Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes

A causal model of job stress among Thai nurse-midwives

Objective

To test a causal model of job stress among nurse-midwives working in labor and delivery units in Thailand.

Methods

Random and convenience sampling was used to recruit 282 nurse-midwives with at least 6 months of work experience from 16 regional tertiary hospitals in Thailand. Data were collected from May to December 2020. Research instruments with good internal consistency reliability ranged from 0.83 to 0.91 including the Job Stress Scale and the Thai version of the Job Content Questionnaire (TJCQ). Descriptive statistics and a structural equation model were used for data analysis.

Results

Job demands were the strongest predictor of job stress. At the theoretical level, high job control plays a crucial role in directly reducing job stress. However, the present research provides contrary evidence to the theoretical predictions. When nurse-midwives perceive high job control, they perceive pressure to meet the expectations of their supervisors and colleagues. Therefore, high job control can contribute to job stress. Likewise, job support had an indirect effect on job stress among nurse-midwives through job control. The modified model fitted the empirical data (χ 2 = 57.76, df = 22, CMIN/df = 2.62, goodness of fit (GFI) =0.96, adjusted goodness of fit (AGFI) =0.91, comparative fit index (CFI) = 0.95, and root mean square error of approximation (RMSEA) = 0.07). The effects of job demands, job control, and job support on job stress among Thai nurse-midwives can explain 67% of the model's total variance for job stress.

Conclusions

Nurse-midwives who encounter high job demands and less control over their work control suffer from job stress. Job support does not directly affect nurse-midwives’ job stress but influences it through perceived job control. Strategies to decrease job stress among Thai nurse-midwives should focus on how to balance job demands, and enhance job control, and job support.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates

BACKGROUND

The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes.

PURPOSE

Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers.

METHODS

We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated.

RESULTS

Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions.

CONCLUSIONS

Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Using Institutional Ethnography to Explicate the Everyday Realities of Nurses' Work in Labor and Delivery

Fetal health surveillance is a significant everyday work responsibility for labor and delivery nurses. Here, nursing care is increasingly focused on technological interventions, particularly with the use of continuous electronic fetal monitoring. Using Institutional Ethnography, we explored how nurses conduct this work and uncovered the ruling relations coordinating how nurses "do" fetal health surveillance. Analysis revealed how these powerful ruling relations associated with the biomedical and medical-legal discourses coordinated nurses' fetal monitoring work. Forms requiring documentation of biophysical data caused nurses to focus on technological interventions with much less attention given to holistic and supportive care measures. In doing so, nurses inadvertently activated and participated in these powerful ruling discourses. The practice of ensuring the safe birth of the baby through advances in technological surveillance and medical interventions took priority over well-established approaches to holistic nursing care.

Intrapartum Nurses' Beliefs Regarding Birth, Birth Practices, and Labor Support

OBJECTIVES

To examine the relationships among intrapartum (IP) nurses' beliefs regarding birth (physiologic birth/medicalized birth) and their experience, education, and certification; to assess IP nurses' beliefs about birth practices and labor support; to describe the birth practices of the most effective IP nurses; and to elicit recommendations from IP nurses for quality improvement in IP nursing practice.

DESIGN

Cross-sectional, descriptive study.

SETTING

Three urban hospitals from one state in the northeastern United States.

PARTICIPANTS

One hundred twelve IP registered nurses who were primarily staff nurses.

METHODS

We collected quantitative and qualitative data using a Web-based survey that included the Intrapartum Nurses' Beliefs Related to Birth Practice-Modified scale. We used Burgess's conceptual definition of laborsupport as the framework to analyze findings.

RESULTS

Participants favored physiologic birth and not medicalized birth, and their beliefs were associated with experience (p = .01) and certification (p = .04). Participants reported that effective IP nurses demonstrate labor practices supportive of physiologic birth. Recommendations from participants for quality improvement in IP nursing practice included ways to optimize physical support, emotional support, informational support, and advocacy for women during labor. Participants made no recommendations related to partner support.

CONCLUSION

Participants held beliefs that favored physiologic birth and supported many labor practices that can facilitate physiologic birth. However, some labor practices associated with medicalized birth were also supported. Further quality improvement strategies to provide partner support during labor are needed.

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.

Fifty Years of the Rise in Cesarean Birth in the United States and Opportunities for Improvement

Factors that shaped and promoted cultural norms in the 1900s continue to influence current obstetric practice today. The incidence of cesarean birth too often has little to do with the health needs of the woman or the fetus and more to do with multiple factors over which the woman has no control. Nurses and midwives can reduce unnecessary cesarean births and have the necessary knowledge, competence, and skills to help women give birth without medical intervention.

Theory analysis of social justice in nursing: Applications to obstetric violence research

The dual purpose of this article is to present a formal theory analysis combined with recommendations for the use of social justice in nursing as a framework for the study of obstetric violence in US hospitals. A theory analysis of emancipatory nursing praxis as a middle-range theory of social justice in nursing was conducted using the strategy by Walker and Avant. The theory of social justice in nursing was determined to be logical, useful, and generalizable. The soundness and usability of the theory support the recommendations made for it to be applied to the study of obstetric violence, plus quality and outcome problems in maternity care that have been resistant to sustained progress and may benefit from a new paradigm for continued study. The alignment for obstetric violence to be studied with a social justice framework is linked to the theory's origins in critical social theory and the evolving concept of obstetric violence as a sex-specific form of violence against women that is a violation of human rights. The postmodern expansion of the body of work based on critical theory provides examples from emancipatory and feminist researchers for recognizing how the study of obstetric violence is compatible with a theoretical framework for social justice in nursing. The suitability of this framework to guide the further research needed to better understand, identify, and minimize harms from the occurrence of obstetric violence is argued. In addition, "The Code" for the American Nurses Association (ANA) is cited as a professional reference that outlines nurses' responsibilities for practice based on ethics, human rights, and social justice that are antithetical to the occurrence of obstetric violence.

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points

OBJECTIVE

To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.

DATA SOURCES

Medical record data from nine hospitals in Washington State from January 2016 through September 2018.

STUDY DESIGN

Retrospective, observational cohort design using an aggregated database of birth records.

DATA COLLECTION/EXTRACTION METHODS

Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared.

PRINCIPAL FINDINGS

The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.

CONCLUSION

Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.

Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours

BACKGROUND

Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women.

PURPOSE

We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing.

METHODS

This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest.

DISCUSSION

While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Implementation of the Fetal Monitor Safety Nurse Role: Lessons Learned

BACKGROUND

The fetal monitor safety nurse role was created as a supplemental support for nurses assessing fetal heart rate tracings in response to an adverse event. An experienced labor and delivery nurse without a patient care assignment was designated to continuously assess all active fetal monitoring tracings, via an electronic display away from the main nurses' station, as an adjunct to the care and assessment of the nurse with primary responsibility for the patient.

PURPOSE

The purpose of this project was to evaluate the views of nurses who served as fetal monitor safety nurses about various aspects of the role.

METHODS

Nurses who served as fetal monitor safety nurses were invited to attend a small group session where they completed a survey about the role and then received information on the importance of fetal monitoring safety. Two weeks later, they were asked to take the survey again to evaluate potential changes in viewpoints.

RESULTS

Thirty nurses attended small group sessions and completed the survey. Of those, 22 nurses completed the post survey 2 weeks later. There was minimal change in nurses' views of the fetal monitor safety nurse role after attending the small group sessions. Nurses expressed comfort in notifying peers about concerns related to the fetal heart rate tracing and perceived overall safety benefits; however, they felt that safe staffing measures were not in place to support the role. Concerns were expressed about a nurse being in a nondirect patient care position during times of high census and acuity.

CLINICAL IMPLICATIONS

The fetal monitoring safety nurse may be an innovative potential solution to minimize risk of adverse events during labor that are related to accurate assessment of electronic fetal monitoring data and timely and appropriate interventions. More data are needed on improvements in fetal outcomes and adverse events potentially related to the fetal monitor safety nurse role. Budgetary support and adequate nurse staffing are required to make the role operationally feasible and safe. Valuing and seeking nurses' input as bedside experts about perinatal safety initiatives should be a part of implementing new practices.

Nurses' perceptions of the dynamics and impacts of teamwork with physicians in labour and delivery

Interprofessional teamwork is touted as essential to positive patient, staff, and organizational outcomes. However, differing understandings of teamwork and divergent professional cultures amongst healthcare providers influence the success of teamwork. In labour and delivery, nurse-physician teamwork is vital to safe, family-centered maternity care. In this focused ethnography, the perceptions of obstetrical nurses were sought to understand nurse-physician teamwork and the features that facilitate or impede it. These nurses acknowledged working in a normative hierarchy, with physicians ultimately responsible for patient care decision-making. They described myriad ways in which they navigated traditional power dynamics and smoothed working relationships with physicians, such as circumventing disrespectful behaviors, venting with each other, highlighting their own autonomy, using tactical communication, and managing unit resources. According to these nurses, key facilitators of functional nurse-physicians relationships were time, trust, respect, credibility, and social connection. Further, the nature of their working relationships with physicians influenced their perceptions regarding intent to stay, workplace morale, and patient outcomes.

Implementing an intervention to promote normal labour and birth: A study of clinicians' perceptions

OBJECTIVE

Prior to implementation of a Normal Labour and Birth Bundle (NLBB) at a regional maternity service in Victoria, Australia, this study aimed to understand clinician factors that may influence the uptake, acceptance and use of the NLBB.

DESIGN

This was a mixed methods study in which The Theory of Planned Behaviour (TPB) provided the framework for the conduct and analysis of the staff survey and focus groups. Descriptive and multiple regression were used to analyse the survey data and thematic analysis was used for the focus group data.

PARTICIPANTS

Participants for the survey and focus groups included clinicians providing publicly funded care and management of labour for women birthing at the health service. Maternity care clinicians were invited to participate in both the survey and the focus groups.

FINDINGS

Seventy-six clinicians (88.8%) responded to the survey. Mean scores for TPB constructs were well above the mid-scale score of 4, indicating strong positive attitudes, high levels of self-efficacy and positive social pressure to use the NLBB and strong intentions to use it in the future. Self-efficacy was the strongest independent predictor (β = 0.45, p < 0.001) of intention to use the NLBB (overall model R2=0.38). A valued consequence of implementing standardised and objective guidelines, highlighted in the focus groups, was the positive impact on clinicians' confidence in their decision-making.

KEY CONCLUSIONS

This study found that midwives and obstetricians were in favour of using a normal labour and birth care bundle and perceived the bundle to align with the expectations of work colleagues and the women they care for. The findings of this study show that clinicians at the health service had strong intentions to use the normal labour and birth care bundle in the future.

IMPLICATIONS FOR PRACTICE

Implementation science is important in embedding and sustaining practice change. Understanding staff perceptions is an essential first step of this process.

Clinicians' views of factors influencing decision-making for caesarean section: A systematic review and metasynthesis of qualitative, quantitative and mixed methods studies

BACKGROUND

Caesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians' and midwives' views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians' and midwives' views on the factors that influence the decision to perform caesarean section.

METHODS

The electronic databases of PubMed (1958-2016), CINAHL (1988-2016), Maternity and Infant Care (1971-2016), PsycINFO (1980-2016) and Web of Science (1991-2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians' and/or midwives' views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al's 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies.

RESULT

The review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: "clinicians' personal beliefs"-('Professional philosophies'; 'beliefs in relation to women's request for CS'; 'ambiguous versus clear clinical reasons'); Theme 2: "health care systems"-('litigation'; 'resources'; 'private versus public/insurance/payments'; 'guidelines and management policy'). Theme 3: "clinicians' characteristics" ('personal convenience'; 'clinicians' demographics'; 'confidence and skills').

CONCLUSION

This systematic review and metasynthesis identified clinicians' personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians' characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future.

Intrapartum Nurse Perception of Labor Support After Implementation of the Coping With Labor Algorithm

The purpose of this research project was to determine if using the Coping with Labor Algorithm would lead to changes in the perception of the intrapartum (IP) nurses' beliefs toward birth practices and frequency of labor support interventions. Twenty-three participants completed the preintervention survey, which included the IP Nurses' Belief Toward Birth Practice Scale and the Labor Support Scale. Following completion of the preintervention survey, participants received a copy of the Coping with Labor Algorithm and Toolkit and then began implementation of the Coping with Labor Algorithm. After implementation, 13 IP nurses completed the postintervention survey. The surveyed IP nurses reported positive changes in their perceived frequency of labor support and a slight change in their birth beliefs.

A Qualitative Study on Women's Experiences of Intrapartum Nursing Care at Tamale Teaching Hospital (TTH), Ghana

Introduction: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care. Taking care of a mother through delivery with no side effects is the task of a professional midwife who is trained with the skill to take the responsibility of caring for mothers and babies. Therefore, the aim of this study was to explore mother's experiences regarding quality of intrapartum nursing/midwifery care. Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 TTH, Ghana using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in the post natal ward after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited post natal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis. Results: The average age of women were 29 years with ranging from 19-43 years. Participants' experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers' behavior, pain management and availability of nurses/midwives. Conclusion: The study findings have revealed that women's experience of care is affected by a wide range of determinants. Therefore, maternal health programs and policies in Ghana must take into account women's perspective on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills.

Variation in Cesarean Birth Rates by Labor and Delivery Nurses

OBJECTIVE

To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses.

DESIGN

Retrospective cohort study.

SETTING

One high-volume labor and delivery unit at an academic medical center in a major metropolitan area.

PARTICIPANTS

Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation.

METHODS

Data 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.

RESULTS

Seventy-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.

CONCLUSION

The 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.

The Value of the Maternity Care Team in the Promotion of Physiologic Birth

The benefits of normal, physiologic birth have been well documented. Health care providers such as nurses, midwives, and physicians have distinct and significant roles in the promotion of physiologic birth processes. By supporting women and families, doulas can enhance the maternity care team and further facilitate physiologic birth. A collaborative maternity care team can foster and support a common goal of safe, satisfying, and affordable care practices associated with physiologic birth.

Clinical indications associated with primary cesarean birth

Cesarean birth is the most common surgical procedure in the United States and is associated with increased morbidity and mortality when compared to vaginal birth. Of the more than 4 million births a year, one in three is now a cesarean. A better understanding of the clinical indications contributing to the current prevalence in primary cesarean rates can inform prevention strategies. This column takes a second look at two recent studies in which researchers evaluated the clinical indications associated with primary cesarean birth rates.

Reliability and validity of an instrument to measure the beliefs of intrapartum nurses

Intrapartum nurses assume a central role in the birth process and make decisions driven by a set of beliefs. Therefore, the purpose of this study was to develop a valid and reliable instrument to measure birth beliefs of intrapartum nurses related to birth practice. A total of 313 intrapartum nurses accessed this online, self-administered instrument over a 3-month period. The Theory of Planned Behavior guided development of the Intrapartum Nurses' Beliefs Related to Birth Practice scale and provided a basis for the connection between beliefs and practice. This article describes the psychometric analysis of the instrument. Findings include a moderate, positive correlation with a similar instrument, a Cronbach α of 0.797, and 2 factors identifying belief systems. With further revision, this instrument may provide an accurate measure of the birth beliefs of intrapartum nurses.