Intrapartal Nursing Care: Research into Practice

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Intrapartal Nursing Care:Research into Practice ~

Linda Mayberry, RN,PhD

One of the nursing profession’s major goals is to advance the ideal of research-based nursing practice. Much has been written during the past decade about the difficulties inherent in achieving the goal of applying research findings to practice. With the increasing national interest in promoting optimal women’s health care reforms, one area that should receive renewed interest is that of intrapartal nursing care in the hospital setting. In particular, second stage labor management is supported by considerable research, much of it conducted by nurses, that has not been incorporated into mainstream nursing care. This article discusses the issues surrounding research utilization within the context of nursing practice today, particularly in relation to existing barriers. Using intrapartal nursing care as a focal point to examine these issues, implications for a stronger emphasis on an empirical basis for practice are be identified. Recommendations for approaches to facilitate the process of research utilization by maternity nurse clinicians also is delineated.

and true’ practices for second stage labor support ‘state of the art’?’’This was an introductory question put forth into an audience of maternity nurses at the 1993 National AWHONN Conference in Reno, Nevada, in reference to the gaps in research utilization by nurse clinicians providing labor and delivery care in hospital settings throughout the United States today. Although perinatal nurses have become adept at integrating the newest technologies introduced to obstetric management in our nation’s hospitals, such as use of continuous fetal monitoring and bedside ultrasound techniques, much less effort has been spent modifying basic intrapartal nursing care in accordance with an empirical basis for practice that has been available for several years. For example, nursing management of the second stage of labor typically includes encouraging the technique of sustained closed-glottis o r Valsalva-type

bearing-down efforts (BDE) in a recumbent position (Holland & Smith, 1989). The proposed alternative, based o n available research findings, is the promotion of self-regulation during the second phase involving short open-glottis BDE in conjunction with the urge to push in a more upright or squatting position (Roberts, Goldstein, Gruender, Maggio, & Mendez-Bauer, 1987). Adverse consequences of sustained breath-holding from the Valsalva response include circulatory changes, accompanied by alterations in maternal blood flow (Bartlett & Humenick, 1982). In addition, it has been reported that straining against a closed glottis increases stress on the perineum a n d results in a higher incidence of episiotomy o r lacerations (Yeates & Roberts, 1984). Although the frequently used second stage positions of recumbent and lithotomy may be conducive for birth attendants, research has d e m onstrated negative effects on hemodynamic status a n d progress of labor in these positions. Maternal hypotension and decreased urinary output can occur as a result of occlusion of the inferior vena cava (McKay, 1981).These positjons also fail to use the force of gravity, thereby potentially slowing the progression of the second stage. Alternative upright positions, such as recumbent a n d squatting, have been shown in the research to exert positive effects on hemodynamic (increased uterine blood flow) changes a n d length of second stage (Holland & Smith, 1989). Much of the research in this area is not limited to nursing studies. A two-volume publication based o n a 10year systematic study o n worldwide existing data from medical, midwifery, and nursing studies related to childbirth addressed many intrapartal practice issues, including the benefits of varied positioning during labor (Sheep, Roberts, & Chalmers, 1989). AWHONN recently has begun to address the issue of research utilization by perinatal and maternity nurses by developing a set of Research Utilization Project Priorities. Based on findings from a task force convened in 1990, topics were identified a sufficient research base to guide implementation and that have evaluation of changes in clinical practice. Two of the maternity nursing priorities are (1) use of upright

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Intrapartal Nursing Care: Research into Practice

versus recumbent positions during second stage labor to reduce fetal compromise and maternal pain and ( 2 ) exhalatory versus sustained bearing down during second stage labor to reduce abnormal fetal heart rate patterns and low Apgar scores. When confronted with all of this support for changes in practice, why are we stuck with the outdated ways of providing nursing care in the second stage of labor? Based on the number of articles in the literature that describe the difficulties in putting research findings into practice, it is likely that this is an issue in other specialty areas of nursing. However, the timeliness of focusing on maternity, and specifically, intrapartal care is highly justified in an era of health care reforms that include the promotion of safe, quality, and cost-effectivewomen’s health care. We need to make concerted efforts to examine innovative strategies for facilitating the transition of research into practice by nurse clinicians.

Barriers to Research Utilization To create such strategies, acknowledgement of new and longstanding barriers confronting nurses will need to be addressed. For this discussion, nurses working primarily in hospital settings throughout the United States are the targeted group. Obviously, there are many differences among nurses and the clinical settings in which patient care is provided. However, there also are many commonalities, particularly in relation to obstacles faced in orchestrating changes in practice, which is what research into practice represents. Research Versus Practice The first barrier surrounds the problem of research continuing to be associated with academia in nursing and viewed as separate from the everyday practice of nurses. MacGuire (1990) referred to this barrier as the “credibility gap between researcher and practitioner” (p. 619). Most nurses “keep up” with their clinical knowledge and skills by reading clinical journals, attending in-service education offerings, and participating in professional meetings. In addition, it has been recommended that nurses be encouraged to read research articles regarding innovations in practice, but this will not serve as the primary impetus for changing practice. Research or the jargon-sounding concept of “research utilization” is considered outside the realm of clinical practice. In addition, although it is thought that nurses such as clinical nurse specialists with a background in research evaluation are more likely to facilitate research to practice, we should not depend on this as the only answer. According to Brett (1987), who studied the extent to which nurses use selected research findings, there was no relationship between educational preparation at the master’s degree level and “increased innovation adoption” (p. 348) in the clinical setting studied.Although this study is not representative of all clinical nurse specialists, it highlights the fact that factors other than educational background

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are involved in the nurse’s choice to evaluate practice changes or not. Another reason research may appear in opposition to nursing practice is the perception of the transfer of research findings as an “endpoint,” rather than on the continuum of improving patient care. Increased understanding of the process of research utilization as a means of evaluation and exploring new or different questions needs to be addressed. For example, concerns about the effect of varying positional changes in labor when women receive epidural anesthesia illustrates the type of new research questions that could be elicited from evaluation of a research-based protocol that supports this practice. Finally, labor and delivery nurses often are compelled to experiment from patient to patient with different approaches, such as relaxation techniques, labor support measures, and pain management. Understandably, they have come to expect a high level of autonomy in this regard. The problem arises when protocols based on research findings that do not coincide with an individual nurse’s experience are perceived as not personally applicable and thus are rejected. This potential barrier to change was highlighted in questions posed by Fawcett (1984) that were formulated on the need for evaluation of research in terms of “relevance for practice” (p. 61). The questions concerned significance to clinical practice, the extent of control by nurses over the variables involved, and valid feasibility issues. Time Limitations Time as a limiting factor in the complicated process of change will continue to be a major barrier for nurses in the clinical setting. In the fast-paced hospital labor and delivery unit, with diminishing numbers of nurses available to meet patient’s needs, it is not surprising that goals for implementing new research findings seem unattainable. Cronenwett (1986, p. 7) remarks, “In most nursing practice settings, no commitment to the use or generation of new knowledge exists. Resources are committed only to the provision of direct services to clients.” Even when nurses are in a position to take efforts to introduce innovations based on research tied concepts to such as nurse-led group projects, they may be stymied by procedural obstacles. Reports on research utilization projects in the literature (Goode, Lovett, Hayes, CL Butcher, 1987) delineated lengthy committee work to establish clinical research specificity and staff preparation to read t h e related research literature. In the case of intrapartal nursing care, nurses encounter the added dimension of time-consuming approval committee structures that often involve physicians because of the potential overlap in the division of professional domains for patient care. Researcb Overload MacGuire (1990) referred to the problem of research “overload” because of the lack of available synthesis of cumulative research findings. Without this step, clinicians can not make even the initial decisions about priorities in the development of empirically based protocols

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for deriving new standards of patient care. In addition, particularly in the perinatal/obstetric field, it is the extensive scope of pertinent research findings affecting nursing practice that is a barrier to timely research utilization. How can nurses decide to shift priorities to basic labor and delivery nursing management strategies when burdened with the impact of a constant influx of research related to new and complex technology for high-risk pregnancy monitoring?

strategies f o r Promoting Research into Practice There are no easy answers to overcoming these and other barriers to research utilization. However, the key may lie in targeting multiple strategies that have an impact on professional nurses making choices related to researchbased practice and on those closely influenced by the choices, including physicians, administrators, and the consumers of care (pregnant women). Highlighting Research Utilization as a Professional Issue Barnard (1985) spoke to a portion of the clinician’s role involving investment in “time and energy in finding new solutions for client care” and “being open and wilIing to seek and adopt innovations” (p. 224). This makes sense in theory but becomes a problem if the profession at large or individual nurses d o not perceive, or actually disagree with, the relative importance of a set of specified research findings for nursing practice. Perhaps the first step in overcoming these barriers is to spotlight research utilization as an issue with highly significant implications for professional practice. Using the example of intrapartal nursing care, there are two closely related reasons for shifting priority to research-based practice in this area of nursing care. Legal and Ethical Implications. It is the disparity between the type of nursing care delivered in labor and delivery and the information our consumers receive through childbirth education classes and the general media that serves as a reinforcer for the need to promote research-based practice. Childbirth educators currently include class content on use of varying positions during labor, accompanied by open-glottis pushing during the second stage of labor, but upon entering the labor and delivery unit as a patient and progressing to full cervical dilation, a woman is typically told that she should “hold her breath as long she can and push hard.” In an issue of the women’s magazine Glamour (Young, 1993), a column on health‘and pregnancy titled “Learning How to Push” included the following statement:

During the second, or active, phase of labor, uterine contractions push the baby out-with your help. Yet pushing doesn’t come naturally. Most women push incorrectly-holding their breath and bearing down. ‘This actually slows labor by tensing the muscles in the pelvic floor,’says Julie Tupler, R.N.,

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founder of the New York City-based Maternal Fitness and exercise program that teaches basic labor skills. ‘It also may cause dangerous changes in maternal and fetal heart rate and blood pressure (p. 6 4 ) .’

Parade (Ubeli, 1993,February 71, a syndicated insert to Sunday newspapers across the United States, also carried an article on hospital childbirth practices entitled, “Are Births as Safe as They Could Be?” The article profiled findings from the study conducted by Chalmers et al. (1989) and included the statements: A revolution in health care has caught Americans off

guard. New research tells us that much of what our doctors and hospitals d o for pregnancy and birth is wrong, expensive and dangerous. That same research has found good, inexpensive, and safe methods for bringing babies into the world (p. 9). Criticized by the study is the birthing position common in most urban hospitals-women lie flat on their back or put their feet in stirrups, with the pelvis slightly tilted. Research suggests lying on the back can adversely effect labor by interfering with the blood supply of mother and baby (p. 10). Should nurses be concerned about potential legal, and certainly ethical, considerations of their intrapartal care that sometimes are in opposition to what women learn and read as being based on current scientific understanding? Particularly at this juncture in the United States, when women are becoming more knowledgeable and have increasingly better access to research findings through the media, are there potential risks looming ahead for the profession if more attention is not paid to research utilization in clinical practice? Patient Outcomes. The second strategy for highlighting research-based practice is to validate the possibility that certain nursing practices have direct or indirect effects on patient outcomes. In relation to intrapartal care, a stronger appreciation is needed of the potential significance of what are usually considered “only” basic supportive care-giving practices but which may have greater implications within the scope of healthy outcomes of mother and neonate than most nurses realize. For example, Butler, Abrams, Parker, Roberts, and Laros (1993) published a large-scale retrospective study comparing patients who received physician-managed care with those who received nurse-midwife-managed care in relation to the incidence of cesarean deliveries and labor abnormalities. Numerous factors are involved in unraveling the complexity of this type of study. However, even if a direct causal pathway between nursing care parameters and cesarean delivery rates would need to be determined with a prospective design, the findings suggested that less frequent labor abnormalities and a lower incidence of cesarean deliveries may be associated with nurse-midwife-managed care. This finding indicated to the investigators that specific components of nursing care

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during labor (albeit care by nurse-midwives in this study) may contribute to shaping maternal-fetal outcomes. Another recent study (Radin et al., 1993) also addressed this area with a report on differences among labor and delivery nurses in cesarean deliveries with possible links to variations in labor support practices. These type of findings have strong implications for the conduct of nursing care, and thus create a major practice issue that requires attention. According to Edwards-Beckett (1990), “Professionally, utilization of nursing research provides a basis for policy and practice decisions” (p. 29). In addition, the underlying message for nurses is that secondary gains will include validating the need for additional nursing research and justification of the indispensable role of nursing in the delivery of intrapartal health care. Reconceptualize use of ‘Research Versus Practice.’ The final tactic for highlighting research utilization is to discourage the separateness of research and practice in our clinical settings. We need to emphasize that “research equals practice” by combining, for example, research and practice committees in hospitals. Rather than maintaining research committees that comprise nurse-researchers and clinical nurse specialists, we need to incorporate clinicians who will provide a perspective on practice that is acknowledged and included as important input in evaluating the applicability of research findings. Research-Based Practice as a Collaborative Efort The resilience of the barriers described in this article indicates that it would be naive to expect individual nurses to tackle the challenge of propagating changes in practice alone. Instead, the second strategy recommended for facilitating research utilization is to institute mechanisms for nurses to support one another in this. endeavor. For example, the formation of collaborative projects among hospitals for the purpose of developing jointly evaluated research-based protocols for nursing care can be effective. Establishing protocol “sites” within close geographic proximity of each other can provide not only “strength in numbers” but also serve as a vehicle for sharing resources in expertise and influence. Protocols can be developed with the assistance of academic nurses who can help with synthesis of pertinent findings relative to the protocol topic area. This approach could alleviate the barriers associated with time constraints and academic “credibility gap.” It is time that researchers accept that clinicians do not have the time, and in some cases, the background to critique and research the literature. However, clinicians can contribute greatly to feasibility aspects of nursing care protocols and lend clinical expertise to assessment and documentation parameters. Leadership for implementing this type of collaborative project should be based on the interests of and consideration to the individual who has the necessary “sphere of influence” within each of the involved clinical sites. This could include clinical nurse specialists or nurse clinicians, as appropriate. There also are two other

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important components that overlap with the leadership considerations. Process and Content. I t is important at the onset of a project of this type to achieve a certain level of continuity among the sites in relation to the content of the protocol (although variations may be needed in preliminary evaluations), but we have learned that attempts at maintaining tightly controlled guidelines, addressing the process of implementing a protocol, almost certainly fail. As with time constraints, we have to accept the reality that hospitals become a separate social and cultural milieu, which based on multiple factors, have inate differences that must be acknowledged. For this reason, it behooves nursing pioneers in research utilization to evaluate, not only the protocol outcomes, but also the process taken to reach the point of incorporating a new protocol into care practices (even if only on a trial basis). Process is defined as the necessary steps taken to begin protocol evaluation and includes questions to answers such as:

What hospital “structures” will help or hinder the process? Who are the essential colleagues involved in each step of the process? How will nursing staff members be introduced to the protocol? What is an acceptable timetable? In the case of second stage labor protocols, how will the overlap with the medical aspects of care be best addressed? Nurse Autonomy. What about the barriers surrounding independent nursing care judgments and the perceptions of protocols as final dicturns? It is suggested that these barriers can be overcome, but not by expecting the old concept of “group think” to occur. Brett (1987) explored the stages that nurses evolve through when exposed to an innovation in practice. The findings indicated that more nurses were in the (later) implementation stage than the persuasion stage, suggesting that “use of innovation sometimes was actually a part of the persuasion stage and represented a testing of the innovation” (Brett, 1987, p. 349). This finding serves to validate that nurses will advance through the research utilization process uniquely, and that is acceptable. We cannot wait until everyone is “on board” to make practice changes; this finding indicates that staff consensus may not be needed before trying an innovation. However, it may take the initiative of key nurse clinicians; for examples, key clinicians on a labor and delivery unit may have to evaluate use of the squatting position during the second stage of labor with several women before other nurses are similarly motivated. Brett (1987) found that it is not policies that contribute to innovation adoption but the perception that policies exist. Policies are better represented, in this sense, by professional sup-

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port for accepted and appropriate changes, rather than by written regulations.

Conclusion Research into practice is a complex process that demands attention from nurses at all levels of the profession. Although difficult in terms of the realities inherent to care delivery in hospitals, the impact of sophisticated mass media, improved childbirth education standards, and legal/ethical considerations create a focus on research utilization in maternity and intrapartal health care that is criticat. The profession has not yet developed a systematic way to expeditiously apply and evaluate findings in the clinical practice situation. Until this occurs, a rudimentary process involving collaboration among motivated groups of nurses can serve to test areas designated as priority by influential professional organizations and examine the process involved to do so.

References Barnard, K. E. (1985). Research utilization: The clinician’s role. MCN:American Journal ofMaternal Child Nursing, 11,24. Bartlett, M. M., & Humenick, S. S. (1982). Infant outcome in relation to second stage labor pushing method. Birth, 9, 221-228. Brett, J. L. (1987). Use of nursing practice research findings. Nursing Research, 36,344-349. Butler, J., Abrahms, B., Parker, J., Roberts, J.M., & Laros, R. (1993). Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. American Journal of Obstetrics and Gynecology, 168,1407-1413. Cronenwett, L.R. (1986). Research and the staff nurse: Troublesome issues. Journai ofNursingAdministration, 16 7-8. Edwards-Beckett, J. (1990). Nursing research utilization techniques. Journal ofNursing Administration, 20, 25-30.

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Fawcett, J. (1984). Another look at utilization of nursing research. Image, IG,58-62. Goode, C. J . , Lovett, M. K., Hayes, J . E., & Butcher, L. A. (1987). Use of research based knowledge in practice. Journal of NursingAdministration, 17, 11-18. Holland, R.L., & Smith, D.A. (1989). Management of the second stage of labor: A review/Part 11. South Dakota Journal of Medicine, 42, 5-8. MacGuire, J.M. (1990). Putting nursing research findings into practice: Research utilization as an aspect of the management of change. Journal of Advanced Nursing, 15, 614620. McKay, S. (1981). Second stage labor: Has tradition replaced safety?American Journal of Nursing, 81, 1016- 1019. Radin, T. G., Harmon, J. S., & Hanson, D. A. (1993). Nurses’ care during labor: Its effect o n the cesarean birth rate of healthy, nulliparous women. Birth, 20, 14-21. Roberts, J . E., Goldstein, S. A., Gruender, J. S., Maggio, M , 8r Mendez-Bauer, C. (1987). A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor. JOGN& 16 48-55. Sheep, J., Roberts, J., & Chalmers, I . (1989). Care during the secondstage of labor. In I. Chalmers, M. Keirse, & M. Enkin (eds): A Guide to Effective Care in Pregnancy and Chiidbirth. London: Oxford University Press. Ubell, E. (1993, February 7). Are births as safe as they could be? Parade Magazine, p. 9-12. Yeates, D. A,, & Roberts, J. E. (1984). A comparison of two bearing down techniques during the second stage of labor. Journal ofNurse Midwqery, 29, 3-1 1. Young, S. (1993, March). Health and pregnancy. GiamourMagazine, p. 64.

Addressfor correspondence: Linda Mayberry, RN, PhD, 141 H Lane, Nouato, CA 94945. Linda Mayberry is an adjunctprofessor of the Nell Hodgson Woodruffschool of Nursing at Emory University in Atlanta, Georgia.

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