1. Gregory, Katherine E. PhD, RN
  2. Associate Professor

Article Content

In this volume of The Journal of Perinatal & Neonatal Nursing, one of the focal topics is on the transition to extrauterine life. The transition to extrauterine life is of interest to perinatal and neonatal nurses because it is a time of dramatic change in the human condition and one that often requires our nursing care and clinical expertise. As I reflect on the importance of this transition, I can't help but think about the importance of change. Without change in our biology, a fetus cannot become an infant; a woman cannot become a mother. Without change in our clinical practice, we would not have newborn intensive care units and preterm infants who most often become bright-eyed school children. Change, whether in our biology or clinical practice, is necessary and important to human health. In our current healthcare environment, it feels almost constant. Yet, while most of us agree that we like progress and innovation, very few of us like change.


Change is necessary and important; however, it can be difficult to experience. Several metaphors can be drawn from studying the state of the science on the transition to extrauterine life in tandem with best practices from change management. In this column, I have applied these metaphors to the initiation and implementation of clinical practice changes. Some pertinent examples include the following: (1) establish a sense of urgency; (2) plan an incremental approach; (3) communicate the vision and goals; and (4) build an effective team.


Establish a Sense of Urgency. Birth and the transition to extrauterine life are characterized by a certain sense of urgency. While the onset of labor and the process leading up to birth may be more or less urgent depending on the woman and the infant, this transition is unlike almost any other type of biological change experienced over the life span in the sense of urgency it brings for the patient, family, and healthcare team. In the setting of preterm labor and birth, the clinical interventions required to support the transition to extrauterine life most often create a significant amount of urgency for everyone involved. While this urgency may be associated with some angst for the team caring for high-risk pregnant women and infants, it is ultimately an extremely effective stimulus for clinicians to take action and cooperate with one another, 2 critical elements in initiating any successful change process.


Initiating and implementing change almost always rely on establishing a sense of urgency.1 Without a sense of urgency, individuals may remain complacent in their current practice, with little reason and no momentum to change. Thus, the first step in launching a successful change in clinical practice is to establish a sense of urgency or time-sensitive importance for making the change. The following are some examples of the factors that may contribute to creating a sense of urgency for initiating a change in clinical practice:


* A culmination of clinical research providing evidence that a current clinical practice is no longer optimal for patient care outcomes and/or a new clinical practice results in better outcomes.


* Adoption of a new technology that requires clinical practice changes so that the technology can be most effective for patient care.


* Shifts in the demographic and/or clinical characteristics of the patient population.


* Transitions in the expertise of the healthcare team (ie, influx of new clinicians, departure of experienced clinicians, changes in the specialty expertise of the team).


* Organizational changes that may influence the type of patients cared for and thus the clinical practice required for these new patients.


* A specific case or series of cases that result in a patient safety event.



Whatever the stimulus may be for creating a sense of urgency to making a clinical practice change, it is important to impress upon all parties involved in making the change that remaining complacent may result in a lost opportunity to improve care, or worse, a crisis. Establishing a sense of time-sensitive importance, not unlike how we approach our interventions at the time of preterm labor and birth, set the foundation for taking action and cooperation, 2 elements that are required throughout the change process.


Plan an Incremental Approach. The transition to extrauterine life requires a cascade of very well-orchestrated events. While it may seem like these events occur rather rapidly and all at once, in truth, they occur in an incremental fashion, with one change building on the next. The more we learn about the transition to extrauterine life, the more we are coming to understand that this change is an evolving process. While it is one that does create a sense of urgency, it is also one that should be treated with extreme care. Our traditional practice of rapid resuscitation and intubation at the time of birth for preterm infants must now be balanced against new evidence suggesting that "gentle interventions and care," which focus on supporting the infant's own vitality, result in better outcomes for preterm infants.2 While further study and more evidence are needed in this area of our practice, these early observations propose that interventions during the transition to extrauterine life are perhaps most optimal when approached with a "gentle" and incremental approach.


Interestingly, the literature on implementing and sustaining clinical practice changes underscores that once there is a sense of urgency about the need to change, there is an importance to making incremental changes that occur in an orchestrated stepwise approach.3 Three reasons why I believe that this might be important to making effective and lasting changes in our clinical practice include the ability to (1) ensure buy-in from the majority of stakeholders, (2) break down a big change into small parts, thereby mitigating the anxiety that is often associated with change, and (3) provide an opportunity to monitor change and the need for adjustments to the change in real-time. Making changes that are targeted, addressing one part of a problem at a time facilitates an ability to manage and measure change effectively.3 Certainly, there are times when rapid and aggressive interventions are required at the time of birth to facilitate a safe transition to extrauterine life. And, certainly there are times when clinical practice changes must be made immediately, without an incremental stepwise approach. However, when possible, an incremental and well-orchestrated approach to change is most optimal for all involved.


Communicate the Vision and Goals. Effective communication among the care team during the time of transition to extrauterine life is critical. There are several strategies that help facilitate optimal communication and team preparedness during neonatal resuscitation. One relatively novel approach is the use of checklists during neonatal resuscitation.4 In the study reported, the team implemented a checklist that included both pre- and postresuscitation, along with discipline-specific sublists relevant to the transition to extrauterine life and neonatal resuscitation. One of the major distinctions of this work was not only the development of a neonatal resuscitation-specific checklist but also the communication process that followed the resuscitation. This debriefing discussion occurred at the end of the resuscitation and covered issues of what was done well, not well, and how the resuscitation might have been improved. Interestingly, following the implementation of the checklist and new approach to neonatal resuscitation, the number of times where communication was identified as a problem decreased from nearly 25% to less than 5% (P < .001).4 This study highlights that the use of a structured document such as a checklist not only facilitates timely identification of issues that need to be addressed by clinical leadership but also that planning in advance to ensure that effective communication will occur at the time of neonatal resuscitation is key to success.


The use of a checklist underscores that clear and effective communication regarding the plan and goals for the patient is critical to effective team performance and patient care.5 This is similar to successfully navigating the process of implementing change, where one of the main dogmas is to communicate the change vision effectively from the beginning to the end of the project. John Kotter,1 expert in change management, identifies 7 key elements in the effective communication of change. These are all relevant to implementing clinical practice changes and include the following:


1. Simplicity: Keep the message clear and concise.


2. Metaphors, analogy, and example: Develop imaginative ways to communicate your message.


3. Multiple forums: Find many different opportunities to share your message.


4. Repetition: Repeat your message multiple times.


5. Leadership by example: The behavior of leadership is a powerful mechanism to communicating your message and implementing successful change.


6. Explanation of seeming inconsistencies: When inconsistencies are associated with the change, communicate openly with the team about the issues and seek resolution when possible.


7. Give-and-take: Two-way communication is always more effective than 1-way communication.



Effective communication is time-intensive and takes practice. Much like the work published on communication during neonatal resuscitation,4 debriefing on what has worked well, less well, and what could be better in future communication efforts is time well spent when implementing clinical practice changes.


Build an Effective Team. Women have been accompanied by midwives at the time of birth for centuries. Today, in industrialized nations where adequate healthcare resources exist, women and their infants are cared for by midwives and/or multidisciplinary clinical teams at the time of birth. However, it is important to note that lack of a skilled birth attendant remains one of the leading causes of perinatal and neonatal morbidity and mortality in nations with limited healthcare resources.6 This fact underscores that the transition to extrauterine life, just like any change, should not be managed alone. A team of skilled clinicians, who have the ability to utilize resources in the event of a complication, is an important component in successfully navigating the transition to extrauterine life.


Implementing clinical practice changes relies on engaging all of the people in the process and setting expectations about the change. In short, almost no one can make effective clinical practice changes independently. Thus, leaders need the ability to build and develop a team of clinicians who will work together and with others outside the team throughout the change process. Three simple rules for building a project team have been proposed by the Six Sigma approach to process improvement and change management.7 The first is to not be too rigid in who participates on the team. There may be a core group of members who work with the team from start to finish. However, depending on the evolving needs of the team, there may also be individuals who contribute to the work on a more ad hoc or as-needed basis. The second is to match the talents of individual members to specific needs of the team. The team leader(s) is responsible for determining the needs of the team and then populating the team with the talent to meet the goals of the project. Finally, the team must have a common purpose that is built on developing a common identity. The team members should know what is expected of them and where there may be challenges in meeting the goals and expectations of the project. Following these 3 rules will contribute to the development of effective team members who will be positioned for success as a result of their ability to harness their unique expertise in initiating and implementing clinical practice changes.


The transition to extrauterine life represents change. We can learn a great deal from our patients about change, specifically how to make clinical practice changes, from our observations about the successful transition to extrauterine life. This unique transition is not always a rapid event that occurs immediately at the time of birth. Rather, it involves many small but significant steps toward the end point. I have identified some relevant themes from this biological transition in parallel with the literature on change management, which I hope will be helpful in guiding our collective experience in coping with the ever-evolving nature of our clinical practice. Approaching changes in our clinical practice with a time-sensitive importance, incremental approach, ongoing communication, and collaborative team work will provide a path to patient care that is increasingly based on the state of the science. As a result, our care will contribute to optimal outcomes for patients and their families.


In sum, it is timely that this issue of The Journal of Perinatal & Neonatal Nursing is partly focused on the transition to extrauterine life and I have used this as a metaphor for making clinical practice changes, given that the authorship of this column has recently changed. Jacqueline McGrath has written the Neonatal Expert Opinion column for the past 8 years, and as she transitions to her new role as coeditor of Advances in Neonatal Care, I am thrilled to have the opportunity to write this column for you. I hope to develop a relationship with you and, in doing so, will learn more about what is most important to you, your clinical practice, and the patients who you care for. I hope that you enjoy reading the column and that you find it both helpful and relevant to your work. Feel free to contact me via e-mail to share your thoughts and insights about neonatal nursing-I look forward to hearing from you!


-Katherine E. Gregory, PhD, RN


Associate Professor


Boston College, W.F. Connell School of Nursing


Chestnut Hill, Massachusetts


Haley Nurse Scientist


Brigham and Women's Hospital


Boston, Massachusetts




1. Kotter JP. Leading Change. Boston, MA: Harvard Business School Press; 1996. [Context Link]


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3. Pexton C. Lean and Six Sigma: fixing healthcare a process at a time. iSixSigma. 2010. Accessed February 17, 2014. [Context Link]


4. Katheria A, Rich W, Finer N. Development of a strategic process using checklists to facilitate team preparation and improve communication during neonatal resuscitation. Resuscitation. 2013;84(11):1552-1557. [Context Link]


5. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009. [Context Link]


6. UNICEF. Countdown to 2015: Maternal, Newborn, & Child Survival. Accessed February 20, 2014. [Context Link]


7. McIntyre W. Building a Six Sigma project team. iSixSigma. 2011. Accessed February 20, 2014. [Context Link]