Implementation of a Nurse-Initiated Protocol for Prenatal Care in a Carceral Setting

Abstract

Objective: To evaluate the effect of a nurse-initiated protocol on the times to order and implement prenatal care, nurses’ intentions to change practice based on an educational session, and nurses’ perceived barriers to initiation of the protocol in a carceral facility. Design: Quality improvement project. Setting/Local Problem: Southeastern United States carceral facility. Participants: A total of 44 nurses employed by a state women's carceral facility. Intervention/Measurements: Participants attended a 30-min educational session on a nurse-initiated intake protocol, including use of the Clinical Opiate Withdrawal Scale. The session was offered multiple times during shifts to maximize attendance. Participants then completed an adapted Continuing Professional Development–Reaction Questionnaire. We abstracted de-identified data from the charts of adult incarcerated women in the pre-implementation (n = 26) and post-implementation (n = 24) phases. We compared time to order (interval from admission to entry of order for a laboratory test, medication, or intervention) and time to implementation (interval from entry of order to initiation of the laboratory test, medication, or intervention) before and after implementation of the protocol. We assessed barriers to implementing the protocol 3 months after implementation. Results: The time to order a prenatal diet and schedule a first obstetric appointment decreased significantly (p < .001), whereas the time to order prenatal labs increased significantly (p = .03) after implementation of the protocol. We identified the following themes as barriers to implementing the protocol: Lack of Integration of the Protocol Into the Electronic Health Record, Interruptions in the Flow of Care, and Limited Resources. Conclusions: Use of a nurse-initiated protocol standardized and improved the timeliness of the delivery of prenatal care in a carceral facility and has the potential to enhance health care quality and maternal–fetal outcomes in this high-risk population.