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Labor and delivery nurses: A survey of attitudes toward third-year medical students and their education
American Journal of Obstetrics and Gynecology (2004) 191, 1828e33
www.ajog.org
Labor and delivery nurses: A survey of attitudes toward third-year medical students and their education Valerie A. Capstick, MD,a,* Dwight Harley, PhDb Department of Obstetrics and Gynecology,a and Division of Studies in Medical Education,b University of Alberta, Edmonton, Alberta, Canada Received for publication May 10, 2004; revised June 15, 2004; accepted July 7, 2004
KEY WORDS Medical students Clerkship Obstetrics Labor and delivery nurses Attitudes
Objective: Forty-six percent of third-year medical students at the University of Alberta rated labor and delivery nurses as a negative influence on their obstetrics and gynecology rotation. We hypothesized that the nurses would have mostly negative opinions toward students and their education. Study design: Labor and delivery nurses were surveyed with regard to their views on the following: (1) student learning objectives, (2) factors causing a patient to reject or accept a student, and (3) the role of the nurse in medical student education. Results: Eighty-nine nurses ranked student tasks (objectives) as very appropriate, appropriate, neutral, inappropriate, and very inappropriate. History and physical examination, witnessing deliveries, assisting at deliveries, and following up women in labor were rated very appropriate or appropriate by more than 96% of nurses; 85% approved of students doing supervised deliveries. Nursing staff were equally divided in approving or disapproving of pelvic exams in labour and outpatient assessment by students. Artificial rupture of membranes, fetal scalp electrode application, and episiotomy repair were not approved of by more than 70% of nurses. The most important factors causing a patient to reject or accept a student were felt to be bedside manner and previous experience with a student, with least important being attractiveness, gender, and the nurse’s opinion. Eighty-seven percent of nurses declared that one of their roles is to help students gain experience, but 71% said they would protect women from students with whom they were not comfortable. Conclusion: Labor and delivery nurses generally have a more positive attitude toward students and their learning than review of evaluations by the students would suggest. However, nurses have reservations about students performing technical procedures in the labor and delivery room. Creation of guidelines (objectives) with nursing input and better briefing of students with regard to nursing expectations may improve the student’s experience. Ó 2004 Elsevier Inc. All rights reserved.
Presented at the 2004 CREOG and APGO Annual Meeting, Lake Buena Vista, Fla, March 3-6, 2004. * Reprint requests: Valerie A. Capstick, MD, Department of Obstetrics and Gynecology, Community Services Building, Royal Alexandra Hospital, 10240 Kingsway, Edmonton, Alberta, Canada T5H 3V9. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.07.063
Declining medical student interest in obstetrics and gynecology as a specialty has become a significant problem for residency program directors in North America. Factors that appear to contribute to the negative image of our specialty are lifestyle, perceived discrimination against males, and medical malpractice
Capstick and Harley
1829
Figure 1 Nurses’ opinion of ‘‘appropriateness’’ of typical student learning activities. Question: the student has a variety of tasks and learning objectives when they start their rotation in the LDR. Please indicate the degree of appropriateness you would place on each of the following activities (mean response with 95% confidence interval). Table The influence of staff on the experience of students on obstetrics-gynecology rotation: responses to a survey completed by 61 third-year students on completion of obstetrics and gynecology rotation Nurses Residents Preceptor Other staff physicians
Very positive (%)
Positive (%)
Neutral (%)
Negative (%)
Very negative (%)
2 29 24 12
14 23 22 35
16 3 7 9
19 (32) 0 2 (3) 1 (2)
8 (14) 0 4 (7) 0
(3) (49) (41) (20)
(24) (39) (37) (59)
concerns. An additional issue may be the quality of our clinical clerkships. Obstetrics and gynecology clinical rotations are rated as the least popular core rotation by graduating classes in Canada and the United States.1 The Association of American Medical Colleges Canadian Medical School Graduation Questionnaire of the graduating class of 2003 asked students to rate the quality of their rotations on a Likert scale of excellent, fair, good, or poor. Their obstetrics-gynecology rotation was rated as poor by 15.2% of respondents across the country; 19.5% of graduates from the University of Alberta ranked the rotation ‘‘poor.’’ The core rotation at the University of Alberta with the second highest ‘‘poor’’ score was psychiatry (5.2%).2 The obstetrics-gynecology rotation at the University of Alberta is 6 weeks in duration and occurs in the third
(27) (5) (12) (15)
year of a 4-year curriculum. Two community and 1 tertiary care hospital accept students. Candid and informal discussions with students and residents consistently reveal that it is the attitudes of the staff (nursing and medical) that have the greatest influence on the quality of the rotation. To learn more about this aspect of the problem, we surveyed 63 students (half of the class of 2004) completing their obstetrics-gynecology rotation between January and August 2003 with regard to their experience on the rotation. Sixty-one surveys (97%) were completed (33 males and 28 females). The rotation was rated great (30%), okay (41%), neutral (2%), not great (22%), or awful (5%). There was a tendency for the male students to rate the rotation as not great or awful (29%), compared with female students (22%). The students were also asked to rate the nature of the influence of the
1830
Capstick and Harley
Figure 2 Why patients accept or reject further involvement of students. Nurses rank importance of student characteristics. Question: Given that most patients will meet a medical student for their admission to the LDR, please rate the following factors for their contribution to the patient’s decision with regard to further involvement by the student (mean responses with 95% confidence interval).
staff: nurses, residents, and preceptor and other staff physicians (Table). The finding that 46% of the students considered the nursing staff a negative or very negative influence on their experience led to the decision to survey the labor and delivery (L&D) staff about their attitudes because most comments from students indicated this area was the main concern. A search of medical education literature revealed no published attempts to assess L&D nurse attitudes toward medical students.
Material and methods A questionnaire with suggestions for content provided by interested medical students, residents, and an L&D nurse manager was developed. The study received approval from the Health Research Ethics Board of the University of Alberta and the 3 hospital administrations. The precise number of nurses working in L&D was difficult to determine because some worked in more than 1 unit as casual staff. Staff working in more than 1 site were asked to answer based on the site
worked at most often. Approximately 150 questionnaires were distributed to L&D nurses over a 2-week period in August 2003. The first area of inquiry of the survey concerned common student objectives (or tasks) in the labor and delivery room (LDR), such as performance of history and physical examination and observing, assisting at, and performing deliveries (see Figure 1 for complete list). Nurses rated the degree of appropriateness of these learning objectives on a 5-point Likert scale that ranged from very inappropriate to very appropriate activities for students. The second area of questioning concerned what the nurse believes influences a woman in her decision to include or exclude a student from her delivery. A 3-point Likert scale from irrelevant to very important was used to rate such items as gender, tidiness, bedside manner, and attitude. The third area of inquiry was an attempt to understand a nurse’s view of her own role with regard to students, her ability and desire to influence patients regarding students, and her views on how her own unit deals with students. We then asked for reactions concerning possible changes and improvements to the rotation. A comment page was included to allow elaboration of concerns.
Capstick and Harley
Figure 3
1831
Nurses’ perception of own ability and desire to influence the experience of students (mean responses with 95% CI).
Statistics usage Descriptive statistics were calculated using SPSS (Statistical Package for the Social Sciences, Chicago, Ill).
Results Eighty-seven of 150 questionnaires were completed and returned by L&D nurses, giving a 58% response rate. There was only a 2-week opportunity in the summer for completion of the survey. The majority of respondents had significant experience in L&D, with 58 (67%) working 10 or more years in the labour and delivery suite. Ages reflect this, with 49 (56%) indicating they were over 40 years of age. Only 10 (12.2%) of those responding reported being trained midwives. Forty-one percent of nurses agreed or strongly agreed with the statement, ‘‘I believe that students and L&D nurses have very different ideas about the experiences the student should be getting on their rotation.’’ Figure 1 presents the responses to a series of questions about typical tasks a student might be expected to perform while on the rotation. Tasks involving history taking, observing deliveries, and assisting at deliveries were considered appropriate or very appropriate by the vast majority of nurses. A surprising 53% felt that performing a delivery was inappropriate or very in-
appropriate; however, written comments in a later section of the survey suggest that many of these nurses interpreted the statement ‘‘perform deliveries’’ to mean without supervision. Later in the survey, the statement ‘‘I approve of medical students doing supervised deliveries’’ had 74 nurses (87%) agreeing or strongly agreeing. Opinion about students performing outpatient assessments and pelvic exams in labour was the most divided, 55% of respondents stating these were appropriate and 43% declaring them inappropriate. The lowest rates of approval were toward students performing artificial rupture of membranes (12%) or fetal scalp electrode application (9%) or repair of episiotomy (24%). The activity receiving greatest approval from nurses (100%) was having the student follow up a patient in labour. Figure 2 illustrates what nurses think influences women to accept further participation by a medical student after they have met the student. Bedside manner and prior experience with a student are the most important, with attractiveness and gender least important. The impact that the nurses feel they can have and wish to have on a student’s experience is shown in Figure 3. The majority of nurses (78%) felt that they
1832
Figure 4
Capstick and Harley
Nurses’ view of their role in the LDR. Question: The role of a LDR nurse includes.. (mean responses with 95% CI).
could influence a patient in her decision about a student, and most indicated that they would attempt to influence in favor of the student. However, 73% were prepared to protect the patient from students with whom the nurse was not comfortable, despite the indication from most respondents that this was not the role of an LDR nurse (shown in Figure 4). Nine percent felt that students should not be doing supervised deliveries. Students who are perceived as being uninterested will clearly miss experiences; 64% of nurses were inclined to not assist these students. When asked to indicate the tendencies of the LDR unit as a whole, 99% percent felt that an available and visible student will ‘‘get’’ more deliveries, and a minority (4.6%) felt that being female was an advantage for the student. Figure 4 reveals what nurses feel their role is with regard to the patient and student. The intent of this question was to determine how much of the interaction with students is ‘‘extra’’ to their role as a nurse in L&D. In other words, do they consider it their job to support students? The majority did consider supporting students as part of their job (87%), with only 26% considering ‘‘protecting patients from house staff’’ part of their job description.
Figure 5 shows the strong degree of nursing support for a variety of proposed changes in the curriculum and strategies to improve patients’ willingness to accept students.
Comment The response rate (58%) might have been better if the survey had been offered twice, avoiding the summer holiday time. The case room managers indicated there was considerable interest in the survey, and much discussion was generated by the questions among nurses, residents, students, and medical staff. Many of the surveys were completed with carefully considered comments, some more than 2 pages. The finding of this survey that would not surprise most medical students is the fairly high number of nurses who do not approve of certain activities in which many students wish to be involved. Most nurses support the more intellectual pursuits of history and physical examination (but not necessarily pelvic examination), following labor and observing deliveries. The more hands-on an activity is, the less likely the nurses are to approve. A possible explanation for this is that these
Capstick and Harley
1833
Figure 5 Nurses’ degree of approval of potential strategies to improve student experience in LDR (mean responses with 95% confidence interval).
tasks are not permitted to many of the nurses, although they may have the technical ability and knowledge to perform them effectively. A surprising 9% of nurses thought students should not be doing supervised deliveries. Clerkship coordinators quickly learn that the number of deliveries performed by students is one of the most important measures students will use to assess the quality of their experience. Not getting called for the delivery of a patient they have been following up is, for many students, the most significant negative of the clerkship. If almost 10% of our nurses (consciously or unconsciously) obstruct a student’s access to deliveries, it is not surprising that there is such a high rate of negative evaluations of nurses. The results of this survey have led us to conclude the following: an obvious deficiency in our program is the lack of clear objectives for students that everyone involved supports. It is, however, a positive and reassuring finding that most of the nurses feel that it is
part of their role to be involved in the education of medical students. Various projects are under consideration to improve the experience for medical students and nurses. These projects include: reviewing and rewriting objectives (with nursing input), providing nurse preceptors for medical students, and log books that need a signature of staff or nurse when a task is performed. Evaluations from students completing the rotation after the survey was distributed are under review with the thought that simply asking the nurses to think about and report their attitudes may have changed the nature of their interaction with medical students, before any changes are made to the rotation.
References 1. Medical School Graduation Questionnaire; 1978-2004. Washington (DC): Association of American Medical Colleges; 2002. 2. Canadian Medical School Graduation Questionnaire. Association of American Medical Colleges; 2003.
www.ajog.org
Labor and delivery nurses: A survey of attitudes toward third-year medical students and their education Valerie A. Capstick, MD,a,* Dwight Harley, PhDb Department of Obstetrics and Gynecology,a and Division of Studies in Medical Education,b University of Alberta, Edmonton, Alberta, Canada Received for publication May 10, 2004; revised June 15, 2004; accepted July 7, 2004
KEY WORDS Medical students Clerkship Obstetrics Labor and delivery nurses Attitudes
Objective: Forty-six percent of third-year medical students at the University of Alberta rated labor and delivery nurses as a negative influence on their obstetrics and gynecology rotation. We hypothesized that the nurses would have mostly negative opinions toward students and their education. Study design: Labor and delivery nurses were surveyed with regard to their views on the following: (1) student learning objectives, (2) factors causing a patient to reject or accept a student, and (3) the role of the nurse in medical student education. Results: Eighty-nine nurses ranked student tasks (objectives) as very appropriate, appropriate, neutral, inappropriate, and very inappropriate. History and physical examination, witnessing deliveries, assisting at deliveries, and following up women in labor were rated very appropriate or appropriate by more than 96% of nurses; 85% approved of students doing supervised deliveries. Nursing staff were equally divided in approving or disapproving of pelvic exams in labour and outpatient assessment by students. Artificial rupture of membranes, fetal scalp electrode application, and episiotomy repair were not approved of by more than 70% of nurses. The most important factors causing a patient to reject or accept a student were felt to be bedside manner and previous experience with a student, with least important being attractiveness, gender, and the nurse’s opinion. Eighty-seven percent of nurses declared that one of their roles is to help students gain experience, but 71% said they would protect women from students with whom they were not comfortable. Conclusion: Labor and delivery nurses generally have a more positive attitude toward students and their learning than review of evaluations by the students would suggest. However, nurses have reservations about students performing technical procedures in the labor and delivery room. Creation of guidelines (objectives) with nursing input and better briefing of students with regard to nursing expectations may improve the student’s experience. Ó 2004 Elsevier Inc. All rights reserved.
Presented at the 2004 CREOG and APGO Annual Meeting, Lake Buena Vista, Fla, March 3-6, 2004. * Reprint requests: Valerie A. Capstick, MD, Department of Obstetrics and Gynecology, Community Services Building, Royal Alexandra Hospital, 10240 Kingsway, Edmonton, Alberta, Canada T5H 3V9. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.07.063
Declining medical student interest in obstetrics and gynecology as a specialty has become a significant problem for residency program directors in North America. Factors that appear to contribute to the negative image of our specialty are lifestyle, perceived discrimination against males, and medical malpractice
Capstick and Harley
1829
Figure 1 Nurses’ opinion of ‘‘appropriateness’’ of typical student learning activities. Question: the student has a variety of tasks and learning objectives when they start their rotation in the LDR. Please indicate the degree of appropriateness you would place on each of the following activities (mean response with 95% confidence interval). Table The influence of staff on the experience of students on obstetrics-gynecology rotation: responses to a survey completed by 61 third-year students on completion of obstetrics and gynecology rotation Nurses Residents Preceptor Other staff physicians
Very positive (%)
Positive (%)
Neutral (%)
Negative (%)
Very negative (%)
2 29 24 12
14 23 22 35
16 3 7 9
19 (32) 0 2 (3) 1 (2)
8 (14) 0 4 (7) 0
(3) (49) (41) (20)
(24) (39) (37) (59)
concerns. An additional issue may be the quality of our clinical clerkships. Obstetrics and gynecology clinical rotations are rated as the least popular core rotation by graduating classes in Canada and the United States.1 The Association of American Medical Colleges Canadian Medical School Graduation Questionnaire of the graduating class of 2003 asked students to rate the quality of their rotations on a Likert scale of excellent, fair, good, or poor. Their obstetrics-gynecology rotation was rated as poor by 15.2% of respondents across the country; 19.5% of graduates from the University of Alberta ranked the rotation ‘‘poor.’’ The core rotation at the University of Alberta with the second highest ‘‘poor’’ score was psychiatry (5.2%).2 The obstetrics-gynecology rotation at the University of Alberta is 6 weeks in duration and occurs in the third
(27) (5) (12) (15)
year of a 4-year curriculum. Two community and 1 tertiary care hospital accept students. Candid and informal discussions with students and residents consistently reveal that it is the attitudes of the staff (nursing and medical) that have the greatest influence on the quality of the rotation. To learn more about this aspect of the problem, we surveyed 63 students (half of the class of 2004) completing their obstetrics-gynecology rotation between January and August 2003 with regard to their experience on the rotation. Sixty-one surveys (97%) were completed (33 males and 28 females). The rotation was rated great (30%), okay (41%), neutral (2%), not great (22%), or awful (5%). There was a tendency for the male students to rate the rotation as not great or awful (29%), compared with female students (22%). The students were also asked to rate the nature of the influence of the
1830
Capstick and Harley
Figure 2 Why patients accept or reject further involvement of students. Nurses rank importance of student characteristics. Question: Given that most patients will meet a medical student for their admission to the LDR, please rate the following factors for their contribution to the patient’s decision with regard to further involvement by the student (mean responses with 95% confidence interval).
staff: nurses, residents, and preceptor and other staff physicians (Table). The finding that 46% of the students considered the nursing staff a negative or very negative influence on their experience led to the decision to survey the labor and delivery (L&D) staff about their attitudes because most comments from students indicated this area was the main concern. A search of medical education literature revealed no published attempts to assess L&D nurse attitudes toward medical students.
Material and methods A questionnaire with suggestions for content provided by interested medical students, residents, and an L&D nurse manager was developed. The study received approval from the Health Research Ethics Board of the University of Alberta and the 3 hospital administrations. The precise number of nurses working in L&D was difficult to determine because some worked in more than 1 unit as casual staff. Staff working in more than 1 site were asked to answer based on the site
worked at most often. Approximately 150 questionnaires were distributed to L&D nurses over a 2-week period in August 2003. The first area of inquiry of the survey concerned common student objectives (or tasks) in the labor and delivery room (LDR), such as performance of history and physical examination and observing, assisting at, and performing deliveries (see Figure 1 for complete list). Nurses rated the degree of appropriateness of these learning objectives on a 5-point Likert scale that ranged from very inappropriate to very appropriate activities for students. The second area of questioning concerned what the nurse believes influences a woman in her decision to include or exclude a student from her delivery. A 3-point Likert scale from irrelevant to very important was used to rate such items as gender, tidiness, bedside manner, and attitude. The third area of inquiry was an attempt to understand a nurse’s view of her own role with regard to students, her ability and desire to influence patients regarding students, and her views on how her own unit deals with students. We then asked for reactions concerning possible changes and improvements to the rotation. A comment page was included to allow elaboration of concerns.
Capstick and Harley
Figure 3
1831
Nurses’ perception of own ability and desire to influence the experience of students (mean responses with 95% CI).
Statistics usage Descriptive statistics were calculated using SPSS (Statistical Package for the Social Sciences, Chicago, Ill).
Results Eighty-seven of 150 questionnaires were completed and returned by L&D nurses, giving a 58% response rate. There was only a 2-week opportunity in the summer for completion of the survey. The majority of respondents had significant experience in L&D, with 58 (67%) working 10 or more years in the labour and delivery suite. Ages reflect this, with 49 (56%) indicating they were over 40 years of age. Only 10 (12.2%) of those responding reported being trained midwives. Forty-one percent of nurses agreed or strongly agreed with the statement, ‘‘I believe that students and L&D nurses have very different ideas about the experiences the student should be getting on their rotation.’’ Figure 1 presents the responses to a series of questions about typical tasks a student might be expected to perform while on the rotation. Tasks involving history taking, observing deliveries, and assisting at deliveries were considered appropriate or very appropriate by the vast majority of nurses. A surprising 53% felt that performing a delivery was inappropriate or very in-
appropriate; however, written comments in a later section of the survey suggest that many of these nurses interpreted the statement ‘‘perform deliveries’’ to mean without supervision. Later in the survey, the statement ‘‘I approve of medical students doing supervised deliveries’’ had 74 nurses (87%) agreeing or strongly agreeing. Opinion about students performing outpatient assessments and pelvic exams in labour was the most divided, 55% of respondents stating these were appropriate and 43% declaring them inappropriate. The lowest rates of approval were toward students performing artificial rupture of membranes (12%) or fetal scalp electrode application (9%) or repair of episiotomy (24%). The activity receiving greatest approval from nurses (100%) was having the student follow up a patient in labour. Figure 2 illustrates what nurses think influences women to accept further participation by a medical student after they have met the student. Bedside manner and prior experience with a student are the most important, with attractiveness and gender least important. The impact that the nurses feel they can have and wish to have on a student’s experience is shown in Figure 3. The majority of nurses (78%) felt that they
1832
Figure 4
Capstick and Harley
Nurses’ view of their role in the LDR. Question: The role of a LDR nurse includes.. (mean responses with 95% CI).
could influence a patient in her decision about a student, and most indicated that they would attempt to influence in favor of the student. However, 73% were prepared to protect the patient from students with whom the nurse was not comfortable, despite the indication from most respondents that this was not the role of an LDR nurse (shown in Figure 4). Nine percent felt that students should not be doing supervised deliveries. Students who are perceived as being uninterested will clearly miss experiences; 64% of nurses were inclined to not assist these students. When asked to indicate the tendencies of the LDR unit as a whole, 99% percent felt that an available and visible student will ‘‘get’’ more deliveries, and a minority (4.6%) felt that being female was an advantage for the student. Figure 4 reveals what nurses feel their role is with regard to the patient and student. The intent of this question was to determine how much of the interaction with students is ‘‘extra’’ to their role as a nurse in L&D. In other words, do they consider it their job to support students? The majority did consider supporting students as part of their job (87%), with only 26% considering ‘‘protecting patients from house staff’’ part of their job description.
Figure 5 shows the strong degree of nursing support for a variety of proposed changes in the curriculum and strategies to improve patients’ willingness to accept students.
Comment The response rate (58%) might have been better if the survey had been offered twice, avoiding the summer holiday time. The case room managers indicated there was considerable interest in the survey, and much discussion was generated by the questions among nurses, residents, students, and medical staff. Many of the surveys were completed with carefully considered comments, some more than 2 pages. The finding of this survey that would not surprise most medical students is the fairly high number of nurses who do not approve of certain activities in which many students wish to be involved. Most nurses support the more intellectual pursuits of history and physical examination (but not necessarily pelvic examination), following labor and observing deliveries. The more hands-on an activity is, the less likely the nurses are to approve. A possible explanation for this is that these
Capstick and Harley
1833
Figure 5 Nurses’ degree of approval of potential strategies to improve student experience in LDR (mean responses with 95% confidence interval).
tasks are not permitted to many of the nurses, although they may have the technical ability and knowledge to perform them effectively. A surprising 9% of nurses thought students should not be doing supervised deliveries. Clerkship coordinators quickly learn that the number of deliveries performed by students is one of the most important measures students will use to assess the quality of their experience. Not getting called for the delivery of a patient they have been following up is, for many students, the most significant negative of the clerkship. If almost 10% of our nurses (consciously or unconsciously) obstruct a student’s access to deliveries, it is not surprising that there is such a high rate of negative evaluations of nurses. The results of this survey have led us to conclude the following: an obvious deficiency in our program is the lack of clear objectives for students that everyone involved supports. It is, however, a positive and reassuring finding that most of the nurses feel that it is
part of their role to be involved in the education of medical students. Various projects are under consideration to improve the experience for medical students and nurses. These projects include: reviewing and rewriting objectives (with nursing input), providing nurse preceptors for medical students, and log books that need a signature of staff or nurse when a task is performed. Evaluations from students completing the rotation after the survey was distributed are under review with the thought that simply asking the nurses to think about and report their attitudes may have changed the nature of their interaction with medical students, before any changes are made to the rotation.
References 1. Medical School Graduation Questionnaire; 1978-2004. Washington (DC): Association of American Medical Colleges; 2002. 2. Canadian Medical School Graduation Questionnaire. Association of American Medical Colleges; 2003.