Improvement of Nursing Self-Efficacy for Labor Support Techniques and Implementation of the Coping With Labor Algorithm

Abstract

There is a 15-fold variation in cesarean birth rates across the United States, yet only 25% can be explained by health risks or objective diagnoses.1,2 This suggests that care practices in hospitals may influence cesarean birth rates. The implementation of care bundles is intended to reduce practice variations. The Promoting Comfort in Labor bundle from the American College of Nurse-Midwives’ Reducing Primary Cesarean Collaborative (RPC) was adopted by our hospital in south central Virginia. Bundle items include provision of continuous labor support ( CLS ), availability of nonpharmacologic tools for comfort, assessment of coping instead of pain, and initial and ongoing education for nurses on nonpharmacologic comfort methods. We used the Nurses’ Care of Women in Labor Survey to guide and evaluate effectiveness of policy changes and education for nurses and implemented the Coping With Labor Algorithm as the unit’s pain-assessment tool. We sent the nursing staff an e-mail and administered the survey using an online survey tool in 2016, 2017, and 2019. All employed labor and delivery nurses were invited to voluntarily participate. The rate of patients receiving CLS and assessment for coping was tracked on a monthly basis. The work was Institutional Review Board–exempt as quality improvement related to participation in the RPC Collaborative. From 2016 to 2019, nursing knowledge of the benefits CLS and confidence in the ability to use CLS techniques increased (p = 1.81E-09, and p = .00000, respectively). From baseline in 2015 to 2019, the rate of patients receiving CLS increased from 3.93% to 4.87% (p = .307). The rate of pain assessment as coping–not coping increased from 44.5% before formal implementation to 79.6% (p = .0000021) after 18 months. Survey-guided education resulted in increased knowledge of outcomes associated with labor support as well as self-efficacy for skill and comfort using labor support techniques. More women received CLS. Use of coping–not coping as the tool to assess labor pain increased. Areas to improve included provider education, better collaboration with doulas, and establishing a program for annual competency assessment for nurses. Additional changes to documentation fields in the health record are needed to make it simpler to consistently document CLS and coping for improved data tracking and improvement.