Effect of Supportive Measures Guidelines on Nurses’ Practices during Labor ()
1. Introduction
The new Sustainable Development Goals to 2030 aim to reduce maternal mortality and provide equitable access to maternal healthcare. Compromised access to maternal health facilities in low-income countries, and specifically in Africa, contribute to the increased prevalence of maternal mortality. Goal 3 of the new Sustainable Development Goals to 2030 aims to reduce global maternal mortality ratio to less than 70 per 100,000 live births [1]. Maternal mortality could be attributed to poor socio-economic conditions, low quality of care (QoC), lack of well-trained healthcare professionals, lack of proper infrastructure, and barriers to accessing medical facilities [2].
According to the World Health Organization [3] globally, the proportion of births attended by a skilled birth attendant in less developed countries increased from about 50% in 1990 to 60% in 2006. To be specific, regions with the lowest proportions of skilled-birth-attended deliveries were eastern Africa (34%), western Africa (41%) and south-central Asia (47%). The majority of approximately 140 million births that occur globally every year are among women without risk factors for complications for themselves or their babies at the beginning and throughout labor. Also, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labor and childbirth. The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries compared to high-income countries [4].
Therefore, improving the quality of care around the time of birth, especially in low- and middle-income countries has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies [5]. While numerous studies and systematic reviews suggest the use of nonpharmacologic approaches to pain management either as a primary method, or as a complement to pharmacologic approaches. Complementary and alternative therapies for pain relief involve non-pharmacologic measures that may be used either as a woman’s total pain management program or to complement pharmacologic interventions [6].
Yet the road map of labor provides a useful framework for educator nurse to explain the psychological and physiological processes of labor, and a variety of activities for comfort and labor progress for women and their partners to use. By focusing on the normal unaltered process, parents learn to separate the norm from the numerous interventions that alter the process, sometimes for the better, sometimes for the worse [7]. Nurses play a multidisciplinary role as a direct care provider, health educator and counselor, as a researcher and as administrator.
2. Significance of the Study
Provision of support in labour is one of the evidence-based nursing practice standards known to reduce morbidity and mortality with better labour outcome [8]. Moreover, Emotional, physical, and informational support is positively affected mother’s mental and physical health around the time of childbirth [9].
Furthermore, there are many beneficial effects of supportive measures provided by the nurses during labour as the cesarean section rates decreased, the length of labour shortened, the need for analgesics reduced, fear alleviated, pain in labour and incidence of postpartum depression perceived. Also it creates a positive attitude towards childbirth and turns the moments of pain into the most memorable moments of a woman’s life which consequently lead to happier and comfortable labour experience and enhancing parturient woman's satisfaction [10].
According to the study of [11] who recommended design and implement the training program for nurses about supportive measures during labour to improve nurses’ practices. So, the present study is based upon previously mention studies finding which aimed to enhance the nurses’ practices of supportive measures during labour.
2.1. Aim of the Study
To investigate the effect of supportive measures guidelines on nurses’ practices during labor.
2.2. Research Hypothesis
Application of the supportive measures guidelines was expected to enhance nurses’ practices during labor.
2.3. Subject and Methods
2.3.1. Setting
The study was conducted at obstetric departments at Nasser Institute Hospital.
1) Study Design:
A quasi-experimental (an intervention pre and posttest study).
2) Sampling:
All nurses (40 nurses) who were working at previously mentioned study setting.
3) Exclusion Criteria:
Nursing director, assistant and supervisors will be excluded.
4) Tools of Data Collection:
Three tools were used after reviewing the advanced related literature. All tools of data collection implemented pre intervention then immediate and eight weeks post intervention but satisfaction tool was implemented eight weeks post intervention only.
The first tool: a self-administered questionnaire sheet which included two parts and it was designed by researcher: the first part assessed nurse’s general characteristics (age, level of education, qualification, years of experience, attendance of guidelines, and place of residence). While the second part assessed nurses’ knowledge related to supportive measures provided to laboring women, which involved 9 questions that included the following: (definition of supportive measures, types of supportive measures, effect of supportive measures on laboring women’s physical, emotional and mental wellbeing, and effect of supportive measures on labor progress and outcome). Nurses’ knowledge scoring system was assessed as the following each question was evaluated as two scores for correct answer and one score for incorrect answer. While the total knowledge correct equal (≥60%) and the total knowledge incorrect equal (<60%).
The second tool: an observational checklist was adapted from [11], it was utilized to assess nurses’ practices and skills to concerning Supportive Measures during Labor. It’s included in three parts. The first part which included 15 items concerned with physical care which comprised of the following (9 items related to 1st stage of labor and 6 items related to 2nd, 3rd and 4th stage of labor). The second part which included 13 items about training and information provided to laboring women it involved (8 items related to 1st stage of labor and 5 items related to 2nd, 3rd and 4th stage of labor). The third part which included 11 items about emotional supports which comprised of (7 items related to 1st stage of labor and 4 items related to 2nd, 3rd and 4th stage of labor). Scoring system: This tool was included thirty-nine items; each item in the observational checklist was evaluated as two score for correct practice and one score for incorrect practice. The total correct practice was scored as ≥60% while incorrect practice total scored as <60%.
The third tool: nurse’s satisfaction sheet was adapted from [12], which included two parts as the following: The first part nurse’s satisfaction tools related to their satisfaction regarding implemented guidelines about supportive measures during labor, which included nine statements to assess nurses’ satisfaction regarding supportive measures guidelines during labor. Each nurse was responded upon each item as satisfied, uncertainly satisfied and unsatisfied. The second part assessed the barriers that prevent nurses to comply with supportive measures during labor. Each nurse was responded (yes or no) upon each statement. This was utilized follow-up four weeks post intervention.
All tools were utilized pre intervention, immediately post intervention then follow-up four weeks post intervention but satisfaction tool was used follow-up four weeks post intervention.
An educational guideline was utilized according to nurses’ learning needs.
2.4. Content Validity and Reliability
All tools of data collections were developed and sent to three specialized university Prof. according to their comments, modification were considered. On the other hand, there was reliability of all questions and high value of Alpha Cronbach.
2.5. Ethical Consideration
· An official approval was obtained from Maternal and Gynecological Nursing Department then Scientific Research Ethical Committee in Faculty of Nursing, Ain Shams University before starting the study.
· An official approval letter was sent to the director of Nasser Institute to conduct the study.
· Approval consent was obtained from the research scientific committee in Nasser institute.
· Oral consent was obtained from each participant in the study.
· The researcher was clarified objective and aim of the study to each participant included in the study.
· All tools of data collection didn’t touch nurse’s dignity, culture, traditional and religious & ethical issues and respect human rights. Also didn’t include any immoral statement.
· Each nurse had right to withdraw from the study at any phase.
· All tools of data collection were kept after statistical analysis to promote confidentiality of the study.
2.6. Field Work or Operational Design
The study was implemented through three phases included the preparatory, implemented and evaluation phase.
2.6.1. Phase One (Preparatory Phase)
The current advanced national and international literature related to the study topic were reviewed, then prepared tools for data collection and designed guidelines. Finally, conducted a pilot study on 10% of the sample size (4 nurses) to evaluate the content validity, clarity and applicability of the tools used, according to statistical analysis of a pilot study, no modification was considered.
2.6.2. Phase Two (Implementation Phase)
Firstly, three nurses /day were interviewed according to sequence of their attendance in hospital registration book and explained the aim of the study to obtain their oral consent before four weeks from learning guidelines. Interview was conducted in a separate place to maintain confidentiality of the study (duration of each interview 20 min). Three nurses were given the sheets then back after 2 hours to be received the sheets.
Second, nurses’ practices were assessed using an observational checklist, while they are providing care for laboring women.
• Each day, four nurses’ practices were assessed from 9 Am to 9 pm.
• After the completion interviewing all nurses. The supportive measures guidelines were designed and implemented through (10) sessions 3 for theoretical part and 7 for practical training, duration of each session 20 minutes, number of participants (4) nurses.
• Methods of teaching were (group discussion, lectures, brain storming, demonstration and bed side teaching).
• Media used lab-top, figures, videos, role play as well as audiovisual aids (data show presentation) and module of laboring women were used for practical sessions through demonstration and application on group of mothers (Figures 1-4).
2.6.3. Phase Three (Evaluation Phase)
All tools of data collection were used pre intervention then immediately and four weeks post-intervention but the nurses’ satisfaction tool was used only four weeks post intervention. Nurses’ practice was assessed on four nurses then the mean was obtained for statistical analysis.
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Figure 1. Frequency distribution among the studied sample according to their total knowledge regarding to labor supportive measures at pre, immediate post and follow up the guidelines (n = 40).
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Figure 2. Frequency distribution among the studied sample according to their total practices of labor physical supportive measures pre, immediate post and follow up the guidelines (n = 40).
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Figure 3. Frequency distribution among the studied sample according to their total practices of labor informational provided supportive measures pre, immediate post and follow up the guidelines (n = 40).
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Figure 4. Frequency distribution among the studied sample according to their total practices of labor emotional supportive measures pre, immediate post and follow up the guidelines (n = 40).
3. Results
Table 1 showed that, (27.5%) of the studied sample their age was less than 25 years with mean 32.9 ± 7.9 years. Concerned to residence, (95%) of the studied sample residing in urban areas. Regarding to educational level, (55%) of the studied sample had diploma education. Also, (47.5%) of the studied sample their years of experience were more than 15 years with mean of 11.9 ± 6.49 years. Moreover, the studied sample not attended previously guidelines related to supportive measures during labor.
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Table 1. Frequency distribution among the studied sample according to their general characteristics (n = 40).
Table 2 showed that, there was a marked improvement in knowledge of the studied sample about labor supportive measures post implementation of an guidelines with highly statistically significant difference at (p ≤ 0.01) between pre, immediate post and follow up implementation of an guidelines.
Table 3 displayed a highly statistically significant improvement of studied sample’s total practices of labor supportive measures after implementation of guidelines.
Table 4 showed that, (100%) of studied sample the guidelines enhances nurses’ practices and the objective of the guidelines was simple and clear. Also, (97.5%) of studied sample satisfied about the educational sessions cover the objective, number of participant was suitable to the place of training and material of the guidelines was effective and scientific.
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Table 2. Frequency distribution among the studied sample according to their knowledge regarding labor supportive measures at pre, immediate post and follow up the guidelines (n = 40).
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Table 3. Frequency distribution among the studied sample according to their total practices regarding labor supportive measures at pre, immediate post and follow up the guidelines.
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Table 4. Frequency distribution among the studied sample according to their satisfaction regarding labor supportive measures at follow up the guidelines (n = 40).
Table 5 showed that, (90%) of the barriers that prevent nurses to comply with the implemented guidelines were shortage of nursing staff. Also, (87.5%) of the barriers were too much emergencies case and mothers’ misconceptions regarding nursing care provided during labor.
Table 6 illustrated that, there was a highly statistically significant relation between studied sample’s total practice about labor supportive measures at pre and post guidelines and their level of education & at post guidelines and their age and years of experience. Also, there was statistically significant relation at pre guidelines and their age and years of experience. While, there was no statistically significant relation at pre and post guidelines and their residence.
Table 7 showed that, there was a positive correlation between total studied sample’s knowledge related to labor supportive measures and their total practice at pre, immediate post and follow up the program, where p-value = (<0.01).
Table 8 showed that, there was a positive correlation between total knowledge and practice of the studied sample about labor supportive measures and their satisfaction at follow up guidelines, where p-value = (<0.01).
4. Discussion
The present study aimed to investigate the effect of supportive measures guidelines on nurses’ practices during labor. This aim was significantly approved within the framework of the present study’s research hypothesis which was nurses who received guidelines sessions related to supportive measures during labor has enhanced their knowledge and practices.
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Table 5. Frequency distribution among the studied sample according to the barriers that prevent nurses to comply with the implemented labor supportive measures at follow up the guidelines (n = 40).
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Table 6. Relation between the studied sample’s general characteristics and their total correct practice related to labor supportive measures at pre and post guidelines.
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Table 7. Correlation between the studied sample’s total knowledge related to labor supportive measures and their total practice at pre, immediate post and follow up the guidelines.
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Table 8. Correlation between studied sample’s total knowledge and practice related to labor supportive measures and their total satisfaction at follow up guidelines.
The present study finding revealed that the age of nurses ranged from 21 years to 45 years with an average of 32.9 ± 7.9 years. Regarding educational level, more than a half of the studied sample had diploma education followed by a Technical Institute degree in nursing and lower percent had bachelor degree (55%, 40% and 5% respectively). The result of the current study was in harmony with [13] conducted a correlational study aimed to describe and determine the factors related to professional labor support behaviors among intrapartum nurses in the Northeast of Vietnam who showed that the age of intrapartum nurses ranged from 21 years to 58 years with an average of 37.07 ± 10.38 years. More than a half of them had a certificate from secondary nursing school (57.14%). There were (26.2%) of the participants holding a diploma degree in nursing, and (16.66%) of the subjects attained bachelor degree.
Furthermore, the present study research findings revealed that, there was a highly significant improvement of nurse’s knowledge post intervention compared to pre intervention. The present study findings were consistent with [14] conducted a quasi-experimental study aimed to discuss continuous labor support benefits and implementation of an educational program designed to enhance nursing practice with regard to continuous labor support founded that there was significant improvement of nurses’ knowledge post guidelines compared to pre guidelines because staff nurses didn’t have knowledge pre guidelines compare to post guidelines related to implemented guidelines about supportive measures during labor.
Also the present study was supported by [15] conducted a survey-guided education aimed to improve nursing self-efficacy for labor support techniques and implementation of the coping with labor algorithm in the United States who illustrated that the majority of nurses had high level of knowledge post guidelines compared to pre guidelines related to implemented program about labor support techniques guidelines. Furthermore, the present study was agreed with [16] conducted a pretest/posttest descriptive study aimed to design, implement, and evaluate a nursing theory and evidence-based educational program on professional labor support in the Midwest United States who reported that there was a highly significant improvement among nurses regarding total knowledge score post guidelines compared to pre guidelines.
Moreover, the present study finding revealed that the higher percent score was emotional supportive measure followed by providing information supportive measure and lower percent score was physical supportive measure during labor.
The present study finding was in harmony with [17] who carried out a systematic observational study aimed to test the validity and usability of the “Supportive Midwifery in Labor Instrument” and to test the feasibility and acceptability in the clinical intrapartum setting in Scotland, UK and showed that emotional support behavior was the most important category of support among parturient women. The agreement may be due to this study and the present study was the same objective and the same study sample type.
While the current study, findings were in disagreement with [11] who conducted a comparative descriptive study aimed to investigate parturient women’s self-reported measures compared with nurses’ compliance with supportive measures during labor in the Mansoura University Hospitals, Egypt and mentioned that the higher percent score was physical followed by providing information supportive measures and lower percent score was emotional supportive measures during labor (38.8%, 28.9%, and 25.2% respectively). The difference between study findings and this study may be related to the different type of research methodology. This research was comparative study, but the present study is an applied research.
Concerning nurses’ practices, the present study findings had revealed that a significant improvement in nurses’ practices immediately post and follow up intervention. This result is in the same line with [18] conducted a quasi-experimental pre- and posttest study aimed to evaluate the workshops’ effectiveness in improving senior nursing students’ knowledge and self-efficacy in the provision of labor support in the Mid-Atlantic United States founded that improvement in students’ confidence in the provision of labor support after the workshop, inclusion of educational activities which address labor support are imperative. Additionally, this result is in the same line with the present study [16] conducted a pretest/posttest descriptive study aimed to design, implement, and evaluate a nursing theory and evidence-based educational program on professional labor support in the Midwest United States who reported that a highly significant improvement in nurses’ practices regarding supportive measures during labor post guidelines compared to pre guidelines. Thus, there is a clear role in continuing professional development activities of nurses which have ultimate reflection on improving parturient women’s care services.
Additionally, it was observed from present study findings that highly significant relations between nurses’ knowledge and their practices. This because nurses’ knowledge was considered the base for their practices. This result was supported by [15] conducted a survey-guided education aimed to improve nursing self-efficacy for labor support techniques and implementation of the coping with labor algorithm in the United States who found a highly significant relation between obstetric nurses’ knowledge and their practices.
Moreover, the present study findings had pointed out our attention toward the importance of implemented guidelines contribute to the development and updated nurses with advanced knowledge regarding supportive measures during labor and enhance nurses’ practices. Moreover, the majority among studied sample was suggested to replicate the present study guidelines to other nurses in another setting in the future to enhance nurses’ knowledge and practices. The present study findings was supported with [19] conducted a cross-sectional survey aimed to evaluate medical students’ satisfaction with simulation based learning strategy in Riyadh, Saudi Arabia who demonstrated that maternity nurses have been become more satisfied post the implemented guidelines compared to pre guidelines.
Finally, the present study findings illustrated that the main barriers that prevent nurses to comply with the implemented supportive measures guidelines for laboring women were due to shortage of nursing staff, increasing sudden emergencies cases and mothers’ misconceptions regarding nursing care provided during labor (90%, 87.5%, 87.5% respectively). The present study findings were on the same line with the study [11] conducted a comparative descriptive study aimed to investigate parturient women’s self-reported measures compared with nurses’ compliance with supportive measures during labor in the Mansoura University Hospitals, Egypt found that too much emergency situation and work load were the main barriers that prevent them to comply with supportive measures during labor.
5. Conclusion
There was a highly significant improvement in nurses’ knowledge and practices immediately post and following guidelines compared to pre guidelines. Also the majority of the studied samples were satisfied with the implemented guidelines. So the present study hypothesis was significantly approved with the aim of the present study.
6. Recommendations
· Implementation of labor supportive measure guidelines in different childbirth units to improve nurses’ practice.
7. Further Study
· Investigate parturient woman’s satisfaction with childbirth process after implementing of labor supportive measures.
· Study effect of labor supportive measures on childbirth process out-come.
· Reapplication of the present study in another setting and on a large sample size.
Source of Funding
This research did not receive any specific grant from funding agencies in the public or commercial sectors.
Ethical Approval
Reported research was approved by institutional/national Ethics committee at Nursing Faculty Ain-Shams University.
Acknowledgements
Especially thank from the authors to parturient women and nurses who participated in this study, also thank hospital coordinators.