Nursing Delivery Research Articles

Application of Caring Theory to Nursing Care of Women Experiencing Stillbirth.

The purpose of this study was to determine the extent to which labor and delivery nurses used the tenets of Swanson's middle-range theory to care for women whose babies were stillborn. A secondary analysis of qualitative in-depth interview data from 20 labor and delivery nurses obtained during a recent grounded theory study was conducted using the directed content analysis method. The five caring processes as described in Swanson's theory were used as a priori codes to conduct the analysis. Nursing care of a woman experiencing a stillbirth included finding a way to connect with her and to understand what she was experiencing (knowing), spending extra time with her (being with), protecting her and preserving her dignity (doing for), providing information and explanations in a clear and methodical manner (enabling), and ensuring that she did not blame herself to facilitate the grieving/healing process (maintaining belief). The caring processes outlined in Swanson's theory of caring provide a valuable guide that can be used when caring for women experiencing stillbirth.

Doulas in the Operating Room: An Innovative Approach to Supporting Skin-to-Skin Care During Cesarean Birth.

Skin-to-skin care (SSC) immediately after birth is recommended for all women and their newborns. Barriers to SSC after cesarean birth lead to delays in initiation of this practice. The purpose of this quality improvement project was to implement an innovative approach with volunteer doulas to support initiation of SSC after cesarean for all clients. Volunteer doulas in a well-established hospital-based program within an academic health center were trained to provide care during scheduled cesarean births in the operating and recovery rooms. Data on rate and time of SSC and client and nurse satisfaction were collected for a 12-week period. Sixty-six women received doula-supported care in the operating room. All medically stable woman-newborn couplets with complete data (N = 58) initiated SSC in the operating room and were included in the data analysis. Forty-eight women completed a feedback survey after birth. Scores indicated that clients agreed or strongly agreed that the doula was an important part of the birth experience. Feedback from labor and delivery nurses indicated highly positive attitudes about the importance of SSC and the presence of volunteer doulas. All nurses surveyed who had participated in doula care (n = 20) agreed or strongly agreed that they were satisfied with the doulas and that the doulas were prepared for this role. This project demonstrates that volunteer doulas can be prepared to provide supportive care to clients during and immediately after cesarean birth. Doulas can play an integral role in supporting the initiation of SSC after cesarean birth and are perceived as an important member of the maternity health care team by clients and nurses.

Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment: Results of a Randomized Trial.

Assertiveness is essential for communication and/or speaking up. We performed a randomized trial to assess the effectiveness of assertiveness/advocacy/CUS/two-challenge rule (AACT) simulation-based education for labor and delivery, as well as postpartum nurses. We aimed to determine whether this training would improve labor and delivery and postpartum nurses speaking up in the clinical setting. We conducted a randomized controlled trial among nurses on labor and delivery and postpartum units. During the intervention, participants were trained on abnormal vital signs, underwent a baseline assertiveness self-assessment, and were block-randomized (by work location: labor and delivery or postpartum) to either simulation-based AACT (intervention) or I-PASS [Illness Severity, Patient Summary, Action List, Situational Awareness and Contingency Planning, Synthesis by Receiver hand-off tool education] (control) simulation-based education. The outcome part of the study consisted of an in situ simulated clinical encounter during which each individual learner's assertive behaviors were assessed as they found out about a patient's abnormal vital signs. Two raters, different from those that participated in the intervention part of the experiment, and who were blinded to whether the learner was in the control or intervention arm, scored participants. The learner (Registered Nurse) was not aware that this was an in situ simulation and perceived this as a real clinical encounter. The degree to which the learners spoke up was measured using a validated scale (Pian-Smith). Seventy nurses completed the study. There were 34 learners in the intervention and 36 in the control groups. Among those in the intervention group, there were 18 labor and delivery (LDI) nurses and 16 postpartum (PPI) nurses. Among the control group, there were 14 labor and delivery (LDC) nurses and 22 postpartum (PPC) nurses. Using a five-point Pian-Smith scale, we demonstrated that there was no difference in the likelihood of speaking up between the overall intervention and control groups (2.00 ± 1.00 and 1.65 ± 0.82, P = 0.10). Among controls, the likelihood of speaking up was higher for labor and delivery nurses than for postpartum nurses (P < 0.006). There was a significant interaction (P = 0.02) between treatment group and work location. Although the control and intervention groups from labor and delivery showed similar higher levels of speaking up (2.29 ± 0.89 and 2.06 ± 0.95, respectively, P = 0.49), postpartum nurses in the intervention arm were more likely to speak up than were postpartum nurses in the control arm (1.97 ± 1.07 vs. 1.25 ± 0.43, P = 0.007). Although there was no difference in speaking up scores between intervention and control groups overall, simulation-based AACT training among postpartum nurses was associated with a statistically significant increase in the likelihood of speaking up during a challenging simulated clinical encounter. The degree of change makes the clinical significance uncertain. There was no statistically significant difference in the likelihood of speaking up among labor and delivery nurses.

Embedding recovery-based approaches into mental health nurse training

Background: Mental health nursing has undoubtedly progressed as a profession but is at a hiatus that is not assisted by government policy and decreased resources. Aims: This reflective account explores some of the considerable expectations placed upon qualified nurses and the real tensions that influence care delivery standards. Methods: Reflecting on experiences gained in clinical settings, underpinned by literature on recovery, some of the expectations placed on qualified nurses in contemporary mental health service delivery are examined. Conclusion: In order to adequately inform the practices and skill set of contemporary mental health nurses, recovery models and clinical staff input should play a central role in nurse education. Education and clinical practice areas should continue to move towards each other and seize every initiative to ensure both are on the same page.

Educational Preparation and Perceived Proficiency of Nurses Working in Oncology Units at the University College Hospital, Ibadan, Nigeria

Background: Cancer is a malignant pathologic disorder, which poses a global threat to the health and survival of an individual, both young and old. Globally, nurses are considered very vital in all aspects of cancer control due to their impact on the quality of care outcomes which is greatly influenced by specialized training in oncology nursing. However, in Nigeria and some parts of Africa, there is dearth of information and documentation on the nurses' educational preparation and proficiency of nurses in delivery of oncology care. Aim: This study assessed educational preparation and perceived proficiency of nurses working in oncology units at University College Hospital, Ibadan to provide information oncology nursing training of these nurses as well as their perceived proficiency. Methods: The study used a descriptive cross-sectional design. Permission and clearance were obtained from the Joint University of Ibadan/UCH ethical review committee and subsequently head nurses in each unit and the nurses that participated. A purposive sampling method was used for selection of participants and a structured questionnaire with reliability coefficient value of 0.94 was used for data collection. Data were entered using SPSS version 20 and data analysis was done using descriptive and inferential statistics. Results: A total of 104 nurses working in oncology units fully participated in the study. For age, mean ± SD was 35 years ± 6. 54.4% of respondents had diploma professional training in general nursing as their highest level of education. Most of the respondents 88.5% did not have certification in oncology nursing, 77.9% had no form of specialized training in oncology care. The only exposure to oncology nursing training for most of the participants was during their basic training in nursing and midwifery schools but duration of exposure could not be ascertained. Most 64.4% of respondents felt their exposure to oncology nursing care wasn't adequate. 62.7% affirmed there was no educational institution that caters for specialized oncology training in their locality. However, 55.8% of the respondents considered themselves as highly proficient in giving oncology care. There was no statistically significant association between years of experience in oncology care and perceived proficiency χ2 value χ2 = 3.05, pv = 0.11. Conclusion: This findings revealed the training in oncology nursing among nurses is not adequate as the only oncology nursing training exposure was at the basic nursing schools. Hence the need to establish oncology nursing training programs for nurses in cancer care in Nigeria. This will go a long way to influence cancer control.

Association of a Health Care Provider Review Meeting With Cesarean Delivery Rates: A Quality Improvement Program.

To examine the association of a quality improvement effort that was mediated through weekly review of all criteria for cesarean delivery on cesarean delivery prevalence and indications. We conducted a retrospective cohort study using a natural experiment model that compared two timeframes, from 2009 to 2013, at a single institution. We introduced a weekly retrospective review conference to discuss all cesarean deliveries in 2010 that continued over time. The conferences were attended by obstetric care providers, anesthesiology, and labor and delivery nurses. Date of delivery was dichotomized by those delivering before July 1, 2010, and those delivering after. We included women with term singleton vertex gestations in our study population and then examined the rates of cesarean delivery by date of delivery. We then examined indications for the cesarean deliveries during the study period based on surgeon documentation. χ tests were used for statistical comparisons and a P value of <.05 was used to indicate statistical significance. There were 5,541 term singleton cephalic births during the study period. The rate of cesarean delivery declined significantly after our intervention in all women (22.2% vs 27.4%, P<.001) and nulliparous women (23.3% vs 30.9%, P<.001). The adjusted odds ratio of cesarean delivery in all women as related to time cohort is 0.68 (95% CI 0.58-0.79) and 0.56 (95% CI 0.44-0.70) in nulliparous women. We examined indications for the 1,315 cesarean deliveries during the study period by date of delivery. The indications of active-phase arrest, second-stage arrest, failed induction, repeat cesarean delivery, and maternal request decreased significantly between delivery cohorts in all women (P<.001) and in nulliparous women specifically (P<.001). Between delivery cohorts, we found that the prevalence of labored indications for cesarean delivery decreased more than nonlabored indications. Implementation of a weekly review conference was associated with a reduction in both overall cesarean delivery prevalence and labored indications at our institution.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth.

Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada. Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care. Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43). Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

Use of Scorecards as Feedback on Quantitative Blood Loss Measurement Is Associated With Practice Improvement

The purpose of this project was to improve quantification of blood loss (QBL) measurement at delivery by labor and delivery nurses in a community hospital. Scorecards were used to provide feedback on the nurses’ performance. The measurement of QBL had been required by the hospital’s policy since 2013 but compliance remained low, even though QBL is a recognized evidence-based practice.

Peer-Led In Situ Simulations for Clinical Nurse Training by Simulation Clinical Champions

The purpose of the Simulation Clinical Champions (SCC) program was to create, implement, and evaluate an in situ, peer-to-peer, clinical simulation training program that did not negatively impact productivity for labor and delivery nurses.

Implementation of the Sepsis Risk Calculator at an Academic Birth Hospital.

Multivariate predictive models for estimating the risk of neonatal early-onset sepsis (EOS) are available as a Web-based sepsis risk calculator (SRC) and may reduce the proportion of newborns empirically treated with antibiotics after birth. EOS risk assessment based on such models would require workflow changes at most birth hospitals. A multidisciplinary team of obstetric, neonatal, and information technology staff at a large, academic, birth hospital collaborated to implement the SRC. The obstetric electronic medical record was modified to provide a link to the SRC. Labor and delivery nurses calculated the sepsis risk at birth and alerted neonatal clinicians for risk estimates ≥0.7 cases per 1000 live births. Subsequent interventions were based on the risk estimate and newborn clinical examination. We compared the proportion of infants born at ≥36 weeks' gestation with laboratory testing and empirical antibiotics for risk of EOS during the 15-month periods before (n = 5692) and after (n = 6090) implementation. EOS cases were reviewed to assess for safety. Empirical antibiotic use among newborns ≤72 hours old declined by 42% (6.3% to 3.7%; relative risk 0.58 [95% confidence interval, 0.50-0.69]), and laboratory testing declined by 82% (26.9% to 4.9%; relative risk 0.18 [95% confidence interval, 0.16-0.21]). The EOS incidence was not different between the study periods, and no safety concerns were identified. The SRC was integrated into the workflow of a large, academic perinatal center, resulting in significant reductions in antibiotics and laboratory testing for EOS and demonstrating the potential for this approach to impact national practice.

Postpartum Magnesium Sulfate Overdose: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation with a nurse educator maintained the quality and relevance of objectives for nursing participants.The curriculum was prepared to train OB/GYN and anesthesiology residents and labor and delivery nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies.Over an eight-year period, this curriculum has been executed in scenario couplets in a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency, beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice.”In this scenario, participants must evaluate and treat a postpartum preeclamptic woman who is being treated with magnesium sulfate for the purpose of seizure prophylaxis. The patient experiences magnesium sulfate toxicity and subsequent respiratory arrest. Any mannequin that can display vital signs can be used for this scenario.This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Work attitude of Ghanaian nurses for quality health care service delivery: Application of Individual and Organizational Centered (IOC) interventions

Work attitude of Ghanaian nurses for quality health care service delivery: Application of Individual and Organizational Centered (IOC) interventions

From Doc to Post‐Doc to Career: The Transition from Nursing Student to Nursing Scholar

From Doc to Post‐Doc to Career: The Transition from Nursing Student to Nursing Scholar

Labor Pain through the Eyes of Brazilian Women and Delivery Nurses

Objective: Understanding the perception of women who have recently given birth in a Brazilian hospital regarding labor pain and nursing involvement in the labor process. Methodology: exploratory, descriptive and qualitative study carried out in a Maternity part of the supplementary health system in the Federal District (DF). Data were collected between May and July 2015 through interviews using a semi-structured questionnaire. The sample consisted of 16 mothers and data analysis followed Bardin methodology in three phases. Results: The pain experienced during labor is surrounded by feelings and expectations. Both positive and negative feelings experienced by mothers were identified in the interviews and unanimous opinion was the fact that the second stage is the most painful period as continuous pain is experienced. Some of the participants compared pain with strong menstrual cramps, renal colic and back pain; others, said labor pain was the strongest ever experienced. The immediate contact with the newborn was referred to as a reward for coping with breast pain and suffering. Other factors such as the importance of follow-up, support and coping with the pain and care provided by health staff were also highlighted. Conclusion: empowerment of the mother and family through knowledge is considered an important tool to fight pain and cope with the birth process in a positive and physiological way, which in the long run promotes a cultural change in the population regarding the importance of vaginal birth.

Telenursing manual for providing care to patients using clean intermittent urinary catheterization

Abstract Objective: To develop and evaluate apparent and content validity of a telenursing manual to support nurses in the care delivery of patients using clean intermittent urinary catheterization. Methods: Methodological study addressing the development and validation of a telenursing manual. The expert group who validated the telenursing manual was composed of 11 nurses. An inter-rater level of agreement of 70% was considered for each aspect of the instrument. Results: The following levels of agreement were obtained for each aspect: Language 97%, Content 97.7% and Objectives, Relevance, Functionality and Usability 100% each. Conclusion: The manual is available for access and represents an important initiative for the field of telenursing in Brazil, assisting nurses in the telecare provided to patients using clean intermittent urinary catheterization.

Clinical Simulation for Practicing Labor and Delivery Nurses: Advancing Competency through Simulated Nursing Practice

Nurses new to Maternal-Child units in hospital organizations need reality based in-service education in new employee orientation. Experienced nurses must have current, cutting edge staff development sessions that replicate practice scenarios to facilitate currency in practice. Annual clinical skills reaffirmation and new employee orientation commonly include clinical simulation activities that enhance critical thinking, assess clinical competency and reduce the potential for errors in practice. Practice repetition in the Education Department lab setting is a protected area to learn and refine clinical care skills and procedures. Case scenarios through use of clinical simulation are posed to provide current practice initiatives that enhance the nurses’ ability to provide safe, competent patient care. Keywords: Clinical Simulation, Nurse Educators, Nurse Practice, Staff Development

Experiences and Attitudes Among Psychiatric Mental Health Advanced Practice Nurses in the Use of Telemental Health: Results of an Online Survey.

Telemental health (TMH) growth is driven by recent trends in health delivery systems and disparities in access to mental health services. There are currently no standard educational guidelines to prepare psychiatric mental health advanced practice nurses (PMH-APRNs) in TMH delivery. To survey practicing PMH-APRNs across the United States about their experiences and attitudes about use of TMH. Eighty-three participants from the American Psychiatric Nurses Association online discussion board completed a nine-item survey. Length of time practicing as a PMH-APRN, TMH use in practice, populations served, and TMH background. A majority had been practicing as a PMH-APRN for less than a decade and had used TMH, although most reported no prior education or training in this delivery method. Participants did indicate a desire for TMH education. This survey affirms the prevalence of TMH use among PMH-APRN providers, lack of formal training, and necessity for standardized educational guidelines in TMH delivery.

Vicarious Posttraumatic Growth in Labor and Delivery Nurses

Vicarious Posttraumatic Growth in Labor and Delivery Nurses

Variation in Cesarean Birth Rates by Labor and Delivery Nurses

ObjectiveTo examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. DesignRetrospective cohort study. SettingOne high-volume labor and delivery unit at an academic medical center in a major metropolitan area. ParticipantsLabor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. MethodsData were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses. ResultsSeventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. ConclusionThe labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

Decision Making on the Labor and Delivery Unit: An Investigation of Influencing Factors

Objective The aim of this study was to describe the relationship between negative affect (NA), decision-making style, time stress, and decision quality in health care. Background Health care providers must often make swift, high-stakes decisions. Influencing factors of the decision-making process in this context have been understudied. Method Within a sample of labor and delivery nurses, physicians, and allied personnel, we used self-report measures to examine the impact of trait factors, including NA, decision-making style, and perceived time stress, on decision quality in a situational judgment test (Study 1). In Study 2, we observed the influence of state NA, state decision-making style, state time stress, and their relationship with decision quality on real clinical decisions. Results In Study 1, we found that trait NA significantly predicted avoidant decision-making style. Furthermore, those who were higher on trait time stress and trait avoidant decision-making style exhibited poorer decisions. In Study 2, we observed associations between state NA with state avoidant and analytical decision-making styles. We also observed that these decision-making styles, when considered in tandem with time stress, were influential in predicting clinical decision quality. Conclusion NA predicts some decision-making styles, and decision-making style can affect decision quality under time stress. This is particularly true for state factors. Application Individual differences, such as affect and decision-making style, should be considered during selection. Training to reduce time stress perceptions should be provided.