Nurse to Patient Ratios on Labor and Delivery Essay Sample

Nurse to Patient Ratios on Labor and Delivery Pages
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Introduction

            Registered nurses represent the largest single health care profession in the United States (Steinbrook, 2002). More than 1.3 million registered nurses work in hospitals in the United States (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Nurses are vital to the everyday operations that go on in hospitals, nursing homes, and ambulatory care clinics. Needleman et al. (2002) reported that in the United States a higher proportion of nursing care hours provided by registered nurses and a greater number of registered nurse hours per day are associated with better outcomes for hospitalized patients. The outcomes included were a shorter length of stay, lower rates of urinary tract infection, less upper gastrointestinal bleeding, and lower rates of pneumonia, shock or cardiac arrest. A study of 6.2 million patients in the United States found that in hospitals with higher nurse staffing, patient stays were up to 5 percent shorter and complications up to 9 percent lower (Healy, 2002).

There is no consensus yet as to a safe and practical nurse to patient ratio on Labor and Delivery (L&D) units. In spite of this Governor Gray Davis announced proposed ratios in California in January 2002 for various hospital units. For L&D units, the minimum staffing ratio was set at one nurse to two patients (Steinbrook, 2002). Ratios were proposed in spite of the fact that patient acuity and census can change rapidly on L&D units (Loper & Hom, 2000). The role of L&D nurses has evolved over time impacting the amount of time spent with laboring patients (Gale, Forhwegill-Bourbonnais, & Chamberlain, 2001). Nursing support during labor is reported to improve labor and birth outcomes. When nurses can assist women to cope with the stress of labor using a high degree of interpersonal skills, women’s satisfaction with their birth experiences increased (Tumblin & Simkin, 2001. Inpatient maternity services have been influenced by changes in the insurance market, managed care, federal statues, advancements in technology, and most recently the growing nursing shortage (Loper & Hom, 2002). All of these influences impact the current nurse to patient ratios on L&D units. Adequate nurse staffing is crucial to the provision of quality maternity care (Loper & Horn, 2002).

Research Questions

            The purpose of this integrative literature review is to examine the effects of nurse-patient staffing ratios on perinatal outcomes. The integrative review of the literature will ask two research questions:

  1. What are the effects of varying nurse-patient staffing ratios in L&D units on perinatal outcomes?
  2. What are the managerial impacts of varying nurse-patient staffing ratios in L&D units?

Background

            There were 4.1 million births recorded in the United States (US) in 2004. The birth of a baby is the most common reason for admission into US hospitals. A laboring woman today has many choices concerning her pain management during labor. Labor pain and methods to relieve it are major concerns of childbearing women and their families. The experience of labor pain is a complex, subjective, multidimensional response. Labor pain is not associated with pathology but with the most basic fundamental of life’s experiences; the bringing forth of new life (Lowe, 2002).

The laboring woman may elect to have an unmedicated childbirth, a continuous lumbar epidural (CLE), narcotic administration, or hydrotherapy to manage her pain in labor. Labor and Delivery (L&D) nurses need to be familiar and competent in all the above methods for relieving pain during labor. Patients who elect to attempt an unmedicated childbirth require continuous labor support. They need additional guidance on how to utilize the various breathing patterns or styles, relaxation techniques, guided imagery, acupressure, massage therapy, and positioning exercises. Support during childbirth involves the provision of physical comfort measures such as touch, as well as emotional support such as reassurance and praise, instruction/information giving, and advocacy (Miltner, 2000).

Randomized controlled trials (RCTs) have shown that women with a lay supportive companion during labor have better labor and birth outcomes than those who labor alone. Outcomes included: lower cesarean section birth rates, decreased use of oxytocin, decreased use of epidural anesthesia, decreased use of any analgesia or anesthesia, improved Apgar scores, fewer operative vaginal births, fewer admissions to neonatal intensive care  units, and longer breastfeeding durations (Gagnon & Wagohorn, 1996). In most hospital L&D rooms, the L&D nurse is the support person who assists the mother through labor. The L&D nurse, however, also starts intravenous lines, checks vital signs, administers medications, performs pelvic exams, documents labor progress regularly, and usually is responsible for other laboring patients. Such responsibilities often prevent the L&D nurse from providing continuous laboring support, and consequently, the benefits resulting from this support (Winslow, 1998).

            The role of the labor and delivery nurse has changed over the past 20 years in North America. In the 1980s the standard of care was “one-on-one” nursing care, and hospitals advertised that they provided “family-centered” maternity care with attractively decorated birthing rooms. At the same time new technologies were being introduced which became a standard component of maternity care (Tumblin & Simkin, 2001). In the 1990s the increase in inductions, epidural analgesia, and cesarean births gave nurses more equipment to monitor and took more time. The increasing emphasis on documentation for medico legal reasons often require that nurses use computers  out of the  mother’s room or positioned so that the nurse faces away from the woman (Tumblin & Simkin, 2001).

Currently it is common to encounter laboring women, connected to an electronic fetal monitor, receiving an infusion of oxytocin to induce labor as well as an epidural infusion for pain relief. Although nurses’ competence with technology is crucial in caring for laboring women, providing continuous labor support is also an important aspect of care in the birth experience (Miltner, 2000). Nurses in an intrapartum unit are thus required to possess two sets of skills, technical and supportive. However, many studies have shown that intrapartum unit nurses spend only a small amount of their time providing supportive care to women in labor. One study showed the percentage of time spent in supportive care was 6.1 percent (Gagnon & Waghorn, 1996). The Association of Women’s Health Obstetrical and Neonatal Nursing (AWOHN) identified some barriers that can influence the nurse’s ability to provide bedside nursing care. These factors include: limited numbers of available experienced registered nurses, limited financial resources, rigid organizational processes and structures, cumbersome documentation requirements, and decreasing reimbursement by their party payers in the United States (Tumblin & Simkin, 2001).

During the past century, the practices surrounding childbirth have changed dramatically from woman-supported birth in the home to a highly medicalized process in a hospital setting. The needs of maternity patients, however, have not changed. They still require a sense of safety, acceptance, freedom from fear, and the presence of a supportive companion throughout labor and birth (Kayne, Greulich, & Albers, 2001). The L&D nurse, midwife, and physician are often unable to be that support person. Fathers/partners or family members may not be equipped to provide this essential support. The doula has been introduced as an answer to this need. Doula is a Greek word that has come to mean a woman experienced in childbirth who provides continuous physical and emotional support to a laboring woman and her partner (Young, 1998). Doulas are trained to provide a pregnant woman with continuous one-to-one support during childbirth.

The doula is concerned with only one patient for the entire labor and delivery. She focuses on the emotional needs of women, not medical issues like the intrapartum L&D nurse. Doula training helps them remain calm and objective unlike some family members or friends. Continuous labor support by a doula has been demonstrated in RCTs to have a positive effect on perinatal outcomes, including reductions in cesarean deliveries and the need for analgesia during labor (McGrath, Kennell, Suresh, Moise, & Hinkley, 1999). “Continuous labor support, provided under widely varying circumstances by women with varying levels of training, results in lower rates of analgesia and anesthesia use, lower operative delivery rates, lower episiotomy rates, shorter labors, and decreased numbers of infants with five-minute Apgar scores less than seven” (Hodnett, pg. 80, 1997).

Many maternity patients are aware that L&D nurses are not consistently available for providing continuous laboring support. As a result, maternity patients are employing professional doulas to provide continuous laboring support in increasing numbers. They have become aware of the improved clinical outcomes for both mother and baby when utilizing doula services. The number of DONA certified doulas has risen from 31 in 1994 to over 2,400 in 2002 (Stein, Kennell, & Fulcher, 2004). If staffing ratios were set at one nurse to one patient during L&D nurses could then be the sole providers, providing both the technical and supportive care that a registered nurse (RN) can provide. This more intensive care by RNs during L&D might improve birth outcomes as well as satisfaction with care.

In recent decades, the importance of measuring satisfaction within the health care system has been recognized. Since childbearing is the most common reason for accessing health services, assessments of women’s satisfaction with their care during labor and delivery are relevant to healthcare providers, administrators, and policy makers (Hodnett, 2002). Satisfaction involves both a positive attitude and an affective response to an experience. Satisfaction is multidimensional; one can be satisfied with some aspects of an experience and dissatisfied with others (Hodnett, 2002).

Hodnett found that in every instance studied, caregiver support had a major influence on satisfaction. The quality of a laboring woman’s relationships with and support from her caregivers during labor are consistent strong predictors of childbirth satisfaction (Hodnett, 2002). Caregivers frequently assume that optimum pain relief during labor and delivery is very important to most laboring women. Hodnett found that pain and pain relief do not generally play major roles in satisfaction with the childbirth experience, unless expectations regarding either are unmet. Hodnett states that continuous support was consistently associated with more positive views and less likelihood of intrapartum analgesia/anesthesia. Today nulliparous couples still expect to have more direct, individualized attention from their doctors and nurses than they actually receive (Tumblin & Simkin, 2001). It is important for caregivers as well as managers to consider the laboring woman’s expectations about childbirth because fulfilling these expectations can increase her satisfaction with the birth experience (Tumblin & Simkin, 2001). To maximize patient satisfaction managers need to assess, assign, and support appropriate nurse to patient ratios on L&D units so that maternity patients receive continuous laboring support as needed.

A high patient-to-nurse ratio may actually raise expenditures, rather than reducing costs, by increasing the need for unnecessary medical interventions (Scott, Berkowitz, & Klaus, 1999). As hospitals decrease the ratio of L&D nurses to patients they decrease the amount of direct contact and support of women in labor by those nurses. Over the years, technology has replaced the human aspect of patient care without any improvement of outcomes; this might be an appropriate time for managers to reassess the effects of nurses on the labor and delivery process (Gordon, Walton, McAdam, Derman, Gallitero, & Garrett, 1999).

Definitions of Key Terms and Variables

L&D nurse: The registered nurse (RN) caring for a pregnant patient during labor and delivery.

Continuous labor support: The continuous presence of lay women or RNs from hospital admission to birth, during which time touch and speech are used for comfort, reassurance, and praise.

Nulliparous: A woman pregnant for the first time.

Perinatal outcomes: Include but are not limited to the following; live born, stillborn or perinatal death, assistive or cesarean delivery, continuous lumbar epidural or analgesia during labor, apgar scores.

Managerial impacts: Financial aspects, staff retention, and patient rate of return.

Nurse-patient staffing ratio: The number of patients per RN per shift.

Methods   

            An integrative review was chosen as the research design because it allows for generalizations about a topic from a group of studies (Jackson, 1980). The integrative review creates and organizes a body of literature for the examination of the current knowledge base of a particular topic. This allows the reader/investigator to contribute to the development of future research. Strengths of an integrative review include: the generation of new information, answers to questions, the possible creation of new hypotheses, and the subjects are the articles being investigated. Ethical issues related to human rights do not need to be weighed as heavily when compared to studies using human and or animals as subjects. A weakness of the integrative review is that the author in interpreting the works of someone else and these biases may impact the researcher’s results.

This integrative review of the literature used the following search engines: Medline Ovid, CINAHL, Pub Med, Google, and librarians. The key words used for the search include: nurse-patient staffing ratios, labor and delivery (L&D) units, labor support, doulas, perinatal/childbirth outcomes, and L&D management impacts. Three inclusion criteria will be used to assist in the data collection. The inclusion criteria are:

  • Research articles published from 1996-present to support the analysis of the most current information;
  • Research articles written in English or translated into English;
  • Research articles utilize key terms and variables which describe the association between nurse-patient staffing ratios on L&D units and perinatal outcomes or managerial issues.

One exclusion criteria will be utilized: The research articles will be excluded if they do not specifically address the impact of staffing ratios on perinatal outcomes or managerial impacts of varying staffing ratios.

A collective findings table (Table I) will be developed and the data abstracted based on the following elements:

  1. Author/Year
  2. Purpose
  3. Setting/Sample Size
  4. Data Collection and Measures
  5. Strengths and Limitations

The data will be organized in a literature review summary table to try and facilitate its analysis and interpretation. Ganong (1987), states that one of the simplest ways to show characteristics of the primary research is by making tables. This allows the researcher an opportunity to present large amounts of information without overwhelming the reader.

Conceptual Framework

            The Omaha System will be part of the conceptual framework utilized in this review in the analysis of patient impact. The Omaha System is a widely used research-based comprehensive taxonomy of the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes (Monsen & Martin, 2002). In order to determine the effects of varying nurse-patient staffing ratios on perinatal outcomes the three outcome measures, client knowledge, behavior, and clinical status will be utilized and arranged in a table (Table II) for analysis. Table II will list all the research articles used in this integrative review that fall within the inclusion criteria, analyze patient outcomes from varying nurse-patient staffing ratios using the three outcomes measures, and state the implications on nursing practice. The Omaha System is a model that can assist clinicians and administrators with practice, documentation, and information management.

The Balanced Scorecard will be included in the conceptual framework utilized in this review in the analysis of management impact. The Balanced Scorecard includes financial measures that tell the results of actions already taken. It complements the financial measures with operational measures on four other perspectives: customer, systems and processes, and learning and growth (Kaplan & Norton, 1992). In order to determine the managerial impacts of varying nurse-patient staffing ratios the four perspectives: financial, customer, systems and processes, and learning and growth will be utilized and arranged in a table (Table III) for analysis.  Table III will list all the research articles used in this integrative review that fall within the inclusion criteria, analyze managerial impacts from varying nurse-patient staffing ratios using the four operational measures, and state the implications on nursing practice. The Balanced Scorecard captures both the financial and the non-financial elements of a company’s strategy, and discusses the cause and effect relationships that drive business results.

Results

Data Collection and Analysis

At the first stage of the data collection process, an effort was made to incorporate different perspectives on the phenomenon of labor and delivery (as conducted by registered nurses, doulas, hospital administration, etc.) in order to collect the valid and generalizable body of information. Twenty-seven articles met the qualifications for this integrative review. They closely examined the issues of labor support and perinatal/childbirth outcomes in the context of labor and delivery (L&D) units. However, after reviewing the inclusion criteria for this piece of research, 16 articles were excluded. The reasons for their exclusion were they did not specify the impact of nurse-patient ratios on obstetric outcomes.

To be specific, the studies by Ballen and Fulcher (2006), Gordon et al. (1999), Kayne, Greulich, and Albers (2001), Scott, Berkowitz, and Klaus (1999), Scott, Klaus, and Klaus (1999), Stein, Kennell, and Fulcher (2004), Young (1998), and Zhang et al. (1996) described the activities of doulas as providers of continuous support for women in childbearing and breastfeeding conditions. Although this type of care providers deserves attention as the one contributing significantly to the well-being of a mother and a child, the present literature review focuses on nurses. Therefore the aforementioned articles were found irrelevant to the scope of the study.

The studies by Lowe (2002) and Caton et al. (2002) specified nursing activity as part of labor pain management. The former article avoided mentioning nurses at all, whereas the latter summarized the research papers which have been prepared for the symposium held collaboratively by the Maternity Center Association and the New York Academy of Medicine in 2002. Overall, these two articles were excluded from the research framework as being irrelevant to labor support performed by nurses specifically.

The articles by Hodnett (2002), Marmor and Krol (2002), Pearson (2006), Rosen (2004), and Steinbrook (2002) were identified as literature reviews and were therefore excluded from this summative literature review. Finally, the research framework of Yang’s article (2003) was found too general since it examined the effect of nurse staffing variables on patient outcomes overall without an emphasis on obstetric issues. It should be noted, nevertheless, that these 16 writings mentioned above will be included in the reference list to allow readers and future researchers the opportunity to thoroughly examine and critique these articles.

Eleven articles met the inclusion criteria. Data from these articles were organized in a table format (Table I) to facilitate the analysis of information. The designs varied from descriptive studies (Gagnon and Waghorn, 1996; Gale, Fothergill-Bourbonnais, and Chamberlain, 2001) and prospective studies (Hodnett et al., 2002) to applied research projects (Capuano, Bokovoy, Hitchings, and Houser, 2005; Stenske and Ferguson, 1996), randomized control trials (Carabin, Cowan, Beebe, Skaggs, Thompson, & Agbangla, 2005), and surveys (Miltner, 2000; Chen, Wang, and Chang, 2001; Tumblin and Simkin, 2001; Burke, 2003; Sleutel, 2000).

Four studies (Gale et al., 2001; Chen et al., 2001; Sleutel, 2000; Tumblin & Simkin, 2001) analyzed respondents’ reactions qualitatively. The rest of the studies employed quantitative methods of data analysis, including one-way analysis of variance (ANOVA), Pearson’s correlation, contingency table (chi) analysis for categorical and binary variations, Wilcoxon rank sum test, and negative binomial regression analysis.

The data gathered from this integrative review on the issue of nurse-patient ratios will be categorized into the two multi-factor clusters. The first cluster will include the three categories of clients’ knowledge, clients’ behavior, and clients’ clinical status as affected by nurse-patient ratios. The second cluster will comprise the four categories of outcomes that match the following perspectives of the Balanced Scorecard model: financial, customer-oriented, systems and processes, and learning and growth (Kaplan & Norton, 1992).

Characteristics of Sample

 The sample consisted of a total of 252 obstetric nurses (Burke, 2003; Gagnon & Waghorn, 1996; Gale et al., 2001; Miltner, 2000; Sleutel, 2000), over 15,600 women in labor, and 20 hospitals located in the United States, Canada (Burke, 2003; Gagnon & Waghorn, 1996; Gale et al., 2001 ; Hodnett et al., 2002), and Taiwan (Chen et al., 2001). Data were collected through questionnaires, interviews and observations, as well as from national/professional databases, and hospital patient and staff census records.

The majority of nurses were married (living together) females of 46 to 55 years old with children, holding college or university diplomas as registered nurses (RN), employed full time, with 5 to more than 20 years of experience. The age of women in labor ranged from 15 to 48 years. The largest pool of hospitals (n = 13 across the United States and Canada) was observed in the study by Hodnett et al. (2002). The annual birth census in the L&D units across the sample of the current review ranged from slightly above 2000 to 8500 births.

The studies under review demonstrated consistency in regard to nurse-patient ratios. Stenske and Ferguson (1996) recommended matching actual nurses’ staffing with patient volume and acuity within the standard framework proposed by American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) in 1992. Those standards suggested employing the 1:1 ratio in complicated cases of antepartum testing, during the second stage of labors, when initiating epidural anesthesia, dealing with III patients with complications, and when managing circulation for cesarean delivery. The ratio of 1:2 was recommended for uncomplicated cases of antepartum testing, for laboring patients, for oxytocin induction or augmentation of labor, and for postoperative recovery.

The ratios mentioned in the seven articles under research (Burke, 2003; Chen et al., 2001; Gagnon & Waghorn, 1996; Gale et al., 2001 Hodnett et al., 2002; Sleutel, 2000; Stenske & Ferguson, 1996) fitted the suggested framework, although the three of them (Gagnon & Waghorn, 1996; Gale et al., 2001; Chen et al., 2001) tackled upon medical care outside the United States. The articles by Capuano et al. (2005), Miltner (2000), Tumblin and Simkin (2001) and Carabin et al. (2005) did not specify nurse-patient ratios.

The studies with the most representative samples concentrated on organizational issues, whereas the articles covering smaller number of hospitals/units investigated clients’ perceptions as well as physical and psychological status as affected by nursing actions. The variety of managerial and nursing inputs related to patient outcomes will be discussed below.

Patient Outcomes as Affected by Nursing Actions

After reviewing the 11 articles which met the inclusion criteria, three categories of factors were found to be consistent in contributing to patient outcomes of women in labor as affected by varying nurse-patient staffing ratios. The three categories are: 1) patients’ knowledge, 2) patients’ behavior, and 3) patients’ clinical status.

The taxonomy of nurses’ actions that facilitated the exchange of information between L&D units’ staff and patients, enhanced clients’ behavioral patterns, and prevented negative clinical outcomes for women in labor was described in the six articles (Chen et al., 2001; Gagnon & Waghorn, 1996; Gale et al., 2001; Miltner, 2000; Sleutel, 2000; Tumblin & Simkin, 2001). The studies by Chen et al. (2001) and Tumblin and Simkin (2001) examined the elements of supportive and direct care as they were conceptualized by patients, whereas the other four studies analyzed those elements as perceived by nurses.

Research demonstrated that patients and nurses had similar ideas of what constituted the quality care. Nurses’ actions which contributed to increasing the level of knowledge in laboring women were categorized as follows: 1) instructing or coaching; 2) explaining or providing information/advice; and 3) negotiating women’s needs with other stakeholders or providing advocacy. Nurses could encounter certain ethical dilemmas during provision of information to clients (Sleutel, 2000). Sleutel’s case study demonstrated that nurses were likely to balance their efforts of informing clients about the labor course against the professional ethic.

Nurses’ actions that reduced the likehood of negative behavioral outcomes in patients were labeled as psychological support (Chen et al., 2001) or emotional support (Gagnon & Waghorn, 1996; Gale et al., 2001). This type of care could be manifested through: 1) invigorating attitude (reassurance, encouragement, praise); 2) providing companionship; 3) conducting social conversation with woman; and 4) encouraging verbalization of women’s fears, concerns, and needs, as well as soothing and consoling women. Judging by Miltner’s (2000) report, the nursing actions that were normally categorized as informational support (coaching) affected also clients’ behaviors at the active stages of labor. For example, a nurse informed a patient how to alternate relaxation and pushing efforts; consequently, a woman controlled her behavior and felt more comfortable and safe during the process. Sleutel (2000) stressed that nursing activities aimed at improving clients’ behaviors were more likely to be effective when labors were not induced.

Nursing actions that might contribute to clients’ clinical status fitted the five following sub-categories: 1) providing physical comfort; 2) providing direct care in a woman’s room; 3) providing indirect care in a woman’s room; and 4) providing postpartum care. It is worth mentioning that the sub-category of physical comfort (i.e. massaging, bathing, giving fluids, and etc.) was viewed either as a part of supportive care (Gagnon & Waghorn, 1996) or a type of direct care (Gale et al., 2001). Sleutel’s study (2000) expanded the categorization of clinically important nursing actions by reporting about a case of induced labors that were geared by a nurse on the command from a physician. The nurse had to create a cascade of interventions (pitocin, epidural, urinary catheterization) which limited a patient’s mobility and increased risk of operative delivery as well as fetal intolerance of labor. The example demonstrates that nursing actions as related to patients’ clinical status could be either positive or negative.

One and the same action might affect simultaneously clients’ knowledge, behavior, and clinical status. For example, Chen et al. (2001) evidenced that clients displayed fewer negative behaviors such as “high levels of anxiety and tension” (p. 183) when nurses informed clients about the labor course and provided appropriate instruction at the right time. In other words, appropriate nursing care resulted in the improvement of both clients’ behavior and knowledge.

To proceed, Gale et al. (2001) emphasized that, “The presence of a support person providing encouragement and comforting touch had been shown to significantly reduce the likehood of operative delivery and the use of analgesia, and increases mothers’ satisfaction with the birth” (under “Clinical Implications, para. 1, lines 3-5 p. ??? ). Thus a positive relationship was found between nurses’ actions, patient’s behavior and clinical status. The same hypothesis was proven to be true in the study by Miltner (2000). The researcher argued that continuity of nursing care (e.g., when nurses followed patients to OR to check if cesarean was necessary) stabilized both women’s emotional and physical well-being. To summarize, the borderlines between the categories and sub-categories of nursing inputs as related to different client outcomes were reported to be rather flexible.

The comparison of data from the studies under review resulted in a few important findings regarding the relationship between nurse-patient ratios and patients’ knowledge, behavior, and clinical status. Judging from the empirical evidence gathered by three research groups (Gagnon & Waghorn, 1996; Gale et al., 2001; Hodnett et al., 2002), the variable of patients’ clinical status seemed to be the least affected by the variable of nurse-patient ratio. Both a nurse who was in charge for two women at once (Gagnon & Waghorn, 1996) and a nurse who had to look after only one patient (Gale et al., 2001) spent approximately equal portions of time, 10.6% and 8.7%, accordingly, on direct care in the client’s ward. In other words, nurses scheduled their responsibilities that might affect the client’s clinical status (e.g., were busy taking temperature and blood pressure, inserting catheter, and so on) in a similar fashion regardless of how many patients were assigned to each of them.

It is interesting that both nurses working in the L&D units with the 1:2 ratio (Gagnon & Waghorn, 1996) and those working in the units with the 1:1 ratio (Gale et al., 2001) maintained a close contact with patients for hardly the one-forth part of their time (25.2% and 27.8%, accordingly). Hodnett et al. (2002) also proved that clients’ clinical status was not significantly affected by the proportion of nurses’ presence nearby. In that study (the 1:1 nurse-patient ratio) there were control and experimental groups. In the latter type of groups nurses were expected to spend the minimum of 80% of their time with patients. Surprisingly, the rates of clinically important patient outcomes (e.g., cesarean delivery, operative vaginal delivery, perineal traumas, and health problems during postpartum stay) varied insignificantly across the groups.

Those findings demonstrated that nurse-patient ratios were likely to influence clients’ knowledge and behavior. A nurse being assigned to one patient (Gagnon & Waghorn, 1996) was able to dedicate 12.4% of her time to providing supportive care in the form of advocacy, physical comfort measures, companionship, instruction, and so on, whereas a nurse in charge for two patients (Gale et al., 2001) spent only 6.1% of time on analogous activities. It speaks to the fact that nurses were often unable to provide adequate psychological help for their clients. Meanwhile, in women’s conceptualization, such type of care was as significant as clinical interventions.

As Tumblin and Simkin (2001) stated,

When nurses can assist women to cope with the stress of labor using a high realistically prepare pregnant women for the likelihood that the nurse may provide less support than women degree of interpersonal skills, women’s satisfaction with their birth experiences increased. (p. 55)

Women’s reactions registered by Chen et al. (2001) and Sleutel (2000) also supported the assumption that patients highly valued those nursing actions that provided them with information and empathy. Carabin et al. (2005) observed that nursing emotional and informational support mattered also outside hospitals when nurses were enrolled in home visitations of their patients.

As Capuano et al. (2005) proved, nursing activities affecting clients’ knowledge, behavior, and clinical status were influenced not only by nurses’ interpersonal skills but by organizational variables. The following section will summarize findings concerning managerial impacts on nursing practices.

Managerial Impacts on Nursing Activities and Patient Outcomes

The analysis of the articles under review showed that there were four types of managerial impacts on nursing practices and, subsequently, patient outcomes. The categories of impacts are: 1) financial issues, 2) customer-oriented issues, 3) systems and processes issues, 4) learning and growth issues.

Seven articles (Capuano et al., 2005; Carabin et al., 2005; Gagnon & Waghorn, 1996; Hodnett et al., 2002; Sleutel, 2000; Stenske & Ferguson, 1996; Tumblin & Simkin, 2001) provided an account of financial issues affecting hospitals overall and L&D units specifically. For example, Stenske and Ferguson (1996) observed that, since the late 1980s, both actual personnel cost per delivery and staff nurse salaries had been constantly increasing. As Gagnon and Waghorn (1996) acknowledged, the trend was accompanied by reduction of hospital budgets. Among all stakeholders of medical system patients appeared to be the least defended in terms of availability and quality of medical care.

Three articles (Capuano et al., 2005; Hodnett et al., 2002; Sleutel, 2000) directly stated that a substantial share in hospital budgets was spent on nursing service costs. The latter looked as follows (Capuano et al., 2005): 1) RN dollars or salary for regularly scheduled registered nurses; 2) overtime dollars or salary for regularly scheduled RNs working overtime; and 3) agency dollars or salary for nurses who were not employed in the given hospital. The articles under review showed how hospital administration attempted to reduce expenditures on nursing staff.

For example, Capuano et al. (2005) evidenced that hospitals struggling to receive the prestigious “Magnet Status” declined the services of agency nurses and recruited additional personnel in order not to rely so heavily on overtime shifts. Sleutel (2000) hypothesized that labor inductions would also result in cheaper costs of nursing services. The logic was as follows: the periods of patients staying in L&D units would be shorter; subsequently, patient volume would increase; but there would be no need to hire extra nursing staff because nurses’ workload during labor inductions would be lower than in a normal labor process.

To proceed with the theme, social programs sponsored by state budgets (Carabin et al., 2005) were also cited as financially efficient cases of obstetric care. The research by Carabin et al. provided a link between the variables of medical expenditures and of patient outcomes as existing outside the hospital infrastructure. The researchers observed that women of disadvantaged socioeconomic backgrounds followed recommendations in prenatal care more eagerly if their travel fees to the clinic were reimbursed by the state government.

It is clear that the quality of medical and obstetric care was challenged not only by small hospital budgets and expensive staffing costs. The idea was supported by Tumblin and Simkin (2001) who cited the position statement published by the Association of Women’s Health, Obstetrical and Neonatal Nursing (AWHONN). Those organizations stated that the quality of nursing services was undermined by several factors, including “limited numbers of available experienced registered nurses, limited financial resources, rigid organizational processes and structures, cumbersome documentation requirements, and decreasing reimbursement by third party payers in the United States’’ (qtd. p. 55). Thus, financial implications of obstetrics were directly related to the quality of organizational systemic processes and of nurses’ retention and training.

Many scholars emphasized that the transparency and efficiency of system processes and the impetus for professional learning and growth played an important role in providing the quality obstetric care. For example, Hodnett et al. (2002) argued that a commitment to 1:1 nurse-patient ratio should be accompanied by such organizational factors as “regular audits of [organizations’] practices, shared decision-making by multidisciplinary teams, active consumer involvement in policy setting, and a belief system based on labor and birth as healthy life events” (page 17 of 19 in the faxed text, para. 3, lines 8-10). In order to get a clearer conceptualization of systemic and educational processes relevant for obstetric care, the articles under review were compared in a qualitative fashion.

Regarding the factors related to the systems and processes perspective, Capuano et al. (2005) predicted that patient outcomes were affected by nurses’ work environment. The latter was influenced in its turn by the factors of leadership, teamwork, staff competence, resources and stability. It is hypothesized here that the elements of 1) teambuilding (teamwork), 2) system maintenance (resources), and 3) workload (stability) in the abovementioned model could be placed within the category of “systems and processes” of the Balanced Scorecard model.

In Capuano et al.’s research (2005) the quality of teambuilding processes was assessed through 1) coworker cohesion or the presence of supportive relationships in a team, 2) supervisor support or the link between senior and subordinate personnel, and 3) involvement or the opportunities for decision-making. It is worth mentioning that the former two of the three above cited factors were also mentioned by Burke (2003), who researched the dynamics of organizational processes as affected by changes in nurse-patient ratios, under the names of staff coordination and quality service culture. Burke (2003) observed that nurses were more able to coordinate their professional efforts in a team in the hospitals with stable nurse-patient ratios. It was argued that restructuring (either increase in or reduction of the number of patients assigned to one nurse) would negatively affect organizational systems and, subsequently, patient outcomes.

Furthermore, Capuano et al. (2005) viewed system maintenance as integrity of 1) clearly stated goals; 2) managerial control; 3) innovation; and 4) nurses’ physical comfort. Whereas Capuano et al. viewed those processes as positive, Burke (2003) acknowledged that some innovations could produce a negative impact on nurses’ perceptions of their work environment. Specifically, increased nurse-patient ratios could make nurses more fearful of future threats and less satisfied with their jobs.

The variable of workload was researched in-depth by Capuano et al. (2005) and Stenske and Ferguson (1996). The former research group employed nurses’ perceptions of workload as one of the measures to assess the quality of work environment. They found that higher levels of workload could complicate organizational processes through weakening teambuilding skills. Workload was reported as negatively affecting not only nurses who felt themselves overtired and depressed but patients as well. Capuano et al. (2005) evidenced that the greatest number of adverse patient outcomes happened in the last quartile of overtime hours. Stenske and Ferguson (1996) also mentioned workload as a potential stressor for nurses and patients and as an obstacle for building an efficient organizational system.

The negative effect of work pressure was partly mediated by the factors related to learning and growth. As Capuano et al. (2005) witnessed, educational opportunities and leadership culture produced a positive effect on team members. They perceived their work pressure less tragically in the presence of experienced nurses. The variable of nurses’ expertise was highly appraised by Gagnon and Waghorn (1996) who observed that nurses with more than seven years of working experience were able to provide support of higher quality to their patients.

To summarize, researching the routine of L&D units through the lens of the Balanced Scorecard model lent a valuable insight on nursing support as related to patient outcomes. Implications for obstetric practices and future research will be overviewed in the section below.

Future Research

It seems that there should be a clearer conceptualization of factors affecting patient outcomes in obstetric settings. This is regrettable that most of the studies researching the diversity of client-oriented nursing actions abstain from analyzing the same issues at the organizational macrolevel. More research is needed to trace managerial impacts on both nurses and women in labor. Case studies and applied research projects would ensure that specific guidelines are worked out regarding nurses’ activities in the challenging settings of modern L&D units with their reduced budgets, staff shortages, little opportunities for personnel training, and inefficient system processes.

Nursing Implications

The eleven articles under review demonstrated that none of the factors forming any of research perspectives (be it The Omaha System model, the Balanced Scorecard model, or any other models) should be valued by itself. The formative elements should be taken rather in their integrity as interacting and enriching each other. For example, decision-making is highly welcome in organizational settings as the evidence of mature systemic culture and the catalyst of system processes. In the L&D settings, however, the necessity to participate in discussions of unit policy may turn out to be a waste of time. As Gale et al. (2001) indicated, such discussions were not manifestations of democratic decision-making but rather an exuse for nirses to spend a substantial portion of their time outside the patient’s ward. System processes should be run in a maximal proximity to the clients but obstetricians should balance this recommendation against professional ethics in order not to make clients uncomfortable or nervous. Nurses should be trained not only in technical but also in interpersonal skills to provide emotional as well as informational support and advocacy. The needs of patients should be taken as a cornerstone of obstetrics. The 1 :1 nurse-patient ratio would not repair all problems when introduced mechanically without improving the overall organizational culture and motivating nurses to perform their duties at best.

References

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Burke, R. J. (2003). Hospital restructuring, workload, and nursing staff satisfaction and work experiences. Health Care Manager, 22(2), 99-107.

Capuano, T., Bokovoy, J., Hitchings, K., & Houser, J. (2005). Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital. Health Care Management Review, 10(1), 229-256.

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Chen, C., Wang, S., & Chang, M. (2001). Women’s perceptions of helpful and unhelpful nursing behaviors during labor: A study in Taiwan. Birth Issues in Perinatal Care, 28(3), 180-185.

Gagnon, A. & Waghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth Issues in Perinatal Care, 23(1), 1-6.

Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Measuring nursing support during childbirth. The American Journal of Maternal/Child Nursing, 26(5), 264-271.

Gordon, N. P. et al. (1999). Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstetrics and Gynecology, 93(3), 422-426.

Hodnett, E. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186(5),

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Hodnett, E., et al. (2002). Effectiveness of nurses as providers of birth labor support in North American hospitals: A randomized controlled trial. The Journal of the American Medical Association, 288(11), 1373-1381.

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Kayne, M., Greulich, M. B., & Albers, L. L. (2001). Doulas: An alternative yet complementary addition to care during childbirth. Clinical Obstetrics and Gynecology, 44(4), 692-703.

Lowe, N. K. (2002). The nature of labor pain. American Journal of Obstetrics and Gynecology, 186(5), S16-S24.

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Miltner, R. S. (2000). Identifying labor support actions of intrapartum nurses. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29(5), 491-499.

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Scott, K. D., Klaus, P. H., & Klaus, M. H. (1999). The obstetrical and postpartum benefits of continuous support during childbirth. Journal of Women’s Health and Gender-Based Medicine, 8(10), 1257-1264.

Stein, M. T., Kennell, J. H., & Fulcher, A. (2004). Benefits of a doula present at the birth of a child. Journal of Developmental & Behavioral Pediatrics, 25, S89-S92.

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Stenske, J., & Ferguson, R. (1996). Analysis of labor and delivery workload. Nursing Management, 27(6), 30-32.

Tumblin, A. & Simkin, P. (2001). Pregnant women’s perceptions of their nurse’s role during labor and delivery. Birth Issues in Perinatal Care, 28(1), 52-56.

Yang, K. (2003). Relationships between nurse staffing and patient outcomes. Journal of Nursing Research, 11(3), 149-158.

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Table I: Collective findings

Author/Year Purpose Setting/sample size Data collection and measures Strengths Limitations
Burke (2003) ·     To examine the nurse-patient ratio as part of hospital-based nursing staff workload;

·     To find out whether hospital restructuring has affected the nurse-patient ratio;

·     To consider the relationship of changes in the nurse-patient ratio on work satisfaction, psychological well-being, and perceptions of hospital functioning and effectiveness.

925 randomly selected members of the Ontario Nurses’ Association:

·     744 respondents appeared to be still employed as hospital-based nurses after hospital restructuring;

·    N of obstetric nurses = 84 (11.4%).

·     Survey.

·     The three groups (ratio decreased, ratio remained the same, ratio increased) were compared using one-way analysis of variance (ANOVA).

The majority of multiple-item measures had acceptable levels of internal consistency reliability (α > .70).

 

·  The response rate was only 27%;

·  Self reports – response-response biases;

·  Respondents worked as nursing staff in Ontario, Canada – threat to generalizability;

·  Unclear practical significance of results.

Capuano, Bokovoy, Hitchings, & Houser (2005) ·  To understand the ‘microlevel’ of nurse staffing and outcomes through an evaluation of the work environment for nurses at a particular hospital;

·  To identify factors associated with nurse satisfaction and optimal patient outcomes.

 

Lehigh Valley Hospital and Health Network (LVHHN) in Allentown, Pennsylvania which pursued status as an American Nursing Association (ANA) Magnet designated hospital and acquired it in 2002 on the permission of the American Nurses Credentialing Center (ANCC) was chosen as a research site:

·  105 patient care units (including 34 LVHHN units; 19 mother & baby units) were recruited to test a model that evaluated contextual factors related to staffing and outcomes;

·     415 regularly scheduled full- and part-time RNs (a 40 percent simple random sample) participated in a survey; 283 (68%) returned usable surveys.

 

·  This applied research project used an existing structural equation model as an evaluation tool. The model was developed over a four-year period using a mixed method:

  • Inductive qualitative analysis for model specification; and
  • Structural equation modeling to test the model quantitatively for fit on EQS structural equation modeling software.

·  Each factor was measured using manifest variables that were confirmed as valid measures in the sequence of model tests:

  • The factor of Leadership was measured using the Leadership Practices Inventory survey tool;
  • Perception of the work environment was measured using the Work Environment Survey (WES) directly from nurses and their managers.

·  Tests of model fit:

  • Path coefficients from the LVHHN units were compared to the overall database path coefficients;
  • Variable means for each factor were compared to national norms, using one-sample t tests, with Bonferroni adjustments to alpha to compensate for multiple comparisons;
  • Differentiation from other hospitals in the database was analyzed using analysis of variance (ANOVA) for overall leadership and work environment scores and multivariate analysis of variance (MANOVA) for scale scores.
·  Practical usefulness;

·  Initial pool of units was expanded resulting from the original test of model fit. The addition of LVHHN to the database enabled the researcher to add power to the database and confirm the model with more certainty (95% power);

·   LVHHN, as a large teaching facility, added diversity to the types of units represented in the previously existing data.

 

·  In the LVHHN data, the coefficient alpha reliability for the staff expertise evaluation was quite low (.5051) due to measurement error;

·  Reliance on a convenience sample limited generalizability;

·  Some data were lost, as three units submitted unusable data for the Leadership survey. There was some unexplained measurement error in this particular data set, which may have affected specific results;

·  While the post hoc analyses were hypothesis driven, they were unplanned comparisons, therefore the potential for bias existed, as well as the potential for the error associated with multiple comparisons.

 

Carabin, Cowan, Beebe, Skaggs, Thompson, & Agbangla (2005) The Nurse Home Visitation Program (NHVP), developed

by David Olds and used by the Oklahoma Children First programme (C1), has been evaluated in three randomized controlled trials (RCT) for its effectiveness in improving prenatal health habits, social support, perinatal outcomes, and child health and development.

The present study evaluated the impact of the Oklahoma C1 program on birth outcomes, when delivered statewide to a diverse population by a network of nursing professionals. The objectives of the assessment were to compare the risks of:

·  preterm delivery,

·  very preterm delivery,

·  low birthweight,

·  very low birthweight, and

·  infant mortality in first-born children of participants in the C1 programme and in a comparable group of nonparticipating mothers in Oklahoma between 1998 and 2001.

 

·     The first RCT of the NHVP programme took place in 1978 in Elmira, NY. It enrolled 400 first-time mothers who were either of low socio-economic status, adolescent or single. After randomization, 216 women received nurse visitations prior to delivery and 184 women received standard prenatal care. There was a 15-year follow-up.

·     The second RCT was conducted in Memphis, TN in 1990–93. The sample included more than 1100 first-time, primarily single, African American mothers, without a high-school degree, and/or unemployed. The NHVP was offered to 458 women. They were followed through a 2-year period.

·     The Denver RCT examined differences in program implementation and outcomes between nurses and paraprofessionals. More than 700 pregnant women with no previous live births who were eligible for Medicaid or who had no private health insurance were enrolled.

·     The Oklahoma C1 program started in 1997. The study observed its implementation up till 2001. The final C1 sample consisted of 8598 mothers. The final comparison group was identified through birth certificates and included 55737 women. A group of non-C1 mothers had the same distribution of gestational ages at enrolment as the C1 mothers. Nurses visited C1 mothers on a regular schedule, whereas non-C1 participants received standard prenatal care.

·     Data from the C1 mothers were collected through interviews and medical records. The home visitors followed a visit-by-visit protocol that focused on five domains of functioning:

  • Personal health;
  • Environmental health;
  • Maternal role;
  • Life-course development; and
  • Family and friends’ support.

·  The frequency of nurses’ visits in the C1 group included:

  • Weekly visits during the first month of enrolment in the program;
  • Biweekly visits until delivery [Health assessments during the prenatal period were conducted at each visit by registered nurses who focused on early detection and intervention for emerging obstetric complications that could increase the risk of low birthweight and preterm delivery];
  • Weekly visits during the first 6 weeks after delivery;
  • Visits every other week until the 21st month of childhood; and
  • Monthly visits until the child reached 2 years of age.

·      Pregnancy outcomes were measured through birth certificates.

·      Information on socio-economic status was derived from the WIC (Women, Infants, and Children) supplementary nutrition program database (whether a participant receives the Annual Federal Poverty Income, or is eligible for Medicaid, Food Stamps or TANF benefits).

·  Birth certificates were used to create the control group (non-C1 mothers) similar to the intervention group (C1 participants). Thus, similar distributions of gestational age at the start of observation were observed in both groups which were equated in regard to their time at risk for either preterm delivery or LBW.

·  Due to the use of Bayesian statistical models the researchers were able to explore spatial and temporal clustering of the association between C1 and the outcomes of interest despite large numbers of missing data inherent in use of birth certificates and other similar registry data.

 

·        Mothers were not randomly assigned to participate in the C1 program. Therefore, even with statistical adjustment, the researchers did not exclude the possibility that factors other than participation in the C1 program explained the observed differences between the women receiving regular nursing visitations and standard prenatal care. For example, there was no access to data on infections during pregnancy. The result was that important differences between C1 and non-C1 mothers that could have influenced the pregnancy outcomes could not be fully taken into account.

·        The researchers did not have the data necessary to identify which component(s) of C1 might be responsible for producing the effects observed. For example, they did not know what component of the C1 program resulted in a lower risk to C1 mothers of delivering a very preterm baby. It was also unclear if the C1 program had been beneficial in lowering the risk of prenatal infection.

Chen, Wang, & Chang (2001) To capture Taiwanese women’s conceptualizations of relationships with obstetric nurses during labor. ·  A convenience sample of 50 mothers experiencing normal childbirth in Taiwan.

·  A modern labor and delivery unit at a hospital in Tainan, Taiwan, with an average of 230 births monthly during 1999 and 2000, with a 38% cesarean birth rate.

·     Sociodemographic questionnaire.

·     Interviews were conducted, tape recorded, and transcribed. The transcriptions were analyzed qualitatively to develop coding categories and identify themes.

·     Few studies have been conducted to investigate women’s perceptions of obstetric nurses’ treatment of them when in labor.

·     Most of similar research dealt with North American or European women.

 

The interviews were conducted in the hospitals which might introduce a response bias.

 

Gagnon & Waghorn (1996) To examine, what percentage of time intrapartum unit nurses spend providing supportive care to women in labor:

·  Overall,

·  On weekday compared with weekend shifts,

·  According to staff characteristics (experience), and

·  Related to women’s parity and epidural status.

A tertiary care intrapartum unit at a McGill University hospital in Montreal, Quebec (4000 births per year):

·  5 birthing rooms,

·  a high-risk labor unit (4 beds),

·  3 delivery rooms (1 for cesarean births), and

·  a recovery room.

Data were obtained from 38 of 42 nurses employed in the intrapartum unit.

The sampling frame included all times of the day and all days of the week in a period between July 4 and July 25, 1994.

Work sampling method was used:

·  Each eight-hour shift was divided into two four-hour observation periods. Those periods were randomly selected to represent each day of the week and shift in the three-week study. Within each period, eight 15-minute observation times were randomly selected.

·     At each of the eight sets of observation times, an observer followed a predetermined route through the intrapartum unit starting from a randomly selected point. Having located a nurse assigned to the unit at that time, an observer recorded her activities. There were 3367 observations conducted.

·        The total number of observations made exceeded the number required.

·        Observation periods were randomly selected to represent all shifts and all days of the week.

·        To offset the possibility of nurses changing their behavior at the time of observation, instantaneous observations were recorded; nurses remained unaware of an observer’s starting point; and they did not know what an observer looked for.

 

The method of work sampling did not suit perfectly for capturing nonverbal actions (a look of concern, direct eye contact, a smile, etc.).

 

 

Gale, Fothergill-Bourbonnais, & Chamberlain (2001) Two goals:

·        What amount of support do nurses provide to women during childbirth?

·        What factors influenced the provision of support?

 

Twelve nurses were observed over six nonconsecutive day shifts in a birthing unit of a Canadian teaching hospital in Quebec (averaged 4,000 deliveries annually):

·     9 labor rooms,

·     3 birthing rooms,

·     3 delivery rooms,

·     a central nursing station on the unit with satellite electronic fetal monitors, medications, and patient charts.

Seven nurses worked on the average day and evening shifts, and six on night.

·  Work sampling method: the observation times were selected randomly to represent six nonconsecutive day shifts over a three-week period; a total of 404 observations were made.

·     Nurses’ perceptions of supportive care procedures and the factors facilitating the provision of supportive care were identified through personal semi-structured interviews (recorded on tape and ranged from 30 to 50 minutes).

·     Field notes were dictated into the recorder immediately after each interview session.

·     Both interviews and field notes were transcribed verbatim. The data were analyzed through two levels of content analysis:

  • Manifest content analysis was done to identify what categories of supportive care (physical, emotional instructional, informational support, and advocacy) nurses considered to form nursing support.
  • At the level of thematic content analysis, several in-depth readings of the transcripts were performed to trace underlying meanings, being followed by Memoing and open coding (the researcher looked for common words, statements, and/or passages, category derivation, and labeling of categories).
Validity and reliability were ensured by the following factors:

·        The data collector’s path varied throughout each observation session.

·        The nurses observed were unaware of the research focus.

·        Nurses’ activities were focused and categorized (physical care for comfort purposes, emotional support, instructional/informational support, and advocacy).

·        The questions for the interviews were pretested with two nurses from different hospitals to ensure interrater reliability.

·        The pilot interviews were audiotaped and transcribed verbatim. The responses were examined to ensure that relevant information was being obtained. The data from the pilot sessions were not included into the study.

·        Interviews were conducted after the working sampling part of the study to eliminate the informants’ biases as to letting the supportive care focus affect their behavior.

·        Sampling error was decreased by conducting the most possible amount of observations in given circumstances.

 

·        There was “a potential for overlap of some activity elements,” (p. 6); such overlap occurred in 3.5 % of observations.

·        Due to time and fiscal constraints only 6 of 12 nurses on one unit were interrogated (a convenience sample). The results obtained might seem not representative and not generalizable to other units.

·        Support is an abstract concept. The operational definition might not include all possible aspects.

·        The laboring women’s perceptions of the phenomenon were not measured.

·        The presence of the external observer might have influenced the nurses’ behavior during observation. The effect was minimized by letting the nurses unaware of the study focus. The nurses might also have tried to produce a favorable impression on the observer by giving the desired responses.

 

Hodnett et al. (2002) To evaluate the effectiveness of nurses as providers of labor support in North American hospitals. ·        A total of 6915 women who had a live singleton fetus or twins, were 34 weeks’ gestation or more, and were in established labor at randomization.

·        The mean age was 29.5 years old.

·        49% of women were nulliparous.

·        At the time of enrollment, 7% were undergoing augmentation of labor and 6% were receiving epidural analgesia.

·        Women were enrolled during a 2-year period (May 1999 to May 2000) and followed up until 6 to 8 postpartum weeks.

·        3461 patients received usual care, and 3454 patients received a continuous labor support by a specially trained nurse during labor.

·        13 US and Canadian hospitals with:

  • Annual cesarean delivery rates of at least 15%;
  • A 24-hour epidural analgesia service.
·        Randomized controlled trial with prognostic stratification by center and parity.

·        Information about medical outcomes was abstracted from the medical records by the center research nurses.

·        Trial participants completed 2 questionnaires:

  • The Labor Support Questionnaire was completed before hospital discharge to determine if the 2 study groups received different amounts and types of nursing support. It consisted of 23 items concerning physical comfort measures (11 items), emotional support (6 items), information/advice (3 items), and advocacy (3 items).
  • The 2nd questionnaire was completed between 6 to 8 postpartum weeks to assess maternal physical and psychological morbidity, neonatal morbidity, breastfeeding, and views of their birth experiences.

·        Two validated, summated measures:

  • The Labor Agentry Scale to assess women’s sense of control during labor;
  • The Edinburgh Postnatal Depression Scale to assess women’s sense of control during postpartum depression.

·        The groups were compared via contingency table (chi) analyses for categorical and binary variables. Wilcoxon rank sum tests were used. Logistic regression explored interaction effects between baseline variables and cesarean rate, using the Wald (chi) statistic). Statistical procedures were performed using SAS version 8.2

·  To ensure a strong intervention, the nurses trained to provide continuous labor support were volunteers; the training was from an expert.

·  The intervention period began, when the woman was in early or early-active labor.

·  Through the comparisons of participants’ reports it was acknowledged that 2 distinct study groups were retained throughout the study.

 

The amount of support provided by husbands/partners and family members was not measured.

 

Miltner (2000) To identify specific nursing actions that best characterize labor support from the nurse’s perspective. Intrapartum nurses from the United States (n=117) who were AWHONN members. ·  A descriptive survey design using a three-round Delphi technique.

·  A sample was proportional to the geographical distribution of AWHONN members in the United States.

·      An initial set of specific nursing actions was developed from

  • The Nursing Interventions Classification (NIC) system;
  • Field observations; and
  • Interviews with intrapartum nurses.

·        For each nursing action, participants were asked for their extent of agreement.

 

·      The results of each round were analyzed using descriptive statistics (measures of central tendency and frequency distributions of responses, e.g., T-tests of mean scores).

·      An individual response profile for each packet was hand marked with the specific participant’s previous responses.

·      Written comments from the participants were included in the summary of results.

·        Multiple rounds allowed participants to anonymously change their mind about an item without undue influence of a designated expert.

·        An equal opportunity for each participant to influence the overall group consensus.

·        The results of the study are generally consistent with previous studies of maternal views on supportive care.

 

Descriptive design.

Low response rate.

 

Sleutel (2000) The current qualitative pilot study investigated the strategies, interventions, behaviors, and processes that an expert nurse used to enhance labor progress and prevent cesarean births in her patients. The research questions were:

·        How does an expert nurse enhance the process and progress of labor and prevent cesarean sections?

·        What are the attitudes, beliefs, and feelings of the expert nurse who attempts to enhance labor progress and decrease the need for cesareans?

The nurse participant was selected upon several weeks of intermittent observations by the researcher. She worked in the labor and delivery sphere for 3 years, held national certification in intrapartum nursing and a graduate degree in maternal-child nursing, and demonstrated a caring demeanor in patient interactions. ·      A modern labor and delivery unit at a Texas hospital that averaged 70 to 100 births per month.

·      Observation and interviews with the participant served for collecting data.

·      Data were analyzed qualitatively.

·        The present qualitative research helped to uncover the nurses’ intentions, beliefs, and barriers to providing an effective labor care.

·        The consistency between the participant’s verbal accounts and the researcher’s observation served as a check on the validity of the findings.

 

·        The research did not attempt to identify trends and relationships among labor support practices, caregiver practices, and birth outcomes.

·        Data were collected through interviews and, therefore, there was a high risk of personal bias.

·        The researcher observed only one participant – threats to generalizability.

 

Stenske & Ferguson (1996) Describes an inexpensive method of determining the staffing requirements for a labor and delivery unit.

The project pursued two goals:

·  to match actual staffing closely to required staffing as determined by patient volume and acuity and

·  to slow the rate of increase in personnel cost per delivery while maintaining the same quality of care.

 

·        Nursing staff and physicians of a large midwestern teaching hospital (a Level 3 referral obstetric service with approximately 3,200 deliveries annually).

·        The L&D unit was staffed by RNs for patient care and unit secretaries and unit helpers who did not have patient care responsibilities.

·        Data from a total of 56 shifts (448 hours) were analyzed.

 

·     Data from randomly selected over a 3-month period 20 day shifts, 20 evening shifts, and 16 night shifts (in the fall of 1993 – data from 20 day, evening and night shifts ) were collected hourly by an independent observer from the patient flow board to determine the workload by hour of day in this unit.

·     First time the study was done in 1988 and has been repeated four times.

·     Required staffing was calculated hourly by totaling the assignments for each patient in the unit at that time.

·     The sample statistics for average daily deliveries, percent cesarean sections (c-sections), number of antepartum patients, maternal transports and number of procedures were compared to the statistics for the quarter to determine if the sample was representative of activity.

Based on objective information.

 

Low generalizability.

 

Tumblin & Simkin (2001) To identify nulliparous pregnant women’s perceptions of their nurse’s role during labor and delivery (the last trimester of pregnancy).

 

57 nulliparous women in the third trimester of pregnancy completed surveys during childbirth classes (the 2nd class of a 7-week childbirth education series) at a tertiary care center in Raleigh, North Carolina, between October 1999 and January 2000. A questionnaire, ‘‘What do you think your nurse’s role will be during labor and delivery? You may list as many things as you wish.’’

Each item of women’s responses was categorized.

 

Insight into personal perceptions of the nurse role held by pregnant women.

 

·        Low generalizability.

·        Respondents’ personal bias.

Table II

Research article Outcome measures by nurse-patient staffing ratios Implications on nursing practice Other
Client knowledge Behavior Clinical status
Burke (2003) ·        In RNs’ perceptions, patient care and quality service culture in the hospitals with increased nurse-to-patient ratios were the lowest. This could happen due to the increased levels of nurses’ emotional exhaustion and cynicism.

·        Nursing staff reporting reduced ratios indicated that they had less time for patients than before restructuring. It can be explained by the addition of new supervisory responsibilities that took more time than earlier.

·        Nursing staff reporting no change in ratios considered themselves the most efficient, thus, able to positively affect clients’ knowledge.

·        In RNs’ perceptions, patient care and quality service culture in the hospitals with increased nurse-to-patient ratios were the lowest. This could happen due to the increased levels of nurses’ emotional exhaustion and cynicism.

·        Nursing staff reporting reduced ratios indicated that they had less time for patients than before restructuring. It can be explained by the addition of new supervisory responsibilities that took more time than earlier.

·        Nursing staff reporting no change in ratios considered themselves the most efficient, thus, able to positively affect clients’ behavior.

·        Nurses working in the hospitals with increased nurse-to-patient ratios reported about more cases of errors/injuries happening to patients.

·        Nursing staff reporting no change in ratios considered themselves the most efficient, thus, able to positively affect clients’ clinical status.

Additional research should be conducted to trace how the combination of different levels of nursing skill might affect patient need variables. Nursing staff indicating increased patient-nurse ratios reported poorer psychological health than did nursing staff reporting no change in ratios.
Capuano, Bokovoy, Hitchings, & Houser (2005) According to the Structural Equation Model with addition of LVHHN, patient outcomes (including clients’ knowledge) depended on hospital teamwork, resources, and leadership, the latter, in turn, being affected by the factors of staff expertise and staff stability. According to the Structural Equation Model with addition of LVHHN, patient outcomes (including clients’ behavior) depended on hospital teamwork, resources, and leadership, the latter, in turn, being affected by the factors of staff expertise and staff stability. ·        According to the Structural Equation Model with addition of LVHHN, patient outcomes (including clients’ clinical status) depended on hospital teamwork, resources, and leadership, the latter, in turn, being affected by the factors of staff expertise and staff stability.

·        Overtime shifts were strongly associated with negative patient outcomes (e.g., patient falls, urinary tract infection, and medication errors) which were reported to occur during the first and second quartile of overtime hours.

Having a stable, competent nursing staff is essential to assuring optimal outcomes for patients. There was a strong correlation found between the variable of staff leadership and patient outcomes. As the researchers stressed, there existed “a strong impetus to recruit, retain, and promote management talent in our environment where a patient centered care philosophy is paramount” (p. 236).

 

Carabin, Cowan, Beebe, Skaggs, Thompson, & Agbangla (2005) Among the factors associated in prior studies with a 1.5 to 3-fold increase in the risk of preterm and very preterm delivery, there was the one of low socio-economic status that was measured by clients’ education (knowledge). The risk factor of low level of knowledge was more frequently observed in C1 mothers than in non-C1 mothers.

 

Among the factors associated in prior studies with a 1.5 to 3-fold increase in the risk of preterm and very preterm delivery, there was the one of cigarette smoking. This risk factor was more frequently observed in C1 mothers than in non-C1 mothers.

 

·     The crude risks of preterm delivery were equal in C1 and non-C1 mothers and the crude risk of very preterm delivery was lower in C1 than in non-C1 mothers (0.7% vs. 0.9%).

·     C1 mothers had LBW babies more frequently (7.4% of deliveries) than non-C1 mothers (6.8%), but delivered fewer VLBW babies than non-C1 mothers (0.9% vs. 1.2%).

·     Deaths within the first year of life (not adjusted for gestational age) were less frequent among children of C1 mothers (0.3%) than among those of non-C1 mothers (0.6%), this difference being seen only for mortality within the first month of life (neonatal mortality).

C1 program provided a 1:1 nurse-to-patient ratio which was proven to be somehow associated with the decreased risk of very preterm delivery, fewer cases of delivering VLBW babies, and fewer cases of neonatal mortality among C1 participants. ·        After a 15-year follow-up, participants in the NHVP had significantly fewer verified reports of child abuse and neglect, subsequent pregnancies, and behaviour problems resulting from substance abuse and arrests.

·        During the first 2 years after delivery, women receiving the NHVP demonstrated fewer health encounters for injuries among their children and fewer subsequent pregnancies and live births.

 

Chen, Wang, & Chang (2001) ·        86% of respondents (n = 43) received:

  • Instruction in breathing, positioning, ambulation, and pushing;
  • Information and offering advice about the birthing process and procedures used to assist mothers during labor (labor course, maternal and fetal well-being, and the fetal monitor chart).

·        12% of respondents (n = 6) reported about the nurses acting as advocates (supporting decisions and conveying mothers’ wishes to others).

·        26% of women (n = 13) reported that the nurses failed to provide correct or adequate information about the techniques of patterned breathing and relaxation, and gave instructions at the wrong time.

 

·        76% of women (n = 38) received nursing actions that facilitated their self-control, relieved pain and made them feel secure and reassured.

·        68% of women (n = 34) received psychological support from the nurses:

  • Praise;
  • Companionship;
  • Empathy;
  • Soothing/consoling;
  • Invigorating attitude or encouragement.

·        72% of women (n = 36) described the nurses as demonstrating a kind attitude, being calm, tactful, willing to help, warm, smiling, and caring.

·        Patients’ comfort was provided by means of hand holding, massage, applications of heat and cold, sacral pressure, giving water, and help with positioning.

 

 

·        66% of women (n = 38) experiencing uncomplicated vaginal births reported about the nurses’ professional treatment:

  • Taking obstetric history;
  • Monitoring labor progress and vital signs;
  • Administering intravenous fluids, medications, enemas; and
  • Providing baby care.

·        26% of women (n = 13) reported that the nurses failed to provide correct or adequate information about the labor course and fetal condition.

 

The researchers stressed:

·  “The nurse … needs to be capable of giving care at appropriate times using appropriate contact modalities.” (p. 184)

·  “Determining women’s preferences for their care in labor is a reasonable basis for caregiving activities.” (p. 184)

 

Although Taiwanese women differ from Western women in cultural, ethnic and religious norms, they have similar perceptions of nursing behavior. Taiwanese women put special emphasis on professional technical skills.
Gagnon & Waghorn (1996) Supportive care took 6.1% of nurses’ time during the 3-week period. Of this, instruction/information accounted for 50.5% of time:

·        Instruct or coach (e.g., with breathing, pushing);

·        Suggest techniques to promote relaxation or comfort;

·        Explain/provide information (e.g., about progress of labor, monitoring, procedures, etc.);

·        Interpret physician’s findings to woman;

·        Instructions to partner.

 

·        Supportive care took 6.1% of nurses’ time during the 3-week period.

  • Of this, providing physical comfort (e.g., reassuring touch, hand holding, stroking) accounted for 26.7% of time.

·        Emotional support accounted for 17% of this time:

  • Reassurance, encouragement, praise;
  • Being with woman, keeping company;
  • Laughing, joking, social chitchat.

·        Advocacy accounted for 5.8% of time:

  • Listening to woman’s requests, supporting woman’s decisions;
  • Negotiate woman’s wishes with other team members;
  • Discuss with physician about woman’s wishes;
  • Discuss with visitors about woman’s wishes.

 

·    Supportive care took 6.1% of nurses’ time during the 3-week period. Of this, providing physical comfort accounted for

26.7% of time.

·        Using cold face cloth, warm compresses, putting on extra blanket;

·        Bathing or assisting with shower;

·        Changing linen, underpad or gown;

·        Giving ice chips or fluids;

·        Positioning woman for comfort;

·        Massage;

·        Assisting with ambulation;

·        Helping in and out of bed;

·        Helping with walking.

·        Direct care with woman accounted for 10.6% of this time:

·        Taking temperature;

·        Taking blood pressure;

·        Adjusting/reading monitor;

·        Giving/removing bed pan;

·        Inserting catheter;

·        Pericare;

·        Starting/adjusting IV;

·        Taking blood;

·        Giving IV medications;

·        Nursing assessment.

·  Indirect care in room accounted for 4.7% of time.

·        Assisting in procedures;

·        Charting.

·        Postpartum care of mother and/or baby accounted for 3.8% of this time.

The optimum amount of time for a nurse to spend giving supportive care is 100%. Nurses should understand that supportive care is of equal or greater value than technical care.

 

Indirect care not in room accounted for 47.6% of time.
Gale, Fothergill-Bourbonnais, & Chamberlain (2001) Supportive care took 12.4% of nurses’ total time; of this, instruction/information took 70% of time:

·        Instructing or coaching with breathing, pushing (verbal and nonverbal);

·        Helping newborn latch on to breast or showing woman how to hold infant;

·        Suggesting techniques to promote relaxation or comfort;

·        Explaining/providing information (e. g., progress of labor, monitoring procedures, fetal/neonatal well-being, explaining hospital routines, getting information from patient, etc.)’

·        Involving partner in woman’s care;

·        Asking for woman’s birth plan;

·        Listening to women’s requests;

·        Supporting women’s decisions;

·        Negotiating women’s wishes with other team members.

Emotional Support (as part of 27.8% of nurses’ time spent directly with laboring women) increases mother’s satisfaction with the birth experience:

·        Encouraging verbalization of fears; concerns; needs.

·        Reassurance, encouragement, praise.

·        Being with woman, keeping company.

·        Social conversation with woman.

 

Physical Comfort (as part of 27.8% of nurses’ time spent directly with laboring women) reduces the likehood of operative delivery and the use of analgesia. It consists of:

  • Using cold face cloth; warm compresses; putting on extra blanket;
  • Bathing or assisting with shower;
  • Linen and underpad changes;
  • Pericare for comfort purposes;
  • Changing gown;
  • Giving ice chips or fluids;
  • Positioning for woman’s comfort;
  • Massage;
  • Assisting with ambulation;
  • Helping in and out of bed;
  • Helping with walking;
  • Reducing environmental stimuli.

 

Nurses need to provide support when they are with the woman and be cognizant of the importance of their presence.

 

Nurses spent 72.2% of their time on indirect care outside of the woman’s room (38.8%) or performing all other activities (33.4%).
Hodnett et al. (2002) In the usual study group, less than 12% of participants reported disappointment with their study group assignment. ·     Women from the continuous labor support group did not differ from the women assigned to the usual care group in terms of perceived control during childbirth or depression as measured at 6 to 8 postpartum weeks.

·     8.7% of women in the continuous support group (n = 245) had evidence of postpartum depression vs. 10.1% in the usual care group (n = 277).

·     1027 women in the continuous labor support group and 937 women in the usual care group reported they were not breastfeeding at 6 weeks’ postpartum.

 

·        The rate of cesarean delivery in the continuous labor support groups was 12.5% (n = 432), and 12.6% (n = 437) in the usual care group.

·        75% of women in continuous labor support (n = 2590) had continuous labor monitoring vs. 79.2% in the usual care group (n = 2741).

·        No significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. All newborns were born alive, there were 3 neonatal deaths.

·    738 women in the continuous labor support group (26%) and the same number of the usual care group participants (26.7%) visited their physicians for a health problem in the first 6 to 8 postpartum weeks.

·    1.5% of women in the continuous labor support group (n = 42) were admitted to the hospital for a health problem vs. 1.4% in the usual care group (n = 39).

·  In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not precondition cesarean delivery or other medical or psychosocial outcomes of labor and birth.

·     63.4% of women in the continuous labor support group and 46.6% of women in the usual care group preferred continuous labor support.

 
Miltner (2000) Nurses top-rated the following items as supportive nursing care:

·        Urging the mother to empty her bladder;

·        To assure a safe outcome for the mother (75% of responses);

·        To enable the mother actively participate in her birth experience;

·        Teaching and giving information.

Nurses top-rated the following items as supportive nursing care:

·     Nursing actions that assisted the mother to cope with the first stage of labor, i. e., coaching maternal relaxation;

·     Management of the second stage of labor, i. e., coaching maternal pushing efforts;

·     Remaining with the mother if she is fearful or in pain;

·     Holding the mother’s hand.

Nurses top-rated the following items as supportive nursing care:

·    Following the patient to OR to establish if cesarean is necessary (it maintained the nurse-patient relationship and offered continuity of care);

·    Offering medications for pain relief  after nonpharmacologic interventions were unsuccessful;

·    Frequent position changes and delayed pushing;

·    An active management of oxytocin protocol;

·    Using telescope or doppler.

 

·     Supportive nursing care was conceptualized as consisting of 55 specific nursing actions. The nurses clearly distinguished between supportive nursing care and technical aspects of their job.

·     Participants formulated the overall goals of intrapartum nursing as assuring a safe outcome for the newborn (82.8% of respondents) and for the mother (75% of respondents).

·     Group consensus was lacking on the exact categorization of multiple roles and responsibilities of the intrapartum nurse.

 

 
Sleutel (2000) ·        Nursing support techniques

The nurse was positive, encouraging, and supportive to help the mother progress through labor through:

  • Advice/teaching,
  • Patient advocacy.

 

·        Ethical dilemmas: An unwilling partnership

  • The nurse could not tell the mother why she was pushing the Pitocin so hard (physician convenience, the physician planned a c-section, etc.);
  • The nurse could not tell the mother who asked about it that her amniocentesis for lung maturity was not medically indicated, but was done in order to schedule an elective induction without fear of a preterm baby;
  • In prenatal visits the physician told nulliparous mothers that they would probably need a cesarean. The chart indicated a normal pelvis. In labor, the mothers asked the nurse about it.
The nurse had more flexibility when labors was not induced:

·     Supported the mother in doing whatever felt food to the mother;

·     Supported her in having whomever she wanted present;

·     Encouraged her to position herself however she wished throughout labor;

·     Allowed the mother to push when and how she felt like pushing.

Induced labors were geared to fit within physician time limits. A cascade of interventions was created by:

  • Pitocin;
  • Epidural;
  • Urinary catheterization;
  • Limited mobility;
  • Increased risk of operative delivery;
  • Fetal intolerance of labor.
Health care experts and national organizations should address:

·        What are the expectations and duties of nurses in situations when patients are electively induced for non-medical reasons?

·        What liability does the nurse incur should an adverse outcome occur?

·        What options are available to nurses when physicians are verbally abusive to hospital staff?

·        When the interests of patients and the interests of physicians collide, how can nurses meet the interests of both groups?

·        How informed is informed consent in obstetrics?

·        Should elective induction of labor be regulated or restricted?

Nurse-physician conflict is not widely reported within the context of intrapartum care.
Stenske & Ferguson (1996) Hospital administration should match actual staffing closely to required staffing as determined by patient volume and acuity.

·        The recommended staffing ratio for antepartum testing is 1 : 1 -2;

·        The recommended staffing ratio for laboring patients is 1:2;

·        The recommended staffing ratio for patients in second stage of labor is 1:1;

·        The recommended staffing ratio for III patients with complications is 1:1;

·        The recommended staffing ratio for oxytocin induction or augmentation of labor is 1:2;

·        The recommended staffing ratio for coverage for initiating epidural anesthesia is 1:1;

·        The recommended staffing ratio for circulation for cesarean delivery is 1:1;

·        The recommended staffing ratio for postoperative recovery is 1:2.

Hospital administration should match actual staffing closely to required staffing as determined by patient volume and acuity.

·        The recommended staffing ratio for antepartum testing is 1 : 1 -2;

·        The recommended staffing ratio for laboring patients is 1:2;

·        The recommended staffing ratio for patients in second stage of labor is 1:1;

·        The recommended staffing ratio for III patients with complications is 1:1;

·        The recommended staffing ratio for oxytocin induction or augmentation of labor is 1:2;

·        The recommended staffing ratio for coverage for initiating epidural anesthesia is 1:1;

·        The recommended staffing ratio for circulation for cesarean delivery is 1:1;

·       The recommended staffing ratio for postoperative recovery is 1:2.

Hospital administration should match actual staffing closely to required staffing as determined by patient volume and acuity.

·        The recommended staffing ratio for antepartum testing is 1 : 1 -2;

·        The recommended staffing ratio for laboring patients is 1:2;

·        The recommended staffing ratio for patients in second stage of labor is 1:1;

·        The recommended staffing ratio for III patients with complications is 1:1;

·        The recommended staffing ratio for oxytocin induction or augmentation of labor is 1:2;

·        The recommended staffing ratio for coverage for initiating epidural anesthesia is 1:1;

·        The recommended staffing ratio for circulation for cesarean delivery is 1:1;

·      The recommended staffing ratio for postoperative recovery is 1:2.

·      It was recommended to train temporary staff so that they could provide competent care for low-risk patients who anticipated vaginal delivery.

·      It was recommended to train temporary staff so that they could provide recovery care following delivery.

·      It was not recommended to employ resource team staff in management of high-risk patients, or antepartum patients who required intervention with tocolytic agents, or to assist with c-sections unless they were experienced in L&D.

 

 

 
Tumblin & Simkin (2001) 24% of nulliparas expected direct supportive care activities such as information, instruction and advocacy.

 

13% of nulliparas expected direct supportive care activities such as emotional support.

 

 

·        16% of nulliparas expected direct supportive care activities such as physical comfort measures.

·        21% of nulliparas expected direct supportive care activities such as monitoring mother, baby, and labor progress.

 

·        Childbirth educators and perinatal caregivers should prepare pregnant women for the likelihood that the nurse may provide less support than women expect.

·        Nurses should be aware of women’s expectations because meeting these expectations can increase women’s satisfaction with the overall birth experiences.

 

 

Table III

Research article Managerial impacts by nurse-patient staffing ratios Implications on nursing practice
Financial perspective Customer perspective Systems and processes perspective Learning and growth perspective
Burke (2003) When hospitals are undergoing restructuring, their organizational performance and resources are likely to decrease. At the hospitals with increased patient-nurse ratios, nurses reported:

·        More incidents of errors/injuries in regard to patients (16.4% of nurses at the hospitals with increased patient-nurse ratios as compared to 14.8% at the hospitals with the same patient-nurse ratios and 16% at the hospitals with decreased patient-nurse ratios);

·        Less time for patients (15% of nurses at the hospitals with increased patient-nurse ratios as compared to 13% at the hospitals with the same patient-nurse ratios and 14.2% at the hospitals with decreased patient-nurse ratios);

·        Decreased quality of patient care (5.9% of nurses at the hospitals with increased patient-nurse ratios considered patient quality effective as compared to 6.5% at the hospitals with the same patient-nurse ratios and 6.1% at the hospitals with decreased patient-nurse ratios).

·        The level of staff coordination (as part of hospital effectiveness) was reported to be the highest at the hospitals with stable ratios (14.4% as compared to 13.6% at the hospitals with increased and decreased patient-nurse ratios);

·        The level of quality service culture was reported as the most satisfactory at the hospitals with stable ratios (22.7% as compared to 20.7% at the hospitals with increased patient-nurse ratios and 21.4% at the hospitals with decreased patient-nurse ratios);

·        Increased patient-nurse ratios led to:

·        Lower job satisfaction (10.5% of nurses at the hospitals with increased patient-nurse ratios were satisfied with their job as compared to 11.7% at the hospitals with the same patient-nurse ratios and 11.1% at the hospitals with decreased patient-nurse ratios);

·        More initiatives for restructuring (6.7% of nurses at the hospitals with increased patient-nurse ratios as compared to 5.7% at the hospitals with the same patient-nurse ratios and 6.4% at the hospitals with decreased patient-nurse ratios); and

·        Fearfulness of future threats (11% of nurses at the hospitals with increased patient-nurse ratios as compared to 10.3% at the hospitals with the same patient-nurse ratios and 10.5% at the hospitals with decreased patient-nurse ratios).

It seems that nurses are not likely to think over the issues related to learning and growth when their workplaces are undergoing restructuring. ·     The administration of hospitals that are undergoing restructuring and, consequently, changes in patient-nurse ratios should be proactive by providing nurses with different kinds of social support;

·     Administration should involve nurses in decision making when new restructuring policies are introduced.

Capuano, Bokovoy, Hitchings, & Houser (2005) Specific measures for financial resources:

·     RN dollars: salary dollars for regularly scheduled registered nurses;

·     Overtime dollars: overtime salary dollars for regularly scheduled registered nurses;

·     Agency dollars: salary dollars spent for nurses who are not employees of the organization;

·     Supply dollars: general medical/surgical, linen, and intravenous management supply dollars.

Previous research revealed that patients were subjected to a higher degree of risk when more dollars were spent on nursing staff (i.e., RNs working overtime and

agency nurses). At LVHHN, salary dollars did not include agency nurses. Therefore, there was no association found between RN dollars and adverse patient outcomes.

 

 

Developing a work environment that is supportive of nursing care is proven to influence the nurse’s ability to meet the needs of patients. At LVHHN, the low rate of adverse outcomes was observed.

 

·        Teamwork as a factor in the Structural Equation Model was measured through the Work Environment Survey (WES) (Relationship scale):

  • Involvement: The extent to which staff are involved in decisions that affect their jobs;
  • Coworker cohesion: The extent to which staff are supportive of each other and function as a unit;
  • Supervisor support: The extent to which staff believe their supervisors are supportive of their team efforts.

·        System Maintenance (as the WES scale) included:

  • Clarity of goals;
  • Managerial control;
  • Innovation; and
  • Physical comfort.

Overall, the work environment of LVHHN was rated higher than national norms.

·        Staff stability as a factor in the Structural Equation Model was measured, depending on:

  • Raw turnover rate: Total number of nurses leaving the organization voluntarily divided by average staff complement;
  • Accession rate: Total number of newly hired nurses divided by average staff complement;
  • Vacancy rate: Average number of vacant positions divided by average staff complement.

·        Workload as a factor in the Structural Equation Model was measured by:

  • Length of stay: Average length of stay in days;
  • Admissions: Number of patients admitted to the unit.
·        Leadership as a factor in the Structural Equation Model was measured through the five subscales of the Leadership Practices Inventory:

  • Challenging the process (the scale scores for LVHHN were higher than for the other hospitals in the database);
  • Inspiring quality (the scale scores for LVHHN were higher than for the other hospitals in the database);
  • Enabling work;
  • Modeling; and
  • Encouraging the heart.

·        Staff Expertise as a factor in the Structural Equation Model was measured by individual unit managers through the ratings of nurses (using Benner’s criteria) as:

  • Novice;
  • Advanced Beginner;
  • Competent;
  • Proficient; and
  • Expert.

 

·     Staffing issues cannot be resolved exclusively by hiring more nurses.

·     Additional factors (e.g., individual nurse education, certifications, years of experience, ability to think critically, etc.) affect the application of this human resource.

·     The work environment plays a critical role in either increasing or mediating demands on nursing staff. A supportive workplace, perceived through leadership support, teamwork, and availability of resources, can protect against burnout, reduce conflict on the unit and between units, and improve cohesiveness.

 

Carabin, Cowan, Beebe, Skaggs, Thompson, & Agbangla (2005)

 

·     The C1 participants received little financial or social support. The program was sponsored by the state government (Oklahoma).

·     The Memphis RCT of the NHVP showed that when the women with standard prenatal care were reimbursed for their travel fees to the clinic, they followed prenatal care better and were likely to underestimate the effectiveness of alternative programs.

The C1 participants were less likely than non-C1 mothers to

  • Have very preterm deliveries;
  • Deliver VLBW babies; and
  • Lose babies within the first month of life (neonatal mortality).

 

Nurses were allocated to one administrative region where they visited all C1 participants. The researchers argued that the effectiveness of C1 was partly due to geographical clustering.

 

Nurses participating in the C1 program were specially trained to work with their clients during regular home visitations. During the prenatal period, nurses were especially trained in detecting obstetric complications that could increase the risk of low birthweight and preterm delivery.

 

There should be additional research concerning the factors other than nursing care that could have affected adverse delivery outcomes within the population of women of low economic and social status.
Chen, Wang, & Chang (2001) ·     The length of maternity stay in the given hospital was 3 days under the regulation of National Health Insurance.

·     Enema and episiotomy were standard procedures for normal spontaneous delivery.

·     Electronic fetal monitoring was routinely used as a non-stress test for 40 minutes at admission.

·     The use of analgesia and anesthesia was rare.

·     All the nurses at the unit had a diploma degree.

·     The nurse-to-client ratio was 1:3, and during the combination of primary and team nursing care and 3 shifts of work, a woman was likely to encounter 2 to 4 nurses during labor and delivery in the given hospital.

·    60% of women (n = 30) reported about positive nurses’ behaviors and attitudes.

·    40% of women (n = 20) criticized nurses as labor-coping hinderers.

The conceptual model of Taiwanese women’s perceptions of nursing behaviors during labor consisted of:

·        Inputs:

  • Helpful nursing behaviors (emotional support, comfort measures, information/advice, technical skills, and advocacy);
  • Unhelpful nursing behaviors;

·        Processes (positive or negative birth experience); and

·        Outcomes (woman’s long-term memory and self-image).

 

·  98% of participants (n = 49) perceived nurses as labor-coping facilitators, emotional support providers, comforters, information/advice providers, professional/technical skill providers, and advocates.

·  18% of participants (n = 9) complained that nurses talked unprofessionally with them and fellow staff.

·  16% of women (n = 8) reported that nurses failed to perform technical duties adequately.

 

Taking into consideration women’s perceptions of nurses, obstetric team members are able to understand patients’ needs more clearly and, subsequently, provide women with improved support during labor.
Gagnon & Waghorn (1996) In times of reduced hospital budgets, more supportive care can be provided without decreasing nurse-patient ratios (e.g., from 2:1 to 1:1), if nurses maximize their use of time.

 

·    Nulliparous women received 9.2% more supportive nursing care than parous ones.

·    Women with and without epidural anesthesia received similar amounts of supportive nursing care.

·    Women are more satisfied with childbirth when nurses acting as care givers provide greater portions of advocacy.

Nurses spent 47.6% of time outside a ward.

·        37.1% of this time nurses spent reporting on the condition of the patient when care was being transferred from one nurse to another at change of shifts or at scheduled breaks;

·        28.6% of this time nurses spent preparing medications or intravenous infusions;

·         21.5% of this time nurses spent keeping documentation in order.

·     Nurses with less than 7 years of intrapartum unit experience were more likely to stay with patients providing supportive care as compared to nurses with more than 7 years of experience (the difference of 2.7% in time).

·     Widespread use of technology appears to encourage more emphasis on technical expertise and less on supportive care expertise.

·     Nurses should maximize their use of time.

·     Caregivers and hospital administrations should reexamine their philosophy concerning supportive care.

·     Hospitals should introduce competency examinations for supportive care as required for fetal monitoring.

·     Recording of care should be done only in women’s rooms.

·     Documentation structures for nursing care should prompt supportive care.

·     Structural changes should be implemented (i.e., strategically placed chairs and computers).

Gale, Fothergill-Bourbonnais, & Chamberlain (2001) In most Canadian and U.S. hospitals, the 1:1 nurse-to-patient ratio is rarely observed. Researchers considered it to be a substantial improvement when one nurse took care of two women in labor, spending 40% to 50% of time in providing support. ·        Nurses spend 27.8% of time in contact with patients.

·        Greater emphasis should be placed on the importance of respecting the birth plans of the laboring couple and allowing the woman and her partner to define what the experience will be.

·        Opportunity should be provided to caregivers to examine the extent to which their practice is client focused.

·        Reviews of the birth plans, completed by the woman and her partner prior to admission, may help the nurse and physician to understand the couple’s wishes.

 

·        Nurses spent 48.3% of time discussing unit policy;

·        Nurses spent 38.8% of time providing indirect care outside the room.

·        Nurses should not perform nonnursing duties (e.g., restocking shelves and checking supplies).

·        Birthing units should avoid using central nursing stations where healthcare providers typically assemble.

·        Charts and supplies should be kept in women’s rooms.

·        Charting tools (e.g., the nursing admission history and birthing unit flow sheets should be revised to reflect a supportive care focus.

·  Education alone regarding supportive care is not sufficient. There should be the conductive environment. A workshop should be developed to teach caregivers the “whys” and “how-tos” of supportive care.

·  The physical layout of birthing units in large teaching facilities may impede the provision of supportive care by nurses.

·  L&D nurses may contribute valuable suggestions concerning the changes needed.

·     Birthing units should facilitate implementation of continuous intrapartum support.

·     Unit-based longitudinal research should be conducted to determine if strategies developed are effective in enhancing the amount of supportive care provided by nurses.

·     Flexible staffing plans should be considered so that nursing allocation, based upon patient census, would ensure a 1:1 nurse-to-client ratio during labor.

Hodnett et al. (2002) Practice guidelines based on the Cochrane Review trials (widely disseminated in the United States, Canada, and the United Kingdom) recommend using 1:1 nurse-to-patient ratio when providing continuous caregiver support for women during labor. This can be made possible only with assistance of doulas, midwives, and so on. In the United States hospitals, the patient-nurse ratios are not always 1:1 because of high labor costs, as well as variability and unpredictability of patient census. ·        91.3% of the control group (women who received usual care) would prefer to participate in the Nursing Supportive Care program.

·        63.4% of women in the continuous support group would prefer to receive this type of nursing care in a future labor.

·        The research team recommended a more active involvement of consumers in policy making (i.e., women have the right to choose between types of support, they should be informed about possible outcomes as related to the type of support).

·        37.9% of women in the experimental group (n = 1076) felt reassured about their/newborn health because they possessed enough information from nurses on the point. The percentage of well-informed mothers was lower in the control group (22.3%, n = 616).

The decrease in annual overall cesarean rates could be achieved not only due to a commitment to 1:1 labor support by nurses but to some additional organizational characteristics, including:

·        Shared decision-making by multidisciplinary teams;

·        Active consumer involvement;

·        A belief system based on labor and birth as healthy life events; and

·        Regular audits of hospital practices.

Many nurses have not received formal training in labor support techniques.

 

 

·  Results call into question the usefulness of national practice guidelines in the United States, Canada, and the United Kingdom, which recommend that all women receive continuous 1:1 support from specially trained caregivers during labor.

·     To decrease cesarean rates and rates of other intrapartum interventions hospitals should involve all stakeholders to implement comprehensive changes to the routine care of women during labor and birth.

Miltner (2000) No information provided Supportive nursing care includes:

  • Psychosocial support, such as reassurance and encouragement; and
  • Physical comfort, such as positioning.
The following activities (consuming 42.5% to 47.6% of time) were ranked the lowest as examples of supportive care and for their effects on childbirth outcomes:

  • Setting up delivery table;
  • Interpreting fetal monitor data at nursing station;
  • Charting labor progress at nurses’ station.

Nurses stressed the importance of the continuity of supportive care.

 

There may be an opportunity to persuade nurses to shift time spent in indirect care activities to direct care activities (i.e., supportive care) by focusing on the potential for improved outcomes for the mother and newborn. ·  Further study is needed to demonstrate the direct links between intrapartum nursing care and childbirth outcomes in typical hospital childbirth settings.

·  To shift time spent in indirect care activities to direct care activities.

·     Nurses must support the importance of their role with research.

Sleutel (2000) ·     Nursing care was limited by and circumscribed within the constraints of medical practice.

·     In some settings, the cesarean birth rate will remain high unless external forces (i.e., monetary constraints, government guidelines, etc.) are brought to bear.

·     Labor inductions deserve the attention and scrutiny of insurance companies for the substantial cost savings that may result.

·     The nurse respected the mother’s requests about following her body by:

  • Providing opportunities for flexible pushing;
  • Performing partner support behaviors.

·      The nurse carefully balanced the needs of the mother with the limitations of the system and the individual circumstances.

·      The nurse faced ethical dilemmas when:

  • She used aggressive Pitocin for physician convenience;
  • The physician imposed time limits on labor progress or the mother would have a cesarean.

·        Conflicts between nurses and the physicians occurred when physicians undermined and contradicted nurses in front of patients.

·        Nurse may deal with physicians by:

  • Letting them feel in control;
  • Not making them feel threatened;
  • Maintaining good rapport;
  • Not arguing in front of the patient;
  • Not lying for them, but not contradicting them;
  • Being tactful and subservient; and
  • Doing whatever would keep them happy.

 

Labor support is described in terms of 5 dimensions:

  • Emotional support;
  • Information/advice;
  • Physical support;
  • Partner support; and
  • Advocacy.
·     The researcher observed that the medical centers in large communities adhered more strictly to published standards of care, and that elective inductions were less common at those sites. In private hospitals, labor inductions for non-medical reasons were more common.

·     Significant regional variation occurs in medical and nursing practices.

Stenske & Ferguson (1996) ·     The personnel cost per delivery had been increasing at the rate of 10% to 15% annually.

·     A year after the initiation of the project (in 1989), l.5 RN FTEs (full-time equivalents) were added to the personnel budget as the volume of patients continued to increase to 3500 births annually.

·     As a result of more closely matching RN staffing and patient volume and acuity the actual personnel cost per delivery has increased 14% since 1988, while staff nurse salaries have increased 61% when compounded.

·        A staffing pattern was developed that provided adequate staffing for 90% of the patient volume.

·        A minimum staffing of 4.0 FTEs (full-time equivalents) was established regardless of patient census or acuity.

·        Deliveries have increased to 3,800 and the antepartum volume has continued to grow.

·        The patient volume has increased by 600 deliveries (19%).

 

·  Workload was fairly consistent, but lowest across the entire night shift.

·  Workload began to increase at 7:30 a.m., peaking between 8:50 and 10:30 a.m.

·  The pattern of workload distribution was attributed in part to elective labor inductions and c-sections.

·  Variability in workload was noted also from day to day, with the greatest fluctuation occurring on the day shift, the least on the night shift.

 

A core curriculum for education of resource team staff (float pool) was developed and cross-training was completed by staff from the other maternal/child units so that they could provide care for low-risk patients who anticipated vaginal delivery/recovery care following delivery.

 

The effectivity of RNs’ labor can be increased by the following steps:

·     The pattern of required staffing can be matched with the patient volume by rescheduling (e.g., personnel can be moved from the night shift to the day shift; RNs can be scheduled to work during the time of peak activity; personnel can shifted from the weekend to Friday, when volume is highest).

·     A paid voluntary on-call system can be activated when an increase in census or acuity is experienced.

·     Staff from the resource team and other units can assist with patient care when necessary.

 

Tumblin & Simkin (2001) According to the position statement published by the Association of Women’s Health, Obstetrical and Neonatal Nursing (AWHONN), there were several barriers that could “influence the nurse’s ability to provide bedside nursing care,” including “limited numbers of available experienced registered nurses, limited financial resources, rigid organizational processes and structures, cumbersome documentation requirements, and decreasing reimbursement by third party payers in the United States’’ (qtd. p. 55). ·        When nurses could help women to cope with the stress of labor by using a high degree of interpersonal skills, women’s satisfaction with their birth experiences increased.

·        Only 5% of the responses within the 47% of ones related to supportive clinical care activities mentioned indirect care (when the nurse was not present in the room). In other words, the women expected the nurse to be in the room with them all the time, providing ‘‘high-touch.”

 

No information provided. Research has proven that nurses might lack knowledge of, and expertise in, nonpharmacologic methods of pain relief to help the progress of labor.

 

·     Nurses and other perinatal caregivers should search for a better understanding of women’s personal expectations of the role of the labor and delivery nurse.

·     Childbirth educators and perinatal caregivers should answer the following questions:

  • How do they realistically prepare pregnant women for the likelihood that the nurse may provide less support than women expect?
  • How can this be achieved without making the hospital system look uncaring or suggesting that a nurse may be unable to give effective and supportive care?
  • How can good relationships between nurses and childbearing women be initiated and fostered?
  • Should educators strongly suggest that class participants bring more than one support person with them to the hospital?

 

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