weeks,
antenatal corticoid steroids (betamethasone or dexamethasone) need to be given to
30
help with fetal lung maturity (Norwitz & Repke, 2014; Sibai, 2011). Magnesium
sulfate has also been shown to assist with neuroprotection of the preterm fetus if the
mother is on at least two grams for 24 hours (Nguyen et al., 2013). The medical
interventions are designed to keep the mother and fetus safe and continue the
pregnancy to allow the fetus to grow and allow time for the fetal lungs to mature
(Townsend & Drummond, 2011).
Currently, the role for the nurse in the management of preeclampsia is to
protect the maternal/fetal wellbeing and optimize a healthy outcome for both (Bell,
2010). The nurse is responsible for keeping a quiet environment, maintaining seizure
precautions, having emergency medications available, and an emergency birth pack
ready (Lowdermilk et al., 2012). As observed in the clinical setting by the author of
this paper, routine assessments of (a) blood pressure, (b) urine output, (c) proteinuria,
(d) edema, (e) fetal wellbeing, (f) visual disturbance, and (g) epigastric pain are used
to evaluate the severity of preeclampsia for patients not receiving magnesium sulfate.
Again as observed in the clinical setting by the author of this paper, once the patient
is on magnesium sulfate, the hourly assessments include (a) medication infusing on a
pump, (b) lung sounds, (c) deep tendon reflexes, (d) assessment of level of
consciousness, (e) urine output, (f) proteinuria, (g) BP, (h) assessment for visual
disturbances, (i) epigastric pain, and (j) fetal wellbeing. The severity of a patient’s
preeclampsia can change rapidly. An operative delivery must be readily available
with a resuscitation team available to support a preterm baby.
31
Eclampsia occurs in less than one out of 100 women with preeclampsia
(Stoppler, 2014). During an eclamptic event, the fetus and the mother are both
compromised. While the mother is seizing the uterus becomes hypertonic
(Lowdermilk et al., 2012). The contracted uterus can cause rapid cervical dilation,
rupture of amniotic membranes, and placental abruption. Additionally, the mother
experiences a decrease in cerebral perfusion. Placenta perfusion is decreased causing
fetal hypoxia and fetal compromise. The fetal heart tracing may show bradycardia,
late decelerations, minimal variability, and fetal stress. Eclampsia alone is not a
reason for an immediate cesarean delivery (Lowdermilk et al., 2012)
Understanding and defining hypertensive disorders of pregnancy, historical perceptions of
preeclampsia, risk factors for developing preeclampsia, pathogenesis of preeclampsia, and the
current standard of care for the preeclamptic patient allow for foundation of knowledge
regarding the treatment of preeclampsia. Examining current practice, is the best way to
make recommendations for best evidence based practice changes. As stated in the beginning
of this paper, the 17% death rate of American women suffering from hypertensive disorders
of pregnancy can be reduced (Druzin, Shields, et al., 2013). Gaining the knowledge and then
implementing the research and best evidence based practice could decrease maternal,
perinatal, and neonatal mortality and morbidity associated with preeclampsia.
CMQCC TOOLKIT IMPLEMENTATION
When an emergency occurs, whether in ordinary life or professionally, most
people function on auto pilot, doing the things they have been trained to do, and
resolve the conditions that created the emergency. According to Roth, Parfitt, Hering,
and Dent (2014), when dealing with an emergency, many people believe the correct
actions will be taken by the team and all the issues to resolve the emergency will be
considered. This practice uses the assumption that at least one person will identify the
critical steps if another person does not. That way of thinking leads to many
potentially critical steps being missed, even when there is a team of people educated
and trained to resolve such emergencies. Omitting key elements or actions can
significantly change the outcome (Roth et al., 2014). Implementing the use of
effective, evidence based practices help ensure safe patient care. The California
Maternal Quality Care Collaborative (CMQCC) has developed a toolkit to direct the
care for a patient suffering from a hypertensive disorder of pregnancy (Druzin,
Shields, Peterson, & Cape, 2013) The strategies from the CMQCC toolkit will be
discussed in order to develop an educational online study module, a simulation
experience, and a checklist, to provide nurses evidence based knowledge and best
practices to care for patients with preeclampsia at the author’shospital. The materials
that will be presented are a bundle of items that will assist the staff nurse to
understand the history and pathophysiology of preeclampsia, the current
32
33
recommendations from the CMQCC and tools to use when a preeclamptic event
occurs in simulation or clinically.
American College of Obstetricians and Gynecologists
On the national level, 17 experts in the field of obstetrics, maternal-fetal
medicine, hypertension, internal medicine, nephrology, anesthesiology, physiology,
and patient advocacy met three times over nine months during 2011 and 2012
(Martin, 2013). In order to come to a consensus for practice recommendation,
additional hours of writing and deliberating were done, to address the issues of
hypertension in pregnancy. The American Congress of Obstetricians and
Gynecologists (ACOG), task force undertook three tasks (2013):
1) Summarize the current state of knowledge about preeclampsia and other
hypertensive disorders in pregnancy by reviewing and grading the quality of
the extant world literature; 2) translate this information into practice
guidelines for health care providers who; treat obstetric patients affected by
these disorders; and 3) identify and prioritize the compelling areas of
laboratory and clinical research to bridge gaps in our current knowledge.
(Martin, 2013, p. x)
On a regional level, a taskforce from both large and small Obstetric (OB) units
within California, convened multidisciplinary experts to develop a toolkit to
“Improve Health Care Response to Preeclampsia: A California Quality Improvement
Toolkit” (Druzin et al. 2103). Fund were provided by Federal Title V Maternal Child
Health (MCH) block grant from the California Department of Public Health (CDPH)
Maternal, Child and Adolescent Health division and Stanford University, to develop
this toolkit and then disseminate it to the obstetrical providers, hospitals and health
care organizations (Druzin et al., 2013).
34
California Pregnancy Associated Mortality Review
The California Pregnancy Associated Mortality Review (CA-PAMR)
evaluated the overall mortality rate for women suffering from preeclampsia and
associated syndromes from 2002-2004 (Druzin et al., 2013). The results showed a
mortality rate of 1.6 per 100,000 deaths from preeclampsia and associated syndromes.
Those numbers did not include the mortality and morbidity rates of fetus related to
premature birth (Druzin et al., 2013). During CA-PAMR review and analysis,
healthcare providers, failure to recognize and respond to the preeclampsia triggers
and the serious deterioration of the patient’s condition was a significant factor
(Peterson, Shields, & Morton, 2013). Missing key signs or triggers lead to 60% of the
deaths from preeclampsia. The triggers that were missed included proteinuria,
headaches, epigastric pain, deterioration of fetal status, and altered mental status, in
addition to elevated blood pressures. A lack in critical thinking and clinical reasoning
among the healthcare team contributed to the negative outcomes (Peterson et al.,
2013). The emphasis of the preeclampsia task force was related to education of
healthcare providers (Druzin et al., 2013). The three components were;
understanding the importance and accuracy of measuring blood pressures, initiating
antihypertensive medications, and preventing the progression of the disease (Druzin
et al., 2013). Treatment of preeclampsia focuses on rescuing from an acute event,
rather than prevention of the initiating factor. This rescue is the only strategy until
the definitive cause of preeclampsia is found. With the development of the CMQCC
35
toolkit, a standard of interventions for best practice is now available for both
providers, clinical staff, hospitals, and healthcare organizations (Druzin et al., 2013).
California Maternal Quality Care Collaborative
The goal of the toolkit was to provide tools and guidelines that would assist
others in the field of Obstetrics and Gynecology to decrease maternal morbidity and
mortality (Druzin et al., 2013). The CMQCC goal was to develop the methods that
would be used by hospital, providers, and healthcare organizations to facilitate a
timely, organized tool that would improve the response to preeclampsia. Another
goal was to implement a quality improvement program at the hospital and healthcare
organization level to decrease short term and long term morbidity in women related to
preeclampsia (Druzin et al., 2013). Once the goals were identified, building the
toolkit was the next step.
The toolkit consists of three major components; the research articles, tools for
implementation of the toolkit, and a slide set for education (Druzin et al., 2013). The
first section consist of 18 articles which are a compendium of best practices on
multiple topics about hypertensive disorders (see Appendix A). This section of the
toolkit informs the readers of the background, preparation, and management. This
section consists of best practice articles, with of evidence found in the literature to
support the recommendations (Druzin et al., 2013). Each article discussed a different
topic using a literature review for the background section; a table, diagram, or picture
to summarize the information; a recommendation of quality improvement; the level
of evidence including the type of study and level of recommendation; and finally a
36
reference section (Druzin et al., 2013). Secondly there is a collection of checklists,
flowcharts, and table chart formats of care guidelines that were developed using best
practice evidence. This section also includes samples for policy and procedures.
Finally, there was a slide set for education purposes. The slides have been developed
to be shared. Instructions that accompanied the slide set allow users to use the slides
and the CMQCC logo as long as the information has not been changed. Feedback
and recommendations will be shared with the CMQCC regarding the slide sets. The
slides are geared to summarize preeclampsia best practices and assist with the training
and education for preeclampsia.
The CMQCC toolkit will be implemented by applying Kolb’s (1984)
experiential learning theory. The learner-centered approach focuses on the learner
actively problem solving and contributing to the physical experience as with a
simulation experience (Curran, 2014; Lisko & O’Dell, 2010). Experiential learning is
a continuous process that changes the way a person reasons and performs by
transforming the experience into cognitive concepts (Lisko & O’Dell, 2010), where
practicing in-situ simulation allows the learner to use all four stages of the
experiential learning cycle; concrete experience, reflective observation, abstract
conceptualization, and active experimentation (Stutsky & Laschinger, 1995).
Applying the information from the CMQCC toolkit into a computer based learning
module will allow an affordable opportunity for staff nurses to increase their
cognitive skills, problem solving, and clinical reasoning through a self-directed
learning module about preeclampsia and hypertensive disorders of pregnancy.
37
Finally using the checklist, algorithms, tables and charts distributed by the CMQCC,
will provide the staff with a systematic approach in their delivery of care for patient
suffering of preeclampsia. The use of checklist guides the user to select the next
appropriate action or decision by giving structure to critical tasks, reducing the
chance of making an error (Gawande, 2010; Kohn, Corrigan, & Donaldson, 2000).
Implementation
The goal of the culminating project will be to have two online courses
accessible to nurses within the Sutter Healthcare System’s learning management
system. One of the courses will discuss the history and pathophysiology of
preeclampsia (see Appendix B) and was produced from the literature review. The
second course will be the slide set that was created by CMQCC (see Appendix C).
The checklist and algorithms will also be accessible to the staff in a portable
document format (PDF) within the learning module. The Preeclampsia Early
Recognition Tool (Appendix D) is a CMQCC tool, giving staff the criteria to
recognize that the patient condition is getting worrisome and interventions need to
occur (Druzin et al., 2013). The Evaluation and Treatment of Antepartum and
Postpartum Preeclampsia and Eclampsia guideline (Appendix E) is a CMQCC tool
that displays the medications that should be used in the management and treatment of
preeclampsia and eclampsia. The Treatment for Severe Preeclampsia algorithm
(Appendix F) guides the healthcare providers in the treatment for patients that are
experiencing severe preeclampsia. Finally, the Eclampsia Checklist (Appendix G) is
from the CMQCC with a modification, to lead the healthcare providers to perform the
38
important task that should be done during the treatment of eclampsia (Druzin et al.,
2013). The modifications included antihypertensive medications and spaces for the
providers to document the time the interventions were carried out. All of these tools
were created and included to give the healthcare providers evidence based best
practices to care for the preeclamptic and eclamptic patient.
Healthstream® Learning Center (HLC) is a learning management system for
healthcare (2015). The vision of Healthstream® is to assess healthcare workers in
online courses through compliance requirements by streamlining competency and
performance management to improve the quality of healthcare (Healthcare Learning
Center, 2015). Online courses and classes can be built and imported into the HLC.
The courses can be a self-driven power point that staff can self-assign, or be assigned
by their management team. The courses can have knowledge checking questions
embedded in the learning module, or an exam at the end. At the completion of the
course the staff will be given an evaluation tool to evaluate the course and provide
feedback. When all of the components of the learning and evaluation have been
completed the student will be awarded continuing education units.
In-situ simulation will be scheduled for the staff within the author’s facility
following the rollout of the online learning courses. This will be a multidisciplinary
approach to include, Obstetricians and midwives, Anesthesiologist, respiratory
therapist, staff nurses in all areas of the family birthing center and emergency
department. An eclampsia simulation will be schedule and the staff and obstetrical
providers will have the opportunity to manage a patient that will demonstrate signs
39
and symptoms of preeclampsia. During the progression of the in-situ simulation the
patient’s condition will worsen and she will develop eclampsia. The simulation
experience will start with a pre-brief. Expected outcomes will be explained to the
learners along with general knowledge regarding preeclampsia and the medical
management of the disorder. The learners of the simulation will be oriented to the
physical environment, equipment, simulators, participant roles, and they will have the
opportunity to ask questions of the simulation champions. The simulation experience
will last between 15-20 minutes giving the learners the opportunity to manage the
preeclamptic/ eclamptic patient. Immediately following the in-situ simulation, the
learners will debrief the experience with the champions to guide the discussion.
Debriefing is where the actual learning occurs and will last twice as long as the
simulation experience was. During the debriefing, three reflective questions will be
ask of the learner: (a) what did they do well, (b) what could or should they improve,
and (c) what system issues could be improved. The learner will then have an
additional opportunity to immediately experience the eclampsia simulation again, and
apply the knowledge they gain from the first experience and the debriefing. The goal
will be to hardwire the learning and use of the tools, to make a difference in the
quality and safe care of preeclampsia patients.
Although we do not yet understand the full pathophysiology of what causes
preeclampsia, we do know that delivery is the only method of halting the disease.
However, the widely accepted aphorism of “delivery is the cure” does not take into
account that patients with preeclampsia are at a serious risk for days and weeks into
40
their postpartum period (Druzin et al., 2013). It is the hope that one day the
morbidity and mortality for mothers and newborns will be decreased through the
implementation of evidence based practice interventions, such as this CMQCC
preeclampsia toolkit. Having the right information, with the evidence to support
healthcare treatments decisions, healthcare providers will feel confident in the care
they provide, knowing it represents best practice. This educational plan, including
online modules and in-situ simulation will bridge the gap between practice and
research, providing the most current best practice evidence.
EVALUATION
As a nurse educator, the author’s main responsibility is to provide staff with
efficient, up to date, evidence based best practice educational opportunities that are
both cost effective and attainable. When implementing learning modules for the first
time, evaluating the course from the learner perspective is important. Comments
from the participants should be reviewed to guide future alterations or additions to
meet the objectives of the course. One of the goals of this online learning module is
to reward the registered nurse with continuing education units (CEU). To award
CEU, the Board of Registered Nursing (BRN) has regulations that must be met.
Implementing a new clinical practice guideline can have challenges with the adoption
of the information into clinical practice (Dobbins, Davies, Danseco, Edwards, &
Virani, 2005). Listening to the learner and creating educational opportunities that
have value and emphasizes patient safety is the number one priority.
The learning modules, checklist, algorithms, and simulation experience that
this culminating project provides, must be evaluated by the learner who was exposed
to it. An evaluation tool will be used with the online learning module and simulation
experiences to gain information to improve this project. The online learning module
will have questions imbedded in the power points to test the understanding of the
content presented. These questions represent formative evaluation strategies. After
the learner has completed the learning module an evaluation of the course will
automatically launch (see Appendix H), which represents the summative evaluation.
41
42
Once the learning module and evaluation have been completed, the CEU’s will be
awarded.
The ability of the learner in the simulation setting to transfer the learning to
the clinical setting is one of the primary outcomes of simulation (Fisher & King,
2013). The goal of simulation is to enhance confidence, competency, knowledge, and
transfer skills learned in simulation to clinical practice (Fisher & King, 2013). After
the final debrief, following the simulation experience, the learners will be provided
the evaluation tool to complete (see Appendix I). The simulation evaluation tool will
evaluate the checklist, algorithms, and the simulation experience. One of the
stipulations that the California Maternal Quality Care Collaborative (CMQCC)
required was that if their tools were used, users must provide them with feedback
(Druzin, Shields, Peterson, & Cape, 2013). The open-ended comment sections will
be reviewed and sent to CMQCC as feedback.
Board of Registered Nursing
In order to award CEU a review of the requirements established by the
governing body of registered nurses is needed. According to the Department of
Consumer Affairs Board of Registered Nursing (BRN), registered nurses (RN) in
California are required to complete 30 hours of continuing education every two years
to maintain an active license (2015a). There are many regulations required to award
CEU’s. Each hour that is awarded a CEU must be a minimum of 50 minutes engaged
in the learning experiences (Department of Consumer Affairs Board of Registered
Nursing, 2015b). The continuing education can be a variety of forms of learning
43
experiences, with the purpose to increase the knowledge of the RN in direct or
indirect nursing activities and/or patient care. There must be a systematic learning
experience that will increase the knowledge, skills, and information of direct and
indirect patient care. The content must be relevant to the development and
preservation of up-to-date competency while delivering nursing care. The providers
of CEU must have a course outline, a record of the time and place, the instructor’s
vitae, and the names and licensed number of the RN taking the course (Department of
Consumer Affairs Board of Registered Nursing, 2015b). The course outline must
include; clearly stated course description, objectives, and an evaluation (Department
of Consumer Affairs Board of Registered Nursing, 2015c). The BRN allows the
instructors to decide how to evaluate the understanding of the content from a seminar
or attended course. In the case of home study, some method of evaluation needs to
occur that verifies the course was read. The BRN recommends all courses should be
evaluated; related to meeting the objectives pertinent or usable information, the
instructor’s mastery of the subject matter the use of appropriate teaching methods, the
efficient delivery of the course (audiovisuals, handouts, acoustics, etc.), and provision
of an area for additional comments (Department of Consumer Affairs Board of
Registered Nursing, 2015c).
Evaluation Tools
Learner evaluations have the purpose of providing the overall picture of the
effectiveness of the teaching (Emerson & Records, 2007). Evaluation tools should
have a combination of five point Likert scales and open-ended questions to obtain
44
rich data (Emerson & Records, 2007). The Likert data can be quickly reviewed to see
over all trends. Additionally a mean score can be calculated to see trends from the
learners, to evaluate if change is needed. The open-ended responses allow the learner
to expand on his or her opinion of the educational offering. Both evaluation tools will
be used to improve the online modules, as well as the simulation experience and
include the following checklist, algorithms, and evidence of meeting the regulation
that the BRN requires for awarding CEU’s.
As a nurse, providing care that is grounded in the best evidence based practice
is a priority. Patients are consumers and they deserve to have nurses caring for them
with the highest level of knowledge and competence. According to Tarnow,
Gambino, and Ford (2013), educators are challenged with delivering tools and
educational programs which align the public expectations for safe, effective, patient
centered, efficient, timely, and equitable care, that also award CEU’s. Building cost
efficient, relevant educational modules and experiences is a responsibility of any
clinical nurse educator. Evaluating all learning modules to find where the gaps in
learning occur is important. Identifying the gaps can lead to future nursing education,
revisions, or modifications to current learning modules.
Overall Conclusion of Project
Applying original research in the clinical setting can take as much as two
decades to occur (Agency for Healthcare Research and Quality, 2001). The standard
for routine care of patients in any healthcare setting is to provide evidence-based
practice. Evidence-based practice exists where clinical experience, patient preference
45
and current research are combined to produce the best outcomes for patients (Spruce,
2015). This culminating project was developed to bring the current collaboration of
evidence-based best practice to staff nurses managing patients with preeclampsia. A
literature review was completed regarding the various learning styles, theories,
models, and frameworks to education adult learners. Knowles (1989) and Kolb
(1984) was the model and theory used to implement the adult active learning
strategies of computer based learning, simulation, and standardization of care via the
use of a checklist, algorhythm or charts. A second literature review was completed to
look at the history, pathophysiology, and current state of treatment including risk
factors and comorbidities for patient suffering from preeclampsia. The next section of
this project included presenting the findings of the CMQCC (Druzin et al., 2013) the
evidence-based best practice. Providing rational and experiential learning is more
likely to result in compliance when asking nurses to change practice. The educational
module included a computer based learning module and simulation experience with
checklist, algorithms, and charts. The last section of this project was the development
of an evaluation tool for both the online module and simulation experience. Providing
a feedback tool for the participants will allow for recommendations in order to make
future alterations or additions to meet the objectives of the course.
Evidence-based practices must be employed to improve patient outcomes.
According to Rycroft-Malone, drawing from a wide range of practical and organized
approaches will assist with the success of evidence based practice efforts, thus
improving nursing practice and the patient’s experiences (2012). The CMQCC
46
compiled the evidence and this culminating project is a tool to get the information
into the clinical setting. The treatment of preeclampsia is reactive instead of
proactive, on the part of the healthcare team. The overall goal of the CMQCC is to
decrease maternal and neonatal morbidity and mortality from hypertensive disorders
of pregnancy (Druzin et al., 2013).
REFERENCES
48
REFERENCES
Adams, A. (2004). Pedagogical underpinnings of computer-based learning. Journal of
Advanced Nursing, 46(1), 5-12. doi:10.1111/j.1365-2648.2003.02960.x
Agency for Healthcare Research and Quality. (2001). Translating Research Into
Clinical Practice (TRIP)-II Fact Sheet. Retrieved from
http://archive.ahrq.gov/research/findings/factsheets/translating/tripfac/trip2fac
.pdf
American Congress of Obstetricians and Gynecologists. (AGOG). (2013).
Hypertension in pregnancy. Washington, DC: American Congress of
Obstetricians and Gynecologists.
Archer, T. (2013). Airway management in pregnant or postpartum women having
seizures. In M. Druzin, L. Shields, N. Peterson, & V. Cape (Eds.),
Preeclampsia Toolkit: Improving health care response to preeclampsia (pp.
75-77). Sacramento, CA: California Department of Public Health.
Archer, T., Druzin, M., Shields, L. E., & Peterson, N. (2013). Antihypertensive
agents in preeclampsia. In M. Druzin, L. Shields, N. Peterson, & V. Cape
(Eds.), Preeclampsia Toolkit: Improving health care response to
preeclampsia (pp. 46-50). Sacramento, CA: California Department of Public
Health.
August, P. (2014). Preeclampsia: Prevention. UpToDate. Retrieved from
http://www.uptodate.com/contents/preeclampsia-prevention
49
August, P. & Sibai, B. (2014). Preeclampsia: Clinical features and diagnosis.
UpToDate. Retrieved from: http://www.uptodate.com/contents/preeclampsiaclinical-features-and- diagnosis
Bell, M. (2010). A historical overview of preeclampsia-eclampsia. JOGNN: Journal
of Obstetric, Gynecologic & Neonatal Nursing, 39(5), 510-518.
doi:10.1111/j.1552-6909.2010.01172.x
Berg, O., Lee, R. H., & Chagolla, B. (2013). Magnesium sulfate. In M. Druzin, L.
Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving
health care response to preeclampsia (pp. 51-59). Sacramento, CA: California
Department of Public Health.
Blake, H. (2010). Computer-based learning objects in healthcare: The student
experience. International Journal of Nursing Education Scholarship, 7(1),15.
doi:10.2202/1548-923X.1939
Bromley, P. (2010). Online learning: Anywhere anytime education for specialist
nursing. Neonatal, Paediatric & Child Health Nursing, 13(3), 2-6. Retrieved
from http://www.nzno.org.nz
California Department of Public Health (CDPH). (2012). The California pregnancyassociated mortality review: CA-PAMR pregnancy-related death, chance to
alter outcomes by grouped cause of death; 2002-2004. Retrieved from
http://www.cdph.ca.gov/data/statistics/Documents/MO-CAPAMRPublicUseSlideSet-2002-2004.pdf
50
Cant, R., & Cooper, S. (2010). Simulation-based learning in nurse education:
Systematic review. Journal of Advanced Nursing, 66(1), 3-15. doi:10.1111/j.13652648.2009.05240.x
Chagolla, B., Berg, O., & Gabel, K. (2013). Ante, intra, postpartum nursing
management and assessment of preeclampsia: Maternal/fetal assessment and
monitoring recommendations. In M. Druzin, L. Shields, N. Peterson, & V.
Cape (Eds.), Preeclampsia Toolkit: Improving health care response to
preeclampsia (pp. 36-40). Sacramento, CA: California Department of Public
Health.
Champagne, H. (2013). Proteinuria. In M. Druzin, L. Shields, N. Peterson, & V. Cape
(Eds.), Preeclampsia Toolkit: Improving health care response to
preeclampsia (pp. 32-25). Sacramento, CA: California Department of Public
Health.Clark, C. C. (2008). Classroom skills for nurse educator. Minneapolis,
MN: Jones and Bartlett.
Curran, M. K. (2014). Examination of the teaching styles of nursing professional
development specialists, part I: Best practices in adult learning theory,
curriculum development, and knowledge transfer. Journal of Continuing
Education in Nursing, 45(5), 233-240. doi:10.3928/00220124-20140417-04
Department of Consumer Affairs: Board of Registered Nursing. (2015a). California
Board of Registered Nursing Continuing Education for License Renewal.
Retrieved from http://www.rn.ca.gov/licensees/ce-renewal.shtml
Department of Consumer Affairs: Board of Registered Nursing. (2015b). California
51
Code of Regulations Title 16, Division 14, Article 5. Continuing Education.
Retrieved from http://www.rn.ca.gov/pdfs/applicants/ceptitle16.pdf\
Department of Consumer Affairs: Board of Registered Nursing. (2015c). California
Board of Registered Nursing Continuing Education Program: Instructions for
Providers. Retrieved from
http://www.rn.ca.gov/pdfs/applicants/cepinstruct.pdf
Dobbins, M., Davies, B., Danseco, E., Edwards, N., & Virani, T. (2005). Changing
nursing practice: evaluating the usefulness of a best-practice guideline
implementation toolkit. Canadian Journal of Nursing Leadership, 18(1), 3448.
Drews, M., & Tsigas, E. (2013). Education and patient information: Prenatal and
postpartum patient counseling or education*. In M. Druzin, L. Shields, N.
Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving health care
response to preeclampsia (pp. 98-103). Sacramento, CA: California
Department of Public Health.
Druzin, M. (2013). Classification and diagnosis of hypertensive disorders of
pregnancy. In M. Druzin, L. Shields, N. Peterson, & V. Cape (Eds.),
Preeclampsia Toolkit: Improving health care response to preeclampsia (pp.
19-24). Sacramento, CA: California Department of Public Health.
Druzin, M. L., Shields, L. E., Peterson, N. L., & Cape, V. (Eds.). (2013)
Preeclampsia toolkit: Improving health care response to preeclampsia.
Sacramento, CA: California Department of Public Health.
52
Druzin, M. L., Walsh L., Shields, L. E., Morton, C. H., & Peterson, N. L. (2013).
Introduction and historical perspective. In M. Druzin, L. Shields, N. Peterson,
& V. Cape (Eds.), Preeclampsia toolkit: Improving health care response to
preeclampsia (pp. 12-18). Sacramento, CA: California Department of Public
Health.
Edwards-Silva, R. (2013). Posterior reversible encephalopathy syndrome (PRES). In
M. Druzin, L. Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit:
Improving health care response to preeclampsia (pp. 89-93). Sacramento,
CA: California Department of Public Health.
Emerson, R., & Records, K. (2007). Design and testing of classroom and clinical
teaching evaluation tools for nursing education. International Journal of
Nursing Education Scholarship, 4(1), 1-15.
Ennen, C., & Satin, A. (2014). Reducing adverse obstetrical outcomes through safety
science. UpToDate. Retrieved from
http://www.uptodate.com/contents/reducing-adverse-obstetrical-outcomesthrough-safety-science
Fisher, D., & King, L. (2013). An integrative literature review on preparing nursing
students through simulation to recognize and respond to the deteriorating
patient. Journal of Advanced Nursing, 69(11), 2375-2388.
doi:10.1111/jan.12174
Gabel, K. (2013). Patient care and treatment recommendations: Accurate blood
pressure measurement. In M. Druzin, L. Shields, N. Peterson, & V. Cape
53
(Eds.), Preeclampsia Toolkit: Improving health care response to preeclampsia
(pp. 26-28). Sacramento, CA: California Department of Public Health.
Gawande, A. (2010). The checklist manifesto: How to get things right. New York,
NY: Metropolitan Books.
Hahne, A., Benndorf, R., Frey, P., & Herzig, S. (2005). Attitude towards computerbased learning: Determinants as revealed by a controlled interventional study.
Medical Education, 39(9), 935-943. Retrieved from
http://onlinelibrary.wiley.com
Healthstream Learning Center. (2015). About us. Retrieved from
http://healthstream.com/about-us
Hoedjes, M., Berks, D., Vogel, I., Franx, A., Duvekot, J. J., Steegers, E. P., & Raat,
H. (2011). Poor health-related quality of life after severe preeclampsia. Birth:
Issues in Perinatal Care, 38(3), 246-255. doi:10.1111/j.1523536X.2011.00477.x
Imel, S. (1999). Using groups in adult learning: Theory and practice. Journal of
Continuing Education In The Health Professions, 19(1), 54-61.
Karumanchi, S. A., Lim, K., & August, P. (2014). UpToDate. Preeclampsia:
Pathogenesis. Retrieved from
http://www.uptodate.com/contents/preeclampsia-pathogenesis
Kilpatrick, S. (2013). Outpatient management of preeclampsia. In M. Druzin, L.
Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving
54
health care response to preeclampsia (pp. 40-41). Sacramento, CA: California
Department of Public Health.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human:
Building a safer health system. Washington, DC: National Academy Press.
Kolb, D. (1984). Experiential learning; Experience as the source of learning and
development. Englewood Cliffs, NJ: Prentice Hall.
Kotter, J. (1996). Leading change. Boston, MA: Harvard Business School Press.
Knowles, M. (1989). The making of an adult educator. San Francisco, CA: JosseyBass Inc
Lindheimer, M. (2013). Historical perspective: The history of preeclampsia and
eclampsia as seen by a nephrologists. Paper presented at the 2012 Benson and
Pamela Harer Seminar on History Lecture, Chicago, IL.
Lisko, S., & O'Dell, V. (2010). Integration of theory and practice: Experiential
learning theory and nursing education. Nursing Education Perspectives, 31(2),
106-108. Retrieved from http://www.nlnjournal.org
Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2012). Maternity & women’s
healthcare (10th ed.). St. Louis, MO: Mosby/ Elsevier.
Lyndon, A., Walsh, L., & Edwards-Silva, R. (2013). Teamwork and communication.
In M. Druzin, L. Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia
Toolkit: Improving health care response to preeclampsia (pp. 60-69).
Sacramento, CA: California Department of Public Health.
55
Martin, J. (2013). Forward. In American College of Obstetricians and Gynecologist
(AGOG), Hypertension in pregnancy. (pp. ix-x). Washington, DC: American
College and Obstetricians and Gynecologist.
Meyers, M. (2013a). The role of medical simulation. In M. Druzin, L. Shields, N.
Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving health care
response to preeclampsia (pp. 70-74). Sacramento, CA: California
Department of Public Health.
Meyers, M. (2013b). Emergency department recognition and treatment: Focus on
delayed postpartum preeclampsia and eclampsia. In M. Druzin, L. Shields, N.
Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving health care
response to preeclampsia (pp. (pp. 94-97). Sacramento, CA: California
Department of Public Health.
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing
Management - UK, 20(1), 32-37. Retrieved from http://www.nursingmanagement-journal.co.uk
McDowell, D., & McComb, S. A. (2014). Safety checklist briefings: A systematic
review of the literature. Association of Perioperative Registered Nurses
Journal, 99(1), 125-137. doi:10.1016/j.aorn.2013.11.015
Nguyen, T., Crowther, C., Wilkinson, D., & Bain, E. (2013). Magnesium sulphate for
women at term for neuroprotection of the fetus. Cochrane Database of
Systematic Reviews, (2), CD009395.
56
Norwitz, E. R., & Repke, J. T. (2014). Preeclampsia: Management and prognosis.
UpToDate. Retrieved from http://www.uptodate.com/contents/preeclampsiamanagement-and-prognosis
Overview of Learning Styles. (2013). Learning-styles-online.com. Retrieved from
http://www.learning-styles-online.com/overview/
Peterson, N. L., Shields, L. E., & Morton, C. H. (2013). Early recognition. In M.
Druzin, L.Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit:
Improving health care response to preeclampsia (pp. 29-32). Sacramento,
CA: California Department of Public Health.
Phillips, J. (2005). Strategies for active learning in online continuing education.
Journal of Continuing Education in Nursing, 36(2), 77-83. Retrieved from
http://onlinelibrary.wiley.com
Preeclampsia Foundation. (2013a). Preeclampsia: Know the symptoms. Trust
yourself. Retrieved from: http://www.preeclampsia.org
Preeclampsia Foundation. (2013b). 2,400 Years of preeclampsia history. Retrieved
from: http://www.preeclampsia.org/component/content/article/53-healthinformation/257-history-of-preeclampsia
Promoting Adult Learning. (2005). Paris, France: Organization for Economic Cooperation and Development.
Reeves, P., & Reeves, T. (2008). Design considerations for online learning in health
and social work education. Learning In Health & Social Care, 7(1), 46-58.
Retrieved from http://onlinelibrary.wiley.com
57
Roberts, J., & Escudero, C. (2012). The placenta in preeclampsia. Pregnancy
Hypertension, 2(2), 72-83. doi:10.1016/j.preghy.2012.01.001
Roth, C. K., Parfitt, S. E., Hering, S. L., & Dent, S. A. (2014). Developing protocols
for obstetric emergencies. Nursing for Women’s Health. 18(5), 379-390. doi:
10.1111/1751- 486X.12146
Rourke, L., Schmidt, M., & Garga, N. (2010). Theory-based research of high fidelity
simulation use in nursing education: A review of the literature. International
Journal of Nursing Education Scholarship, 7(1),14. doi:10.2202/1548923X.1965
Rycroft-Malone, J. (2012). Implementing evidence-based practice in the reality of
clinical practice. Worldviews on Evidence-Based Nursing, 9(1), 1.
doi:10.1111/j.1741-6787.2011.00240.x
Shmueli, A., Meiri, H., & Gonen, R. (2012). Economic assessment of screening for
preeclampsia. Prenatal Diagnosis, 32, 29-38. doi:10.1002/pd.2871
Shields, L. E. (2013a). Chronic hypertension in pregnancy. In M. Druzin, L. Shields,
N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving health care
response to preeclampsia (pp. 42-45). Sacramento, CA: California
Department of Public Health.
Shields, L. E. (2013b). Special circumstances: Severe preeclampsia at < 34 weeks. In
M. Druzin, L. Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit:
Improving health care response to preeclampsia (pp. 78-86). Sacramento,
CA: California Department of Public Health.
58
Sibai, B. (2011). Evaluation and management of severe preeclampsia before 34
weeks' gestation. American Journal of Obstetrics & Gynecology, 205(3), 191198. Retrieved from http://www.ajog.org/
Silasi, M., Cohen, B., Karumanchi, S. A., & Rana, S. (2010). Abnormal placentation,
angiogenic factor, and the pathogenesis of preeclampsia. Obstetrics &
Gynecology Clinics of North America, 37(2), 239-253.
doi:10.1016/j.ogc.2010.02.013
Smith, B., & Reed, P. (2008). Greater flexibility for learning. Nursing Standard,
23(1), 64.
Spruce, L. (2015). Back to basics: Implementing evidence-based practice. AORN
Journal, 101(1), 106-112. doi:10.1016/j.aorn.2014.08.009
Stoppler, M. (2014). Eclampsia. Emedicinehealth: Experts for everyday emergencies.
Retrieved from http://www.emedicinehealth.com/eclampsia/article_em.htm
Stutsky, B., & Laschinger, H. (1995). Changes in student learning styles and adaptive
learning competencies following a senior preceptorship experience. Journal of
Advanced Nursing, 21(1), 143-153. doi:10.1046/j.13652648.1995.21010143.x
Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic
Nursing,33(6), 267-271. doi:10.7257/1053-816X.2013.33.6.267
Tarnow, K., Gambino, M. L., & Ford, D. J. (2013). Effect of continuing education:
Do attendees implement the tools that are taught?. Journal of Continuing
Education in Nursing, 44(9), 391-396. doi:10.3928/00220124-20130823-17
59
Townsend, N., & Drummond, S. (2011). Preeclampsia; pathophysiology and
implications for care. The Journal of Perinatal & Neonatal Nursing, 25(3),
245-252. doi: 10.1097/JPN.Ob013e318223ad14.
Tweedale, D., & Reiss, C. (2010). How checklists improve outcomes [Peer
commentary on the book “The Checklist Manifesto: How to get things right”
by A. Gawande]. Retrieved from http://www.nlc.org
Zakowski, M. (2013). Consultation triggers in severe preeclampsia for all obstetric.
Shields, L. E. (2013a). Chronic hypertension in pregnancy. In M. Druzin, L.
Shields, N. Peterson, & V. Cape (Eds.), Preeclampsia Toolkit: Improving
health care response to preeclampsia (pp. 87-88). Sacramento, CA: California
Department of Public Health.
APPENDICES
61
APPENDIX A
SUMMARY OF ARTICLES FROM THE CMQCC TOOLKIT

The article by Druzin (2013) used level II-2 and II-3 evidence to classify and
diagnose the hypertensive disorders of pregnancy and included tables and an
algorithm to display the different hypertensive disorders.

The article by Gabel (2013) used level II and III evidence to discuss accurately
measuring blood pressures with using the correct size of blood pressure cuff and
preparing the patient.

The article by Peterson, Shields, and Mortonhahne (2013), used level III-C
evidence to discuss the early recognition of preeclampsia, discussed criteria,
warning signs, treatments and appropriate responses of the healthcare team.

The article by Champagne (2013), used level III-C to discuss values of proteinuria
in preeclampsia as a screening tool (dipstick) or 24-hour urine collection (the gold
standard) to evaluate for severe preeclampsia symptoms.

The article by Chagolla, Berg, and Gabel (2013), used level III-C evidence in the
discussion of ante, intra, postpartum nursing management and assessment of
preeclampsia. It included a table with the recommendations of maternal and fetal
assessment.

The article by Kilpatrick (2013), used level C evidence to discuss outpatient
management including recommendations for maternal and fetal assessments and
under which conditions the patient should be admitted to the hospital.

The article by Shields (2013a), used level I-A and III-C to discuss chronic
hypertension in pregnancy and that this patient population is at risk for developing
superimposed preeclampsia. These women should receive more frequent prenatal
assessments and should be on antihypertensive treatment.

The article by Archer, Druzin, Shields, and Peterson (2013), used level III-C
evidence to discuss the uses of antihypertensive agents, labetalol and hydralazine
in preeclampsia women with systolic blood pressure (BP) greater than 160mm Hg
or diastolic BP greater than 105-110 mm Hg.

The article by Berg, Lee, and Chagolla (2013), used level I-A, I-B, II-B, III, and
IV evidence to discuss the use of magnesium sulfate for the prevention and
62
management of eclamptic seizures. The information included the preparation,
administration, and side effects and toxicity including nursing interventions for
the use of magnesium sulfate in the women with severe preeclampsia.

The article by Lyndon, Walsh, and Edwards (2013), used level II-3 and III
evidence to discuss the importance of effective communication and teamwork as
an essential strategy to ensure safe quality care for all patients. Some of the
components include; mutual respect, shared decision making, resolving clinical
disagreements, SBAR techniques.

The article by Meyer (2013a), discussed how the used of medical simulation has a
growing body of literature to assist teams to identify knowledge gaps through
practice. In situ simulations allows multi-disciplinary teams to train and tests;
new policies and procedures, demonstrate skills, identify system issues and test
new systems, and finally education for the coordination of team in regards to
improving communication.

The article by Archer (2013), used level III-C evidence to discuss airway
management and recommendations for improvements, in regard to the women
having seizures either while pregnant or during the postpartum period.

The article by Shields (2013b), used level II-1A and III-1A evidence to discuss
the special circumstances that can occur with women that have severe
preeclampsia at greater than 34 weeks gestation. The severity of the disease and
the weeks of gestation need to look at to determine the treatment plan or when
delivery should occur.

The article by Zakowski (2013), used level C evidence to discuss when the
delivery team should consult other specialties when conditions related to
pulmonary/fluid, cardiac, neurologic or hematologic medical situations occur as a
result of preeclampsia.

The article by Edwards-Silva (2013), used level III evidence to discuss symptoms
and treatment for women that suffer from posterior reversible encephalopathy
syndrome (PRES).

The article by Meyer (2013b), used level C evidence to make recommendations
for emergency rooms to have protocols that identify women that are in the period
of postpartum up to six weeks and at risk for delayed postpartum preeclampsia
and /or eclampsia.
63

The article by Drews and Tsigas (2013), discussed the importance of educating
women during their pregnancy and in the postpartum period about risk factors and
symptoms related to preeclampsia.
64
APPENDIX B
HISTORY AND PATHOPHYSIOLOGY OF PREECLAMPSIA
65
66
67
68
69
70
APPENDIX C
CALIFORNIA MATERNAL QUALITY CARE COLLABORATIVE:
PREECLAMPSIA EDUCATION
71
72
73
74
75
76
77
APPENDIX D
PREECLAMPSIA EARLY RECOGNITION TOOL
ASSESS
NORMAL
None
WORRISOME
Agitated/Confused
Drowsy
Difficulty speaking
Mild Headache
Nausea, vomiting
Blurred or impaired
Awareness
Alert/Oriented
Headache
None
Vision
SEVERE
Temporary blindness
Unresponsive
Unrelieved headache
Systolic BP (mm Hg)
100 to139
140 to 159
≥ 160
Diastolic BP (mm Hg)
Heart Rate
50 to 89
61 to 110
90 to 105
111 to 129
≥ 105
≥ 130
Respirations
SOB
O2Sat
11 to 24
Absent
≥ 95
25 to 30
Present
91 to 94
< 10 or > 30
Present
≤ 90
Pain: Abdomen or
chest
None
Nausea, vomiting
Chest pain
Abdominal pain
Fetal Sign
Category I
Reactive NST
Nausea, vomiting
Chest pain
Abdominal pain
Category II
IUGR
Non-reactive NST
Urine Output (mm/hr)
≥ 50
Proteinuria
Trace
Platelets
AST/ALT
Creatinine
Magnesium Sulfate
Toxicity
> 100
<70
≤ 0.8
DTR + 1
Respiration 16 to 20
Category III
≤ 30 (in 2hr)
30 to 49
≥ +1 **
≥
300 mg/24 hours
50 to 100
> 70
0.9 to 1.1
< 50
> 70
≥ 1.2
Depression of patellar reflexes
Respirations <12
YELLOW = WORRISOME
GREEN = NORMAL
Proceed with protocol
Increase assessment frequency
Triggers
1
≥2
TO DO
Notify Provider
Notify charge RN
In-Person evaluation
Order Labs.Test
Anesthesia consult
Consider magnesium sulfate
Supplemental oxygen
Triggers
1 of any type
Awareness
Headache
Visual
BP
Chest Pain
Respiration
SOB
O2 SAT
RED = SEVERE
TO DO
Immediate evaluation
T ransfer to higher acuity level
1:1 Staff ratio
Consider Neurology consult
CT Scan
R/O SAH/Intracranial hemorrhage
Labetalol/hydralazine in 30 min.
In-person evaluation
Magnesium sulfate loading or
maintenance infusion
Consider CT angiogram
O2 at 10 L per Rebreather mask
R/O pulmonary edema
Chest x-ray
** Physician shoulde be made aware of
worsening or new-onset proteinuria
Druzin, M. L., Shields, L. E., Peterson, N. L., & Cape, V. (Eds.). (2013). Preeclampsia toolkit:
Improving health care response to preeclampsia. Sacramento, CA: California Department of Public Health p. 107
78
APPENDIX E
EVALUATION AND TREATMENT OF ANTEPARTUM & POSTPARTUM
PREECLAMPSIA
1st Line Anti-Hypertensive Treatment: Labetalol & Hydralazine*
Target BP: 140-160/90-100 (BP< 140/90 = decreased fetal perfusion
TREATMENT
LABETALOL as Primary
Anti-Hypertensive
Magnesium
HYDRALAZINE as Primary
Anti-Hypertensive
Initial Treatment
1. Administer Labetolol 20 mg IV
1. Administer Hydralazine 5 to 10 mg IV
1. Loading Dose: 4-6 gm over 15-20 min
2. Repeat BP in 10 min
2. Repeat BP in 20 min
2. Maintenance 1-2 gm/hr
· If BP threshold is still exceeded,
· If BP threshold is still exceeded,
3. Close observation for signs of toxicity
administer labetalol
administer hydralazine 10 mg IV
Disappearance of deep tendon reflexes
·If SBP <160 and DBP < 100, continue
·If SBP <160 and DBP < 100, continue
Decreased RR, shallow respirations
to monitor BP closely
to monitor BP closely
shortness of breath
3. Repeat BP in 10 min
3. Repeat BP in 20 min
Heart block , chest pain
· If BP threshold is still exceeded,
· If BP threshold is still exceeded,
Pulmonary edema
administer labetalol 80 mg IV
administer labetalol 20 mg IV
·If SBP <160 and DBP < 100, continue
·If SBP <160 and DBP < 100, continue
to monitor BP closely
to monitor BP closely
1. Secure airway and maintain oxygenation
4. Repeat BP in 10 min
4. Repeat BP in 10 min
2. Give 2nd loading dose of 2 gm
· If BP threshold is still exceeded,
· If BP threshold is still exceeded,
Magnesium over 5 min
administer hydralazine 10 mg IV
administer labetalol 40 mg IV and
3. If patient seizes after 2nd magnesium
·If SBP <160 and DBP < 100, continue
obtain emergent consultation from
bolus, consider the following
to monitor BP closely
internal medicine, anesthesiology
5. Repeat BP in 20 min
·If SBP <160 and DBP < 100, continue
Midazolam 1-2 mg IV; may repeat in 5-10
min OR
· If BP threshold is still exceeded,
to monitor BP closely
Lorazepam 2 mg IV- May repeat OR
obtain emergent consultation from
5. Once target BP achieved, monitor BP
Diazepam 5-10 mg IV, may repeat q15 min
internal medicine, anesthesiology
q10min for 1 hour, q 15 min for 2nd hour
to max of 30 mg
6. Once target BP achieved, monitor BP
If Patient Seizes while on Magnesium:
Phenytoin 1 gm IV over 20 min
q10min for 1 hour, q 15 min for 2nd hour
Seizures Resolve
1. Maintain airway and oxygenation
2. Monitor VS, cardia rhythm/ ECG for signs
Druzin, M. L., Shields, L. E., Peterson, N. L., & Cape, V. (Eds.). (2013). Preeclampsia toolkit:
Improving health care response to preeclampsia. Sacramento, CA: California Department of Public Health p. 110
of medication toxicity
3. Consider brain imaging for:
Head Trauma
Focal Seizures
Focal Neurologic findings
Other neurologic diagnosis is suspected
79
APPENDIX F
TREATMENT FOR SEVERE PREECLAMPSIA
Systolic BP≥ 160 mmHg and/or
Diastolic BP ≥ 110 mmHg
If preeclampsia
proceed below
Inform OB Team
IV access
IV
Antihypertensive
Medications
Monitor FHT
Send Labs
Seizure
Prophylaxis
Labetalol 20 mg
Hydralazine 5-10 mg
Magnesium sulfate bolus
dose 4-6 g (over 20
minutes)
Repeat BP in 10 mins if
elevated administer
labetalol 40 mg
Repeat BP in 20 min if
elevated administer
hydralazine 10 mg
Magnesium sulfate
maintenance dose 1-2
g/hr
Repeat BP in 10 min if
elevated administer
labetalol 80 mg
Repeat BP in 20 mins if
elevated administer
labetalol 20 mg
Check serum
magnesium levels
(if indicated)
Repeat BP in 10 mins if
elevated administer
hydralazine 10 mg
Repeat BP in 20 mins if
remains elevated obtain
anesthesia consult
Repeat BP in 10 min if
elevated administer
labetalol 40 mg AND obtain
anesthesia consult
80
APPENDIX G
ECLAMPSIA CHECKLIST
Call for help _______
Establish open airway and maintain breathing (call for RT) ______
Oxygen (non-rebreather mask) ______
Check BP & Pulse ______
Start IV 18 gauge, if not already placed _______
Left Lateral Position ______
Seizure Control
If not on Magnesium sulfate administer 4-6 grams IV bolus (over 20 minutes)______
If already on magnesium sulfate administer 2nd bolus dose of 2 grams (over 3-5 mins )______
Magnesium maintenance dose 1-2 g/h for 24 hour after last seizure or after delivery
If seizure not terminating administer:
Midazolam (Versed) 2mg IV- can repeat in 5-10 minutes OR ______
Lorazepam (Ativan) 4 mg IV over 2-5 minutes OR ______
Diazepam (Valium) 5-10 mg IV slowly (can repeat every 15 minutes up to 30 mg) OR ______
Phenytoin (Dilantin) 1000mg IV over 20 minutes- May cause QRS or QT prolongation _______
Monitor respirations, BP, ECG, and signs of magnesium toxicity (VS)_____________________
Anti-Hypertensive Medications
Labetalol (as Primary) 20 mg IV over 3-5 minutes
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Labetalol 40 mg IV ____________
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Labetalol 80 mg IV ____________
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Hydralazine 10 mg IV __________
Hydralazine (as Primary) 5-10 mg IV over 3-5 minutes
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Hydralazine 10 mg IV __________
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Labetalol 20 mg IV ____________
Repeat BP in 10 minutes, if exceeds 160 and 100 Administer Labetalol 40 mg IV ____________
Once target BP achieved monitor BP q10 minutes for 1 hour, then q15 minutes for 2nd hour
Monitor Fetal Heart Tracing
Ob and Anesthesia to discuss if/when delivery is required
Try to avoid immediate delivery,
Allow time for FHT to return to baseline (FHT)___________________________________
Delivery only for prolonged bradycardia after termination of seizure
Druzin, M. L., Shields, L. E., Peterson, N. L., & Cape, V. (Eds.). (2013) Preeclampsia toolkit: Improving health care response
to preeclampsia, Sacramento, CA. California Department of Public Health P. 108 Labetalol and Hydralazine
recommendations based on 2011 ACOG Committee Opinion #514 and Practice Bulletin #33
81
APPENDIX H
ONLINE MODULE EVALUATION TOOL
Course Developed by: Jennifer Serratos RN, BSN
Course Date: (AUTOMATIC FILLED IN COMPUTER )
Course Location:(AUTOMATIC FILLED IN COMPUTER)
1. Did the presentation and supplemental materials meet the objectives?YES/NO
2. List 3 concepts you learned in this program that you will use in your clinical setting.
3. What could have happened that would have improved this learning opportunity?
4. What did you like best about this course?
5. What did you like the least about this course?
6. Did the online module present the material clearly?
7. What other topics would you like to have presented?
8. Any additional constructive comments?
82
APPENDIX I
SIMULATION EVALUATION
Simulation Evaluation
In order to facilitate improvements to Simulation your feedback is greatly needed. Please complete the
following course evaluation.
Please rate the following:
Course Content
Not at all
Minimally Average
Very
Extremely
helpful
Helpful
Helpful
Helpful
Preeclampsia Early Recognition Tool
1
2
3
4
5
Evaluation & Treatment of
1
2
3
4
5
Antepartum Postpartum
Preeclampsia & Eclampsia
Treatment for Severe Preeclampsia
1
2
3
4
5
Eclampsia Checklist
1
2
3
4
5
OB Preeclampsia Order Set
1
2
3
4
5
Policy and Procedures
1
2
3
4
5
Comments: Please comment on any area you rated 3 or less
Please rate the quality and amount of content presented on the following topics:
List of specific course topics
Not at all
Minimally Average
Very
helpful
Helpful
Helpful
Magnesium Sulfate
1
2
3
4
Hydralazine
1
2
3
4
Labetalol
1
2
3
4
Sign & Symptoms of Preeclampsia
1
2
3
4
Ob Order Sets & access
1
2
3
4
Comments: Please comment on any area you rated 3 or less
Please rate the following:
Simulation
Not at all
Minimally
helpful
Helpful
Pre-Brief
1
2
Simulation Experience
1
2
Debrief
1
2
Simulation Champions
1
2
Equipment
1
2
Room
1
2
Overall Experience
1
2
Comments: Please comment on any area you rated with 3 or less
Average
3
3
3
3
3
3
3
Very
Helpful
4
4
4
4
4
4
4
Extremely
Helpful
5
5
5
5
5
Extremely
Helpful
5
5
5
5
5
5
5
Overall Comments: Please feel free to add any additional comments relevant to this course. Positive
comments as well as suggestions for improvement are welcome.