Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Palandri, Loreli
Master of Science in Nursing - MSN
University of British Columbia
The purpose of this study was to assess nurses’ perspectives of their influence on how a patient birth’s their baby, whether that is a vaginal or via cesarean section. Though c-sections are a medical necessity in approximately 10% of births (WHO, 2015), it has become a mode of birth for more than a quarter of Canadian births (CIHI, 2021). The reasons for operative births are varied and are the result of many intersecting contextual and interpersonal factors. One of these intersecting factors is the role of the care providers, in particular nurses. Nurses play a key role on labour and birth units throughout Canada (Evans et al, 2015), and likely influence decisions about labour and birth, and eventual outcomes. This study utilized the Interpretive Description method, to interview nine nurses of varying labour and birth expertise level and asked them questions relating to their thoughts on birthing practices and how they perceive they do or do not influence their patients. Three intersecting contexts were identified that the participants perceived influenced their labour and birth care and birth outcomes: societal context, practice context, and interpersonal context. While these three contexts were evident in the data, they were not mutually exclusive. The current societal discourse that surrounds women’s empowerment, which pushes for freedom of choice above all else, was highlighted in this study. The participants felt it a top priority to navigate this social discourse and ensure that birthing people felt fulfilled and happy with their birth, regardless of the mode. The findings highlight nurses’ perceptions of the need to navigate what they know to be evidence-based care with these societal pressures, and the nurses that participated in this study demonstrated how this can be hard at times. These nurses noted that their work is about ensuring that birth is within the domain of choice and control, and that the birther was healthy, safe, and content with their eventual birth outcomes.
Nurses’ Perceptions of their Influence on Modes of Birth: An Interpretive Description Study by Loreli Palandri A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF Master of Science in Nursing in The Faculty of Graduate and Postdoctoral Studies The University of British Columbia (Vancouver) December 2021 ÓLoreli Palandri, 2021 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Nurses’ Perceptions of their Influence on Modes of Birth: An Interpretive Description Study submitted by Loreli Palandri in partial fulfillment of the requirements for the degree of Master of Science in Nursing Examining Committee: Dr. Helen Brown, Nursing, UBC Supervisor Dr. Fuchsia Howard, Nursing, UBC Supervisory Committee Member Dr. Gina Wong, Applied Psychology, Faculty of Health Disciplines, Athabasca University Supervisory Committee Member iii Abstract The purpose of this study was to assess nurses’ perspectives of their influence on how a patient birth’s their baby, whether that is a vaginal or via cesarean section. Though c-sections are a medical necessity in approximately 10% of births (WHO, 2015), it has become a mode of birth for more than a quarter of Canadian births (CIHI, 2021). The reasons for operative births are varied and are the result of many intersecting contextual and interpersonal factors. One of these intersecting factors is the role of the care providers, in particular nurses. Nurses play a key role on labour and birth units throughout Canada (Evans et al, 2015), and likely influence decisions about labour and birth, and eventual outcomes. This study utilized the Interpretive Description method, to interview nine nurses of varying labour and birth expertise level and asked them questions relating to their thoughts on birthing practices and how they perceive they do or do not influence their patients. Three intersecting contexts were identified that the participants perceived influenced their labour and birth care and birth outcomes: societal context, practice context, and interpersonal context. While these three contexts were evident in the data, they were not mutually exclusive. The current societal discourse that surrounds women’s empowerment, which pushes for freedom of choice above all else, was highlighted in this study. The participants felt it a top priority to navigate this social discourse and ensure that birthing people felt fulfilled and happy with their birth, regardless of the mode. The findings highlight nurses’ perceptions of the need to navigate what they know to be evidence-based care with these societal pressures, and the nurses that participated in this study demonstrated how this can be hard at times. These nurses noted that their work is about ensuring that birth is within the domain of choice and control, and that the birther was healthy, safe, and content with their eventual birth outcomes. iv Lay Summary This interpretive description focused on nurses’ perceptions of their influence on how patients birthed their baby, and whether they felt their care could influence whether someone had a vaginal or cesarean section birth. Nine nurses were interviewed regarding their opinions on caring for labouring and birthing patients. Three intersecting contexts; societal, practice, and interpersonal; were evident in the data as being the key influencers on birth mode and nursing care. The findings underscore that nurses often navigate in-between these contexts, and work to ensure that birthers satisfaction is at the forefront. v Preface This dissertation is original, unpublished, independent work by the author, Loreli Palandri. The interviews reported in Chapters 3-5 were conducted entirely by the author and were covered by UBC Ethics Certificate number H18-01087. vi Table of Contents Abstract ........................................................................................................................................ iii Lay Summary ................................................................................................................................ iv Preface ............................................................................................................................................ v Table of Contents .......................................................................................................................... vi List of Figures ................................................................................................................................ x Acknowledgements ....................................................................................................................... xi Dedication .................................................................................................................................... xii Chapter One: Introduction ........................................................................................................... 1 The Research Problem ................................................................................................................. 1 Research Question ................................................................................................................... 3 The Research Problem in Context ............................................................................................... 3 The Role of the Nurse at Births ................................................................................................... 4 Significance of the Research ........................................................................................................ 6 Guiding Assumptions of the Researcher ................................................................................. 7 Research Methodology ................................................................................................................ 8 Summary ...................................................................................................................................... 8 vii Chapter Two: Literature Review ................................................................................................. 9 Nurses Thoughts About Decisions on Mode of Birth .................................................................. 9 Nurses’ Perspective on Providing Care during Labour and Birth ........................................... 11 Nurses Ways of Thinking About Birth ....................................................................................... 12 Conclusion ................................................................................................................................. 13 Chapter Three: Methodology ..................................................................................................... 14 Interpretive Description and Constructivist Epistemology ....................................................... 14 Participant recruitment and sample .......................................................................................... 15 Inclusion Criteria ................................................................................................................... 16 Data Collection Methods ........................................................................................................... 16 Data analysis ............................................................................................................................. 18 Analyzing and Composing the Data .......................................................................................... 19 Ethical Considerations .............................................................................................................. 21 Researcher Reflexivity ............................................................................................................... 21 Research Rigour ........................................................................................................................ 22 Conclusion ................................................................................................................................. 23 Chapter Four: Findings .............................................................................................................. 25 Contexts of Influences: Intersecting Impact on Mode of Birth .................................................. 25 Societal Context ......................................................................................................................... 27 viii Nurses Questioning the Meaning of Natural ......................................................................... 27 Prioritizing Non-judgmental Care ......................................................................................... 29 Practice Context ........................................................................................................................ 30 Nurses on the Periphery of Decision Making ........................................................................ 30 Medical Decisions Constrained by Workload ....................................................................... 32 Interpersonal Context ................................................................................................................ 33 Nurses as Influencers of Birth Mode ..................................................................................... 33 Nurses’ Need a Passion for Birth .......................................................................................... 34 Conclusion ................................................................................................................................. 35 Chapter Five: Discussion and Recommendations .................................................................... 37 Societal Discourse ..................................................................................................................... 37 Practice Context ........................................................................................................................ 38 Interpersonal Context: Novice to Expert ................................................................................... 40 Strengths and Limitations .......................................................................................................... 41 Recommendations: Using the Findings to Bring About Positive Change ................................ 43 Practice Recommendations .................................................................................................... 43 Policy Recommendations ...................................................................................................... 44 Future Research Recommendations ...................................................................................... 44 Education Recommendations ................................................................................................ 45 Conclusion ................................................................................................................................. 46 References ..................................................................................................................................... 48 ix Appendix 1: Interview Questions ............................................................................................... 55 Appendix 2: Codes ....................................................................................................................... 56 x List of Figures Figure 1. Participant’s perceptions of intersecting contexts ........................................................ 26 xi Acknowledgements I would like to send my sincere and heartfelt thanks to my supervisor, Dr. Helen Brown. Without Helen, I would have never been able to complete the thesis. Her constant and unwavering support and push to dig deeper, trust my instincts, and go further were so appreciated. Thank you to Dr. Fuchsia Howard and Dr. Gina Wong for their attention to detail and their contributions while sitting on my supervisory committee. They helped elevate me from a very novice researcher and writer to the woman that you see on the pages here today. xii Dedication To my amazing husband, Ryan, my daughters Sophia and Poppy, and all my friends and family who have supported me through this life-changing process of research and writing. They have dealt with my persistent rhetoric of the woes of graduate life. Without you all, this thesis would not have come to fruition. I am forever grateful. 1 Chapter One: Introduction The Research Problem The World Health Organization’s (WHO, 20151) position statement on cesarean section (c-section) rates explains that, while operative deliveries are necessary in specific situations for the safety and health of birthers and newborns, there are risks associated with the operative birth in the absence of medical necessity. People who have an operative birth have elevated risks of infection, venous thrombosis immediately post-partum, perinatal mood and anxiety disorders, and uterine rupture and abnormal placental implantation in subsequent pregnancies (Malik, Malik, & Irfan, 2015; Silver, 2012; WHO). The risks to newborns include respiratory distress in the hours and days after birth (Morrison, Rennie & Milton, 1995; Silver) and long-term complications such as infection needing hospitalization in childhood (Miller et al., 2020). When medically necessary, c-section births reduce maternal and newborn morbidity and mortality, but the WHO states that a c-section rate above 10% can further increase maternal and newborn morbidity and mortality risks, when the surgical births are not medically indicated. In Canada, 2018-2019, the overall c-section rate was 29.4% (CIHI Health Indicators Interactive Tools, 2021) with variation across provinces, with Nunavut having the lowest at 9.4%, and British Columbia the highest at 36.7%. Since 1997, there has been a national increase 1 The World Health Organization has not put out another position statement relating to c-section rates since this one in 2015. They have since released recommendations for non-clinical interventions to reduce unnecessary caesarean sections (Opiyoi et al., 2020). 2 in C-section rates from 18.7% to 29.4% reported for 2018-2019 (CIHI). Given the WHO statement of c-section risks when rates are above 10%, and Canada’s c-section rate of 29.4%, along with variations among provincial rates, the rise in c-sections may be due to a myriad of reasons other than medical necessity (Hutton & Kornelson, 2012; Fenwick et al., 2008, Minkhoff, 2012). Because birth is a multi-factorial process shaped by a variety of contextual factors, it is necessary to explore the various influences on operative births to determine how to reduce c-section rates to the recommended 10% percent. A significant factor of the decisional context in mode of birth are health care providers such as nurses and physicians. More specifically, given nurses’ proximity and engagement with patients2 during the birthing process (Edmonds et al., 2016), as compared to other health care providers, nurses constitute a significant part of birthing experiences and outcomes. This study focuses on how nurses view their influence on their patient’s birthing process – specifically intrapartum c-sections -with an emphasis on potential differences in perceptions potentially reflecting nurses’ perinatal level of experience (e,g., from novice to more expert). The study investigated how nurses perceived their 2 The reader will note that the use of the term patient is used interchangeably with the word birther or the term pregnant/labouring/birthing person or people. When writing this paper, I chose the more feminist or constructivist term of pregnant/labouring/birthing person or people. However, I do utilize the word patient when discussing the interviews and points made by the participants, as that was the general term they used throughout our interviews. 3 influence on intrapartum c-sections and how those perceptions may be influenced by perinatal nursing experience. Research Question The research questions that guided this study were: 1. What are nurses’ perceptions of their influence on intrapartum c-sections? 2. How does level of experience as a nurse in labour and birth shape the nurses’ perceived influence over mode of birth? The Research Problem in Context C- section birth rates are influenced by many complex and intersecting factors that cannot be reduced to medical necessity alone. For example, pregnant people are increasingly requesting an operative as opposed to a vaginal birth (Hutton & Kornelson, 2012; Fenwick et al., 2008). Fear expressed about the birthing process and the impact on birthing people’s bodies has been cited as reasons for requesting a c-section birth (Fenwick et al.). Demographics of pregnant patients are also changing. In Western, high-resource countries, including Canada, people are giving birth at more advanced ages. Increasing age at the time of birth increases pre-pregnancy morbidity and intrapartum interventions that contribute to higher c-section rates and maternal and newborn morbidity and mortality (Declerq, et al., 2011; Johnson & Tough, 2012; Rydahl et al., 2019). Despite the Society of Obstetricians and Gynecologists of Canada’s (SOGC) vaginal birth after cesarean (VBAC) recommendations, the highest percentage of people having c-section births are those who have previously given birth via c-section. (Kelly et al. 2013). These subsequent elective c-sections for non-medical necessity are offered to patients, with the 4 discussion of reducing the potential risk of uterine rupture at the scar line of the previous c-section (Kelly et al., 2013). In 2021, CIHI data confirmed that repeat c-sections in 2018-2019 were 81.8%, while less than 20% of pregnant people who had a previous c-section had a VBAC. The SOGC recommends pregnant people with one previous c-section birth have proper counselling and education for a trial of labour for a subsequent pregnancy (Dy, DeMeester, Lipworth, & Barrett, 2019). Health care provider influence has also been cited as a factor influencing c-section birth rates. Fear of litigation relating to morbidity in infants has been specifically proposed as influencing physicians’ tendency to pursue a c-section over vaginal birth (Minkhoff, 2012). This defensive medicine, whereby physicians preform more procedures when they fear litigation, has been linked to higher rates of c-sections in multiple studies (Kucuk, 2018; Rudey, Leal, & Rego, 2021). The Role of the Nurse at Births In traditional hospital settings in North America, nurses are the predominant healthcare provider during the intrapartum period and, as such, play a role in influencing birth outcomes and mode of delivery. Nurses have the greatest proximity of all healthcare providers to labouring people during a traditional hospital birth, while in other settings such as during home birth, caregivers included midwives and doulas. This study specifically looked at nurses in the context of caring for birthing people. There is evidence to confirm that the nurse-patient ratio affects labour and birth outcomes and maternal mental health, with 1-1 care providing the most positive birth experience according to postpartum patients (Evans, Evans, & Brown, 2015). With nurses playing a significant role in the labour and birth process in hospital settings, it is reasonable to assume they have some influence during birth and intrapartum decision-making in relation to 5 mode of birth and potentially even c-section rates. Yet, very few studies exist, to my knowledge, on how nurses understand their influence on mode of birth, and none of these are Canadian studies. Given the myriad factors that may be influencing the decisional context of birth mode, it is also reasonable to investigate how nurses’ experience level might also play into how the nurse influences and cares for birthing people. The findings from this study can contribute knowledge to inform nursing education that could potentially help to lower c-section rates and promote vaginal birth and, ultimately, contribute to decreasing maternal morbidity and mortality, and length of hospital stay. These complex intersecting factors that shape mode of birth – from health provider influence to maternal fear to planned repeat c-section, illustrate just some of the specific contextual factors at play than cannot be disentangled from c-section rates nor interventions or changing practices aimed at reducing operative birth. In the literature, explored in more detail in Chapter 2, are other factors cited such as the labouring person, including their physical abilities and psyche, institutional policies and procedures, as well as societal norms. Birth outcomes are a result of these many different and intersecting contextual and interpersonal factors that connect to influence the choice of c-section for a birthing parent. This study was designed to investigate how Canadian nurses perceive their influence on birth mode as situated within this broader context, while also considering how their perspectives may be shaped by perinatal nursing experience. My overall goal was to generate knowledge to enhance nursing care for birthing people and learn about how nurses understand their influence on birth more to potentially contribute to efforts to reduce c-section rates to the recommended 10% rate. 6 Significance of the Research C-section rates that exceed the WHO’s recommendation of 10%, pose risks for several reasons. C-section births have been associated with challenges in the newborn and postpartum period. For example, Hobbs, Mannion, McDonald, Brockway, and Tough (2016) reported breastfeeding difficulties after birth via c-section. Hobbs et al. noted that breastfeeding after c-section delivery is associated with pain during positioning, a greater need for resources such as lactation consultants, and a shorter overall length of time spent breastfeeding when compared to those who birth vaginally. In addition, partners and/ or family members may need to take extra time off from their paid work to provide post-operative care even in the presence of minimal to no complication given the overall longer recovery time and restrictions on lifting and mobility that are put upon a postpartum person who has birthed via c-section (Morris, 2013). Also, as noted previously, postpartum people who have birthed via c-section are at increased risk of thrombosis, infection, and perinatal mood and anxiety disorders (Malik, Malik, & Irfan, 2015; Silver, 2012; WHO, 2015). Economic costs associated with C-section birth also exist within the context of a publicly funded healthcare system. For example, according to the Saskatchewan Medical Association (2021), for an insured patient, a physician bills $609.30 for a vaginal birth, and $635 for a C-section plus $94.50 if the surgery is performed during the intrapartum period. Adding to those costs are the $30 per day in hospital postpartum. Post-operative mothers generally stay in hospital 1.4 days longer than mothers who give birth vaginally (Liu et al., 2007), thereby resulting in greater healthcare dollars spent for a c-section versus a vaginal delivery. As well, because post-operative mothers spend more time in the hospital on average, this can create competition for admission beds in the labouring units. 7 Notwithstanding the financial costs to the healthcare system, c-section birth creates short-term health risks for mothers, including cardiac issues, hemorrhage, and infection (Liu et al, 2007; Silver, 2012), and long-term morbidity and mortality risks particularly in subsequent births (i.e., placental implantation issues become more prevalent) (Silver, 2012). The impacts of operative births are system wide and significantly impact birthing people themselves; efforts to reduce costs and alleviate and treat c-section birth complications remain a local and global priority. Guiding Assumptions of the Researcher My professional experience underscores several assumptions about the topic under study. These in include: (1) Experienced nurses may potentially perceive greater influence over operative birth decision-making. This assumption arose from my professional perinatal experience as I journeyed from being a novice to expert nurse, seeing the evolution of nursing assessment, care, and practice, as well as interprofessional relationships with medical staff. (2) Nurses would view an optimal birth as one with the least risk and intervention possible to ensure the health and wellbeing for both the birthing person and fetus. (3) Whether novice or expert, that nurses would perceive some influence over mode of birth. These assumptions were revisited continuously through my reflexive analysis and journaling, to be critically conscious of how they were potentially influencing data analysis and interpretation, and ultimately the construction of the findings further described in Chapters 3 and 4. 8 Research Methodology Interpretive description (ID) was the research methodology selected for this exploratory qualitative study. ID provided me with the ability to address the aforementioned research questions to focus on nurses’ experience and perceptions while constructing this knowledge in the natural setting of the research participants (Thorne, 2016). Interpretive description as a research approach focuses on investigating and interpreting practical issues in clinical settings; it is located within a constructivist epistemological paradigm, a critical feature of applied research increasingly being used in nursing research where knowledge is considered to be socially constructed and the knower and the known are inseparable, and the findings are thus created (Appleton & King, 1997). This will be further described in Chapter 3. Interpretive description is based on the perspective that knowledge is constructed within the research context; the research participants and the researcher together create the ‘findings’ from their multiple subjective realities (Thorne). A constructivist epistemology and ID methodology are aligned with my practice-derived research questions to generate clinically relevant knowledge about nurses’ perceptions of their practice and influence on birth modes. Summary Though c-sections are a medical necessity in approximately 10% of births (WHO, 2015), it has become a mode of birth for more than a quarter of Canadian births (CIHI, 2021). The reasons for operative births are varied, and are the result of many intersecting contextual and interpersonal factors. One of these intersecting factors is the role of the care providers, in particular nurses. Nurses play a key role on labour and birth units throughout Canada (Evans et al, 2015), and likely influence decisions about labour and birth, and eventual outcomes. My intent for this research is to uncover and explain those influences from nurses’ perspectives 9 Chapter Two: Literature Review There is a paucity of research focusing on how – if at all – nurses impact the context within which c-section birth takes place. Of published research, there are no studies that I am aware of, to date, that focus on how the level of nurses’ professional experience may interface with their perceived influence over operative birth. There is also a scarce amount of literature that utilizes Canadian nurses and practices in their studies. There is a limited amount of research and literature about the role nurses play, from their perception, in caring for labouring people and shaping decision-making about the mode of birth, particularly in relation to their level of experience. In this literature review I will provide an overview and synthesis of literature that supports the need for the proposed study by discussing related factors. These include (1) factors that shape mode of birth, such as labour support from nurses. These studies help delineate potential influences on how nurses play a role; and (2) nursing practices relating to decisions about the mode of birth, as well as the nurses’ perspectives on that practice. Nurses Thoughts About Decisions on Mode of Birth Simpson and Lyndon (2017) conducted small focus groups to investigate how nurses thought they influenced their patient’s mode of birth. The nurses in the study were all experienced labour and birth nurses practicing in the United States, whom all happened to have at least five years of labour and birth experience, though it was not noted that this was a requirement to participate in the focus groups. These nurses agreed that they had influence over the mode of birth of their patients, and that they utilized multiple strategies to avoid c-section deliveries (Simpson & Lyndon). The strategies the nurses described focused on support for labouring people through the labour and birth process, advocating for patient wishes, and interactions between primary nurses and the physicians assigned to the patients. The study 10 limitations may have been related to the tendency for participants to influence each other’s responses using focus group method; nurses may have tended to respond in agreement with other participants since those who had opposing views may not have felt comfortable speaking up (Simpson & Lyndon). Despite the limitations of this method, this study highlights the importance of investigating the complex interplay of factors shaping nurse’s influence over the mode of birth to achieve the goal of reducing c-section rates. Edmonds and Jones (2013) interviewed thirteen nurses with ten or more years of labour and birth experience about their perception of the influence they held over mode of birth. Nurses spoke of the skills they used to bargain with physicians for more time before choosing operative deliveries for their patients. The nurses involved in this research also discussed that they had learned to “spin the information” given to the physicians to delay c-sections that they felt were unnecessary” (Edmonds & Jones, 2013, p. 8). These researchers highlight how labour and birth nurses of a certain level of expertise, (i.e., those with more than ten years) are aware of the communication skills they utilize to bargain with doctors and help patients avoid c-sections. This study did not contrast the experienced nurses with more novice nurses, but rather just focused on the expert nurses. Furthermore, Radin, Harmon, and Hanson (1993) examined the rates of c-sections for two different sets of nurses. The first set of nurses had the lowest rate of patients with intrapartum c-section; the other group had the highest rate. They found that the patient groups were not statistically different; the researchers concluded that the difference in c-section rates could not be accounted for in the two patient groups and remained an unnamed difference (Radin et al., 1993). The authors did, however, theorize that the difference in c-section rates could be potentially related to nurse’s intrapartum care. These conclusions highlight the need for further 11 research into how the dynamics of intrapartum nursing care influence patient outcomes like mode of birth, an area of study well established in other nursing care areas, termed nurse sensitive patient outcomes (Veldhuizen et al., 2021). Currently there are very few studies that focus on nurse sensitive outcomes relating to obstetrical care. One such study, by Pickens, (2014) attempted to establish a model for assessing nurse sensitive outcomes in perinatal care. This study focused on breastfeeding rates rather than birth mode. In addition, Lyndon, Rice Simpson, and Spetz (2017) explored nurse, patient, and physician perceptions of nursing care in labour and identified that nurses’ support and advocacy were of utmost importance to patient care. Lyndon et al. explained that their research showed strong support to explore patient c-section rates as a nurse-sensitive outcome, but note that framework needs to be developed to do so. This study aims to contribute to this gap in perinatal nursing knowledge. Nurses’ Perspective on Providing Care during Labour and Birth There is evidence that continuous labour support is beneficial to mothers and aides in facilitating vaginal birth (Evans et al, 2015). Because nurses have the greatest proximity to laboring people, they most often provide that continuous support (Edmonds, et al., 2016). With respect to nurses’ perspectives, Sleutal, Schultz, and Wyble (2007) report perinatal nurses’ views on their care and support for intrapartum patients. They found that nurses experienced a wide array of emotions and feelings about the care they were able to provide, and had strong emotions towards their coworkers, both nurses and physicians. The researchers found that nurses’ interactions as well as their attitudes impacted the quality of care they provided, although they did not discuss nurses influence on mode of birth directly. The more experienced nurses in Sleutal et al. also commented that they felt the novice nurses were inadequate in some of their care; veteran nurses believed their junior colleagues lack of experience manifested in not 12 knowing how to support a labouring woman. This was interpreted by the experienced nurses as arising from a lack of the junior staff learning these skills in their baccalaureate education. The researchers noted that the less experienced nurses may feel pressure to conform to more traditional standards of care like having a patient labour in the bed rather than standing; or feeling that they need to prove themselves before branching out and providing care that was considered outside of the norm. These findings illustrate the importance of the proposed study to look deeper into nurses’ perceived influence over mode of birth. Further, the findings underscore the need to study nurse’ level of experience and impact on birthing outcomes. Nurses Ways of Thinking About Birth Regan and Liaschenko (2007) conducted a study to assess nurses’ ways of thinking about birth, where nurses were given an actual picture of a labouring woman to contemplate and describe. The authors found that these nurses could be divided into three groups after viewing and describing the picture; birth as a normal process (BNP), birth as a lingering risk (BLR), and birth as a risky process (BRP). They found that the three groups of nurses varied in their opinions of the patients’ innate capacity to naturally birth, where the BNP’s believed in a woman’s instinctive ability, and the BRP’s did not. They explained great variance in nurses’ opinions on birth, however researchers did not explain or investigate why the nurses’ opinions varied. They did not explain the variables that were similar or different in each group, such as age or years of experience. The link of these attitudes about birthing to their behaviour with birthing persons or the number of types of mode of birth were not calculated. This study highlights differences in nursing perspectives and views on labour, particularly surrounding the natural, physiological process of birth. Understanding why nurses have these varying views, how they perceive and understand their perspective for their influence on the decisions made about birth for labouring 13 patients and the birthing process are critical for perinatal nursing knowledge that optimizes care during birth. Conclusion While a paucity of literature exists on the direct impact nurses have over patient’s mode of birth, from nurses’ perceptions, there are studies confirming that nurses’ views of birth vary and these views likely shape how they engage with and care for labouring patients, as well as how they influence the care that precedes decision about mode of birth For example, if nurses view birth as a risky process, it could be more likely they will support medical interventions during birth, such as c-section. The few studies that do exist underscore how experienced nurses may perceive themselves to have a greater awareness of the skills needed to support labouring people who are having a vaginal birth, and that these nurses possess varying skills they use to help patients have a birth with fewer interventions. There is a gap in knowledge, however, about how expertise and experiences impact those skills and support strategies that shape decisions by the healthcare team, and birthing people and their supports. The results of this study will contribute literature and knowledge to educate and support nurses engaged in supporting decision-making about mode of birth; the ultimate goal being to contribute to efforts to reduce c-section rates in the absence of medical necessity to reduce maternal-infant morbidity and mortality. 14 Chapter Three: Methodology Interpretive Description (ID) is a form of applied research developed to investigate and interpret practical issues in clinical settings (Palmer, 2004; Thorne, 2016). Thorne underscores that truth involves co-construction of meaning between the researcher and the research participants, who together create the truth from multiple subjective realities. As a qualitative exploratory approach, ID is rooted in the constructivist-interpretivist paradigm. Within this paradigm, the researcher participates in active learning, interpreting, and constructing representations and reality by combining their own knowledge and experience with that of the research participants (Thorne, Appleton & King, 1997). Constructivist paradigms recognizes that it is hard to find single, definitive explanations for phenomena, and as such Interpretive description focuses on pragmatism. A pragmatic method of research focuses on outcomes and consequences and recognizes that there are many different ways to interpret the phenomenon being studied, and understanding that multiple viewpoints and realities are possible (Creswell, 2013; Thorne). Benefits of ID also include allowing researchers more freedom to follow procedures that best meet their needs and the needs of the research project and participants and gain new practical insight (Thorne). Interpretive Description and Constructivist Epistemology Subjective and experiential knowledge are important in ID as they are fundamental to gaining insight into practice settings (Thorne, 2016). ID recognizes that human experiences and realities are diverse; people construct meaning in ways that are unique despite experiencing similar events (Thorne, Appleton & King, 1997). The researcher undertakes a study placing value on subjective commonalities and differences of the participants, and “acknowledge(s) an 15 inseparable interaction between the knower and the known, such that the inquirer and the object of that inquiry influence one another in the production of the research outcomes” (Thorne, p. 82). Because ID derives its origins through applied knowledge for nursing practice, this approach is ideally suited for this research project. This research approach focuses on clinically applicable questions, with insight and application in practical settings, allowing the researcher to take the new knowledge and insight back into practice (Thorne). This approach is well aligned with this study wherein the aim was to develop understanding about perception of nurses for their potential role in operative births and c-section rates, while also inquiring into how their level of experience may be influential. ID is flexible in its application; the interpretive aim aligns with the constructivist epistemological ground of this study. The constructivist and pragmatist epistemological basis of the selected ID research methodology was critical for acknowledging during data collection and analysis the ways in which meaning, individual realities and truths are co-constructed between the participants and the researcher. Seeing knowledge as constructed in each moment of the study was an inductive and imaginative process. As the analysis proceeded, I was then able to be led by the data itself, knowing that the findings would be a synthesis of both my own and participants interpretations and meanings created as they shared their perceptions. This approach had both structure and freedom which as helpful as a novice researcher. Participant recruitment and sample Thorne (2016) explains that recruitment of study participants is usually undertaken where the clinical issue arises. With that in mind, participants were recruited from the labour and birth units in hospitals across Saskatchewan (SK). An email was sent to the educator and nurse manager of these units explaining the research study and requesting that they forward the email on to their staff. This email included an explanation of the study, an invitation to participate, and 16 an email address to contact the researcher with questions or interest. Institutional review from the University of British Columbia and the participating SK health authorities were undertaken, and ethical approvals were received. The sampling approach was a convenience sample, with the goal of interviewing eight to ten nurses with a wide range of years of experience in labour and birth. This sample size provided variance within the levels of experience; a larger sample variability and size was beyond the scope of this master’s thesis. Inclusion Criteria The inclusion criteria for the study were: being an actively practicing registered nurse on a labour and birth unit, English speaking, and an ability and willingness for an interview on the topic of their personal nursing care of labouring patients. The recruitment sites employed hundreds of nurses, thereby confirming that a sample size of up to ten was feasible to recruit. Guided by the research questions, I recruited nurses with various levels of perinatal expertise, from novice, new nurses (< 5 years) to those more with labour and birth expertise (> 5 years) (Benner, 2001). To do this, the recruitment email stated that nurses from various levels of expertise were sought. Nine nurses who contacted the researcher met the inclusion criteria and were invited to participate. Data Collection Methods Individual semi-structured interviews were conducted by the researcher and was the method of data collection for this study (See Appendix 1). These interviews ranged from 20-40minutes in length; and all interviewees were asked the same nine questions which then led to individualized follow-up questions that varied for each participant. Research interviews allowed 17 the researcher to sit face-to-face with each participant, ask questions, and allow for reflection and thoughtful responses from both the participants and the researcher. Variation of years of nursing experience within labour and birth was pursued within the sample of nine participants to achieve practical and meaningful results to answer the research questions. Reflective journaling was part of the researcher process during the entirety of this research including the interviewing process, audio-recording was utilized, and follow-up exploratory questions were posed for deeper insights during each interview. Thorne (2016) notes the importance of the researcher situating themself within the data collection and analysis process. Thorne encourages journaling about the process that the researcher is going through, and any transformations in assumptions that ensue. She notes that journaling needs to take place prior to data collection and be carried out all the way through the study until it reaches its conclusion. She also notes that it is important to explain beliefs and motivations surrounding the research to the research participants (Thorne). With this in mind, I began a journal which was initiated while writing the proposal for the research project and continued until the thesis was completed. If asked about my motivation for the study by participants, and only following the interview I would share the overall impetus for the study being to conduct research that may contribute to decreasing operative births. I was aware that this original aim could have influenced participant data if shared as the aim of the study; therein I worked throughout the study to carefully and critically reflect upon and situate my professional experiences, motivations and assumptions underpinning the overall study and for their potential influence requiring reflexive analysis during construction of the findings. 18 Data analysis Thorne (2016) recommends data collection and analysis happen simultaneously, and that the researcher engages in constant comparative analysis. With this method, the researcher continually compares newly collected data to the data already analyzed, assessing for the need for more data collection (Creswell, 2013). Thorne notes that when studying the phenomenon through the collection of data: …you start with the assumption that at least some of the aspects of the reality that you are studying are socially constructed; therefore, to uncover knowledge about those constructions you will want to compare and contrast different kinds of manifestations of them. (p. 109) In planning for this type of data collection and analysis, Thorne (2016) notes that the researcher needs to be continuously reflecting on their own ideals and assumptions about the topic, ensuring they are not biasing what they see and hear. I needed to ensure that the questions asked were not leading the participants to give answers that they thought I wanted to hear; this could mean that my assumptions about the topic were attempting to shape the interviewees responses. I ensured I used open-ended questions and asked for clarification of answers when needed. Thorne explains that stepping out of the role of a nurse and into the role of a researcher is most likely not entirely possible but attempting to do so is important. She explains that attempting to ‘bifurcate the interview’, where one gathers the research data first before addressing any issues that come up as a practitioner, is one way to attempt to deal with this issue. I aimed to practice these skills in this study, and utilized reflective journaling and discussions with my advisor, where I consistently shed light on my assumptions, and circled back to how they may bias my thoughts. I consistently and deliberately made efforts to stay true to what the 19 participants said, rather than what I hoped they would say. Thorne suggests, and I integrated, consistent use of a reflective journal. In ID, journaling and reflecting is reflexive in that the researcher records how and why decisions surrounding the study are made, as well as how reflection on their own values and beliefs within the research itself are brought forth (Lincoln & Guba, 1985; Thorne). Journaling, in this study, was essential to the process of inductive analysis. Analyzing and Composing the Data Thorne (2016) explains that taking guidance from grounded theory methodologies, and using open coding, axial coding, and then selective coding, enables the researcher to build a “coherent theoretical position that explains variation within the phenomenon” (p. 160). In ID, it is suggested that rather than trying to structure the data into rigid codes that may prematurely reify it, the researcher should first categorize the data with meaningful labels to create categories (Thorne). Thorne explains that this will aid in bringing together similar ideas without being too locked into a meaning that has been assumed a priori by the researcher. Guided by Thorne, I focused on coming to know the data, and working with it, organizing, coding, and analyzing it to make sense of the relationships the codes may have within themselves and with other codes or themes. During each interview, I took detailed notes of the participants answers as well as non-verbal cues. Immediately following each interview, I reviewed my notes, and considered codes and themes that emerged from the interviews. I wrote and reflected on these in my journal. Once all of the interviews were transcribed, I then coded each one. Once the data was gathered and coded, I could see the many ways to bring it together, and many different relationships and associations that could be made. At this point, I did a second read through, and began to divide the codes into themes. Thorne explains that the role of the researcher at this stage is to see these 20 various possibilities and conceive the best options to become the most meaningful set of findings from what is available. The original themes that emerged evolved over time, for example, the theme “c-sections called for non-medical/non-convincing reasons” changed to “Nurses erasure of power and influence over birth mode”. I continued to construct meaningful findings by reflecting on the original purpose of and questions guiding the study and then utilized my own disciplinary scaffolding to stay on track during data analysis. As Thorne states: By remembering that you began with a very real purpose, and that you have designed a study to meet a particular need in the body of a\practical or applied understanding, your data analysis will feel less like wandering in the desert and more like you are always within sight of a well-marked logic trail. (p. 165) After careful analysis, considering relationships, patterns, and using inductive reasoning, I was able to “…move closer to something that could constitute findings” (Thorne, p. 181). Interpretive description considers findings to be the interpretation, or the understanding of the researcher, having processed the data separately and together into a form of knowing that was not available prior to the study (Thorne). As the researcher I configured and sequenced the data into sub-themes and then larger themes, to allow this new knowing to emerge. The intent of this research project was to bring together the subjective perceptions and knowledge of labour and birth nurses with varying levels of experience, to generate an interpretive description of nurse’s perceived influence on intrapartum c-sections. These findings could then contribute to understanding that leads to clinical understanding of the phenomenon and give rise to knowledge and concepts that can effect change in reducing the c-section rate. 21 Ethical Considerations Careful consideration and though was given to ethics during this research study, as is required for any research conducted with human subjects (Creswell, 2013). I carefully assessed whether any harm could come to the research participants, and how that might be mitigated. In this study, there were no identified negative effects or perceived harms experienced by participants. Each potential participant was fully informed of the study purpose and intent, and they were given the option to consent to participate. I obtained human research ethics board approval from the behavioral review committees at the University of British Columbia (UBC), as well as the health authority for the hospitals from which participants were recruited. Researcher Reflexivity Within qualitative research, the researcher needs to be aware of how their past experiences and assumptions can influence data analysis and interpretation; therefore, the qualitative researcher aims to be continually reflexive about the potential influence of their experiences, values and biases through maintaining reflexive notes and by making transparent and conscious such influences – rather than trying to ‘eliminate’ or ‘control’ that one’s personal experiences can create (e.g. bias) (Creswell, 2013). For example, I am a labour and birth nurse with 11 years of experience in this area, practicing at an expert level of experience when using Benner’s (2001) framework. The focus of this study emerged from my experience in the labour and birth clinical setting wherein I noted a rise in invasive procedures and operative births. This spurred me to question why this was happening, and how nurses may or may not contribute to the rise in operative births. In the past, I experienced, first-hand, how nurses work to influence their patients to not have a c-section, utilizing their skills in hands-on care, but also utilizing their interpersonal skills with patients and medical staff. At the outset of this thesis, I held the 22 assumption that nurses have the ability to increase a patient’s chances of having a vaginal birth based on the care they provide and their interactions with the care team. Knowing this, it was important that I did not alter the data or hold this bias during analysis of the data to confirm any pre-existing assumptions. It is important that I relay the data provided by the study participants in the way they intended to share it, to be led by the data rather than my own interpretive goals. Also, as noted above, reflective journaling through this process was essential to this reflexive process, ensuring I was not biasing the data analysis. Through the journaling process, I began to write about and reflect on the fact that nurses seemed to be more concerned about how their patients perceived the nurse’s commitment to being non-judgmental and empowerment, rather than actual mode of birth. Research Rigour Research rigour refers to the strictness that a researcher adheres to when ensuring trustworthiness and reliability of the findings (LoBiondo-Wood & Haber, 2013). Thorne (2016) explains how important it is that qualitative researchers within the practice context ensure that all claims made within their research are clearly and logically probed and assessed as credible. Thorne notes that at times, “our findings may well be taken up in the practice context even without the benefit of what other scientists consider essential testing” (pg. 112). Thorne goes on to explain that even small practical research studies can lead to practice change in certain circumstances, when the resonate with clinicians, and have to potential to lead to unconscious practice adjustments. Due to this, Thorne cautions that applied researchers from the healthcare field need to “position their inquiries in relation to an additional set of ideal criteria associated with their disciplinary orientation, including moral defensibility, disciplinary relevance, 23 pragmatic obligation, contextual awareness, and probably truth” (Thorne, 1997, as cited on pg 113, Thorne, 2016) Lincoln and Guba (1995) explain that trustworthiness of a research study is important and enables others to evaluate the study’s value. They explain that there are four parts to research rigour: credibility, transferability, dependability, and conformability (Lincoln & Guba). Applying these concepts to this study, I brough the transcriptions to the participants for reflection and member checking, to construct the rigor necessary for credibility (Lincoln & Guba). This check-in was done via email, once the individual interviews had been transcribed. Of the 9 participants, 4 responded back. All of these respondents stated agreement with the transcripts. This check-in also aided in confirmability, where the research participants confirmed the transcripts were correct, and were given the opportunity to ask questions or clarify issues they might have found. Member checking is a method of establishing credibility and triangulation, as explained by Lincoln and Guba. As the researcher, I also developed a “thick description”, in which rich detail and context was sought, to aid in relevant transferability (Lincoln & Guba, p.124-125). This entailed taking detailed notes about each research participant’s responses to questions, as well as their reactions and non-verbal language. As Thorne recommends, I reflected and explored the relationships I noticed among the data, and assessed its relationship to the disciplinary assumptions and expectations that brought about the research questions and project originally. This allowed me to see what elements and relationships required further thought and analysis which contributed to the study’s dependability. Conclusion Guided by an Interpretive Description approach, I inquired into the perceptions labour and birth nurses have about their care and influence over intrapartum c-sections. Interviews were 24 conducted with nine registered nurses of varying levels of experience to gain understanding and guide nursing practice into the future. Understanding how nurses think they influence a woman’s mode of birth, and how nurses’ perceptions change over the years of care can contribute to knowledge that can better equip nurses and nurse educators to teach and mentor new nurses in labour and birth care. 25 Chapter Four: Findings In this Interpretive Description (ID) study, I explored how nurses perceive their influence during the intrapartum period on birth mode as well as how the level of experience as a labour and birth nurse may influence their care with these patients. The study sample included nine nurses whose professional perinatal experience as a nurse ranged from 5 months to 37 years. All of these nurses identified as female, and they all working on a labour and birthing hospital unit. A reflective journal was kept throughout this process, from the initial interviews until the analysis was completed. Fields notes were integrated into the analysis of participants’ data. Contexts of Influences: Intersecting Impact on Mode of Birth I identified 3 intersecting contexts that the participants perceived influenced their labour and birth care and birth outcomes: societal context, practice context, and interpersonal context (See Figure 1). While these 3 contexts were evident in the data, they were not mutually exclusive. The social, clinical practice, and interpersonal contexts of labour and birthing care intersected to some degree, where social discourse, for example, was evident within the interpersonal context of nurses supporting birthing peoples’ agency and personal birth mode decisions. All participants indicated the impact of societal, practice, and interpersonal contexts as influencing labouring and birth mode. Each participant spoke to these intersecting contexts and their interplay when highlighting their work to navigate these influences on their practice. No single context alone was more influential, although the nuances were expressed differently across the participant data. This is represented visually in Figure 1. 26 Figure 1: Participants perceptions of intersecting contexts3 3 Upon reflection, the way in which the data was assessed resembles a social ecological model. This was not the theoretical model utilized in this research; however, it may be appropriate to approach the data using this type of framework in future research. Social Context(macrosystem)- Erasure of power-Non-judgemental care-Holistic approachTeam & Practice Context(mesosystem) - Unit constraints and patient load- Medicalization of birth- Autonomy and ConsentInterpersonal context (microsystem)- Influence on birth room atmosphere- Nursing as an artNU RSES N AVIGATE INBETWEEN 27 Societal Context The primary societal discourse referenced referred to social messaging about natural and operative births and dominant influences on women4’s choices and decision-making about birth. Participants within this context described upholding nursing values of autonomy and informed consent in relation to women’s right to choose their birth mode, while enacting a non-judgmental role in supporting their decision-making. Participants referenced medicalization of birth when noting how interventions are commonplace and often go unquestioned in ways that may result in an operative birth. Nurses Questioning the Meaning of Natural The participants questioned the dominant social message that there is something inherently wrong with giving birth by c-section. When probed, almost all participants indicated that a vaginal birth would technically or medically be preferred over an operative birth, but they quickly followed that view with the important point that they would not judge someone by virtue of having a c-section. To illustrate, seven out of nine nurses interviewed explained that they felt the route of birth did not matter. During an interview, one nurse noted “I think that they are just two ways of accomplishing the same goal.” (P01, April, 2019). When asked what they thought a natural birth was, three nurses said that there is basically no such thing as a natural birth, with 4 Throughout this thesis, gender-neutral terms and pronouns are used, however the choice of using the word woman here is a purposeful one, given that the societal discourse being discussed by the participants surrounded that of women, and how those people that identify as women are affected and treated by the various factors at play. 28 one nurse stating, “What even is natural?” (P05, personal communication, June, 2019), while three more stated that regardless of how a baby is born, it is all natural. Participant 04 (personal communication, May, 2019) explained “… vaginal birth or cesarian birth, I feel like both are natural ways for an individual to give birth”. The discussion of a natural birth went further for several participants. Two nurses explained that a healthy baby should be the goal, and one of these nurses amended that comment to say that a healthy mom is also important. “Well, I think it [the goal] is to have a healthy, happy baby, so whatever that looks like, whether by vaginal birth or cesarian section doesn’t matter” (P09, personal communication, December, 2019). Within this discussion, nurses explained that the mode of birth should not matter to them as the nurse. When probing further, these nurses explained that they are there as helpers, or guides, and that they should in no way be seen as caring about or judging the way in which a labouring person gives birth to their newborn. Participant 04 said “… there is nothing to say that we [healthcare providers] should lay judgment on a person just because they chose to have a cesarean.” In the interviews where participants expressed this view, I probed further to asked if they felt that one type of birth, in their view, is preferred over another: in particular, asking if a vaginal birth ought to be the goal. Two of the nine nurses interviewed expressed outright that they did not feel that a vaginal birth need be the goal in their practice, and three more explained that, when possible, a vaginal birth is good but is not the top priority. These three nurses gave the notion significant thought before they explained their view that since a c-section is a major open abdominal surgery they would imagine a vaginal birth would be preferred in an ideal setting. One nurse noted, “I think ultimately, how a woman chooses to give birth is her own… whatever she wants to do, it’s her body, we are just here to 29 facilitate that.” (P06, October, 2019). This demonstrated how the participants thought that patient’s choices about birth are important to uphold. The societal influence in relation to people’s choice in their birth mode was a strong driver in the participants nursing care. The nurses interviewed felt that one type of birth was no better or worse than the other. This was an important narrative that threaded through all the interviews. The participants did not want to delineate operative birth as worse or less optimal than vaginal birth, which translated to nurses not perceiving a strong influence over the actual mode of birth. Where the nurses did feel they have influence, however, was in shaping the overall atmosphere in the birthing room to ensure that, whatever the mode of birth, the birthing person felt satisfied with the outcome. Prioritizing Non-judgmental Care The nurses discussed the importance of being nonjudgmental as to the patient’s birth mode within the context of social messaging about women’s mode of birth “choices”; they indicated the importance of their role in being non-judgmental when providing labour care. The nurses spoke about their influence, not in terms of physical outcome, but rather in terms of overall mood and birth giver’s perception and overall satisfaction with their experience during labour and birth. This was directly discussed by four nurses, and indirectly by two more. They explained that they did not want their patients to feel that they were judged by anyone of broader society relative their baby’s birth. When one participant was asked about general societal pressure to have a vaginal birth, they stated “Yes, I think so… Society makes it [pressure to birth vaginally] a thing” (P05, June, 2019). Eight out of the nine participants explained that they felt society viewed vaginal deliveries as better or more desirable than operative deliveries, with two of those nurses going so far as to say that society made women feel as though they were a failure 30 if they had a c-section. One nurse, when discussing a particular c-section birth said, “But I think she felt like a failure, like her body wasn’t meant to do it” (P07, October, 2019). Another nurse stated “I think we sometimes make moms feel like a failure because they had to have a c-section… I think society has made [vaginal birth] preferable over the other… I don’t think it’s right that we have done that.” (P02, April, 2019). This practice, where the participants focused on not judging how people give birth and resisting that there is one best mode reflects social messaging about the importance of empowering choice for individuals giving birth Practice Context The dominant social discourse about empowering women’s choices was also noteworthy for how it contrasted with the power of medical authority over birth mode described by the participants. These power relations were referenced as influential for shaping the intrapartum practice environment. Almost all the nurses interviewed spoke to how, ultimately, the obstetrician, who would perform the surgery, made the final decision about an operative delivery; thus, the nurses perceived that a labouring and birthing patient in essence does not have a choice at all. This also reflects the degree to which nurses were positioned as exerting minimal influence. This hierarchical and paternalistic structural context of birth mode decisions runs counter to the empowerment discourse that participants referenced as the broader societal context. These colliding contexts of influence will be further discussed for their importance in the following chapter. Nurses on the Periphery of Decision Making When discussing c-sections and how decisions for an operative birth are made, eight out of nine nurses noted that, ultimately, the obstetrician is the one who makes that call. When 31 discussing decision making in relation to birth mode, P03 (May, 2019) stated “… we [nurses] don’t get to make that decision, that’s always the physician, but I do think it should be made in a multi-disciplinary sort of discussion…”. This nurse, and two others (P02, April, 2019 & P09, December, 2019) specifically highlighted the lack of interprofessional collaboration when it comes to decisions relating to birth mode in specific patient situations, and that such communication with the patient and the nursing staff is critical and should take place whenever possible. The perceived lack of this teamwork and communication was noted by eight of the nurses as being a contributing factor to non-medically indicated c-sections. One nurse, when asked if collaboration was lacking on the labour unit where she currently works stated: “Yes, definitely you are the nurse, they are the doctor, know your role, kind of thing.” (P09). This nurse went on to discuss why this lack of collaborative discussion was a negative thing, “… we all come with different knowledge, and I think if we listen to each other, we could probably have better outcomes for our patients.” In terms of physicians being the ultimate decision-makers, the same eight nurses noted that they witnessed doctors making questionable diagnoses of intrapartum patients needing a c-section. Three of these nurses referred to the fee for service payment of doctors as a potential motivator for doctors to perform more procedures, and thus bill for more procedures. “There are some obstetricians that will sit on something that’s a little bit bad until after midnight so that billing is a little bit more…” (P08, October, 2019). This same nurse referred to the fact that obstetrics is a highly litigious area of medicine; as such, obstetricians may think they are more likely to avoid a lawsuit by preforming a c-section, even if the clinical picture does not completely warrant one. Participants 02, 03, and 06 (October, 2019) noted that they thought that informed consent was not always obtained for c-sections and other procedures during labour and 32 birth. P02 noted “We do not have informed consent… I think it’s mostly lacking with physician care.” These three participants further explained that while a consent form would be signed prior to a procedure, they perceived that the patient may not always be fully informed by the physician to make a well-justified decision. “I think true informed consent is not always obtained properly… they [patients] should be given both sides to the argument, all the facts involved, and be able to make a choice without pressure.” (P03). The nurses in the study indicated that this hierarchy and power relations created the context in which significant ethical issues arise, to be discussed more fully in the following chapter. Medical Decisions Constrained by Workload Nurses discussed their perception that their work environment was constrained by unit demands. Unit demands included increased patient censuses and increased acuity of patients, which were constrained by high workload and at times, lack a qualified staff. These constraints affected the care they provided or the time and patience that was sometimes lacking during labour, which they understood as leading to an operative birth. Eight out of the nine nurses interviewed discussed the fact that, at times, c-sections were performed for non-urgent or even non-medical reasons. P02 (April, 2019) stated that “… sometimes it’s [cesarian section] done for the convenience of the doctor, and lots of times for the convenience of the unit.” Five nurses noted that conditions on the unit would dictate surgical births. One nurse recounted an experience where the unit had called in extra staff to perform an emergent c-section on one person; at the same time, it was decided to perform a c-section on another patient that was possibly going to need one later, because they had the staff available at that time (P02). Another participant discussed the fact that if the unit was busy, they perceived that several of the obstetricians they worked with would be more likely to preform c-sections that were not 33 necessary (P08, personal communication, October, 2019). These nurses noted that one operative delivery seemed to lead to another due to unit level resources, including timing, staffing and workload efficiency. Interpersonal Context Nurses as Influencers of Birth Mode All nurses interviewed were asked whether they felt they had influence over a patient’s mode of birth. Nurses with more labour and birth experience perceived they had a significant influence, and they believed this to be a positive aspect of their care. Asking whether participants felt they had influence over mode of birth was informed by Benner’s (2001) work outlining how nurses move from novice to expert. In this study, when less-experienced nurses were asked if they felt they had influence over a patient’s birth mode, they were cautious to agree; one of the nurses explicitly said she hoped she did not (P05, June, 2019). Five nurses, all of whom had > 9 year of experience in labour and birth nursing stated they felt that while they did not judge birth mode, they did have some influence over their patient’s labour and possibly their eventual birth mode, which contrasted with nurses with less experience who felt they did not have an impact on birth mode at all. While these experienced nurses understood that ultimately if a c-section was going to be chosen by the obstetrician as the mode of birth, they felt they could not reverse that decision; they expressed an ability to affect change on the patient’s labour before they got to the point of needing a c-section. When discussing their influence on labouring patients, P03 (May, 2019) stated “I think yes [I have influence over birth modes] whether intentionally or not… I think in everything in life, words have influence, we can influence choices that people make.” Three nurses, who had fifteen or more years of experience with this practice area perceived they had significant impact over their patients and their birth 34 mode outcomes. One of these nurses explained that they felt they had a major impact on their patient’s achieving a vaginal birth, by including their mind, body, and spirit throughout their patient care in the labouring process and using words of affirmation to instill confidence in the labouring patient (P04, May, 2019). Six of the nurses indicated they do have influence over the patient’s mindset, or the atmosphere in the labour and birthing room. Eight of the nurses interviewed explained that they felt the labouring person’s mindset played a large factor into how they experienced labour, and their mode of birth. Nurses’ Need a Passion for Birth Many nurses explained that to be an effective labour and birth nurse, and help patients achieve the birth they desire, one needs to have a strong passion and drive for learning the art of nursing in this area. One of the participants stated “I really think that you [nurses working in this area] need to have a passion for obstetrics. [If they do not] They should move on.” (P02, April, 2019). They noted that these types of skills did not come from formal education or orientation, but rather from watching and learning from more senior colleagues. P02 went on to discuss that there is a misconception that labour and birth nursing is about “catching babies” when in actuality it is a very physically and mentally demanding job that requires knowledge of the physiology and psychology of the birthing process. When P08 was asked where she felt her expertise and skills in this area came from, she said, “my senior nurses… That’s the bulk of my knowledge, it came from the senior nurses that I watched, that I listened to, that I heard.” (P08, October, 2019). Three other nurses who had nine or more years of experience, echoed this sentiment, explaining that nursing care in this specialty needs to be passed down from senior nurses to more junior nurses. 35 Two nurses discussed that nursing was an artform, with one stating, “I think the artform of a labour and birth nurse in particular is learned on the floor. Just being present with older nurses… lots of different births… that’s how I feel the art is built in a person.” (P09, December, 2019). This nurse went on to discuss that in the current state of the unit she worked on, this comradery and mentoring no longer took place regularly due to sheer patient volume and lack of nurses. When asked if mentoring was a priority, P09 stated “No”. When asked what the priority is, this nurse went on to say “Surviving. Like, getting patients and babies out alive. Survival mode. That’s what I think they are in right now.” This feeling of being rushed, or lack of time to work together as a team was echoed by six other nurses. Conclusion Taken together, these findings highlight the ways in which these nurses perceived that they influenced their patient’s mindset surrounding birth, and how that then possibly influenced the ultimate mode of birth. The nurses navigated the in-between spaces of patient advocacy, empowerment, and being an interprofessional team member. The participants’ commentaries highlighted their strong belief that birthers should not feel shame or guilt if an operative birth is their mode of birth. They perceived that they did not ultimately make the final decision about patient’s mode of birth but aimed to empower their labouring and birthing patients by encouraging a positive atmosphere in the labour room, which could possibly influence the type of birth, and certainly help their patient feel at peace with their ultimate birth outcomes. They also explained how the art of labour and birth nursing is an important aspect of the care that is provided, and that this is something that can’t really be taught in school, but rather is passed down from senior nurses to the more junior ones. According to the nurses, the medical staff held the most power over mode of birth decision, which was not always desirable. The nurses 36 interviewed explained that having more interprofessional discussions and collaboration surrounding birthing choices may lead to more satisfying mode of birth outcomes for patients. 37 Chapter Five: Discussion and Recommendations Societal Discourse With the context of social discourse of empowering birthing women, it has been argued that nurses may have lost sight of the health risk associated with an open-abdominal surgical procedure and the increased morbidity and mortality for mothers and infants during the immediate postpartum phase (Morrison, Rennie & Milton, 1995; Silver, 2012; WHO, 2015). The findings of this study indicate that nurses work against being paternalistic, which indicates they potentially align with the social discourse regarding empowering women and birthing choice to a greater degree than influencing their medical decisions. When asked to describe a natural birth, the nurses suggested there was basically no such thing; they felt that regardless of how a baby is born, all birth is natural. These beliefs align with participants views that empowering choice is important for supporting women’s agency and autonomy, and especially choice over their body. As Malacrida and Boulton (2012) noted in their exploration of women’s perceptions of childbirth, there are competing discourses of motherhood, sexuality, and selflessness that impact women’s experiences and decision-making within during pregnancy and birth. The participants, who all identify as women and as nurses, are also influenced by societal discourse wherein these tensions were identified. On one hand, nurses’ draw upon evidence-based knowledge from obstetrical studies about c-section births and increased risks for mother and newborn. However, on the other hand, as women, they also value bodily autonomy, thereby resisting the judgment and scrutiny that comes with any dominant gendered societal norms that can and do disempower women. These tensions are influential in how participants viewed their patients and how they provide them with care. Bryant et al. (2007) point to how birth discourse promotes “free” choice for women as self-governing beings while 38 simultaneously indicating c-sections as potentially being the preferred mode of birth. While none of the participants in my research study went so far as to indicate they favoured c-sections over vaginal births, they gave a prevailing sense that c-sections were not just a last resort, or something to try to avoid at all costs. The participants did not promote or dissuade c-sections birth – they took a value-neutral stance on birth mode in favour of promoting autonomy and aligning with empowerment and choice discourse. All but one of the nurses interviewed perceived that dominant societal discourse had ideological power that promotes vaginal deliveries over operative deliveries; two of those nurses went to so far as to say that societal pressure means that some women feel as though they are failure if they had a c-section. Crossley (2007) explains that there is a tension between the idealistic expectations of a ‘natural birth’, and the medicalized birthing reality of hospital birth, where most birthing people give birth in North America. Crossley adds that this tension can lead to negative emotional consequences for birthing people. Perhaps, the nurses interviewed sense this, and thought that since birth in the hospital has been medicalized, their role included tempering patients experiences of this tension postpartum. The findings surface how many of the participants were very concerned with the way they were viewed by their patients, and they did not want to be seen to be judging their patients. This aim to be non-judgmental was described as a greater priority than considering their influence over birth mode, even with empirical evidence of increased morbidity for mothers and newborns associated with c-sections. Practice Context The participants spoke of the importance of interprofessional communication when there is a birth via a cesarian section. Similarly, Wise and Jolles (2019) emphasized that interprofessional communication is critical to providing comprehensive caring for labouring 39 patients. These authors claim that interprofessional huddles, along with implementing best practice checklists for labouring patients, resulted in significantly less intrapartum c-sections in one community hospital. Provost et al. (2015) note that healthcare huddles, or interprofessional team discussions, have resulted in improved patient safety as well as strengthening relationships within the healthcare team. The participants in this study explained that there was a lack of interprofessional teamwork, indicating how the hierarchical and paternalistic nature of their practice made advocating for intrapartum patients difficult (P02, April, 2019; P07, October, 2019, & P09, December, 2019). This lack of collaboration among physicians and nurses meant the nurses in this study felt that their hands were tied, and that they did not often have a say in how a patient gave birth to their newborn. The nurses spoke how their lack of input was bound together with power relations between nurses and physicians which they understood as reducing their potential influence on their patient’s mode of birth. Some nurses discussed the perception that the obstetricians used a fear of litigation as a possible reason for preforming unneeded c-sections. This perception that a c-section is going to fix an impending problem or health related issue with the fetus was discussed in terms of a lack of true informed consent. Adinma (2016) explains that malpractice in obstetrics is on the rise globally, and notes that informed consent and treatment protocols are important in decreasing litigation within obstetrics. The nurses in this study indicated the importance of these procedure but referenced the lack of their implementation in their clinical context. The nurses perceived the lack of informed consent and treatment protocols as resulting in an increase in c-section births. The nurses in this study explained that they felt that c-section were at times preformed without fully informed consent, and for non-medical reasons and indicated their view that decision could, in fact, increase rather than decrease litigation. This lack of interprofessional collaboration 40 limited the degree to which the nurses felt could empower their birthing patients and positively influencing their baby’s birth. Interpersonal Context: Novice to Expert Patricia Benner (2001) explains that a nurse is considered an expert in their field once they have worked within that area for five years and achieved the requisite competencies that align with expert care. During this study, nurses were hesitant to see themselves as the experts in this area until they had many more than five years of clinical experience. In this study, the less experienced nurses felt hesitant to recognize their expertise and how their experience would benefit the patient. As Benner notes, as nurses move from novice to expert, they build their skills and capacity for providing higher levels of competent care (2001). Once the nurse has reached expert level, they are then able to share their skills and knowledge and have the analytical ability to problem solve in new situations (Benner). While Benner notes that it is generally five years of practice in an area to reach this expertise, participants in this study appeared to take longer to recognize expertise in themselves. In this study, it was the nurses with ten or more years of experience who were the ones who spoke freely about their expert knowledge and care. In turn, these nurses were more apt to acknowledge how their experience and knowledge may have a positive influence over a patient’s birth and birth outcomes. The findings related to experience level and perceived influence over birth mode are significant since nurses who feel they can positively influence a patient in their labour and birth experience may be more likely to advocate for patients. They are then better able to navigate the various contexts to carefully balance autonomy, societal messaging, power relations with the interprofessional team, and have the skills for collaborative practice that can promote optimal birth outcomes regardless of mode. 41 Strengths and Limitations Reflecting on the study from the perspective of being a novice researcher, I can see how my own inexperience with qualitative interviews influenced the depth of data collected. I, for the most part, stayed focused on the interview script and did not always follow the lead of participants to explore related but possibly tangential topics. Nor was I adept at asking thoughtful and timely follow-up questions due to a lack of confidence. I can see now, in retrospect, the data may have been richer had I asked more probing questions related to the nurses’ practice context and their perceptions of the power relations influencing birth mode. When taking reflexive notes throughout the data collection and analysis phases of this study, I would often think of questions after the interview that may have contributed to richer data. For example, during memoing, I reflected on how even the most seasoned nurses were adamant that they did not want to be seen as being judgmental of birth modes, and wondered the concept of a women’s right to choice and bodily autonomy was the most important aspect of care for these nurses. However, because this societal discourse was not the main concept on my mind at the outset of this research, I did not explore this very far with more probing questions. I did not feel comfortable deviating very far from the semi-structured interview guide and relied on the structure for data collection. While I acknowledge that more growth and confidence in interviewing skills is needed, I do know that I was able to generate findings to answer the research question guiding the study. Another challenge to the study was the need for me to maintain consistent, critical attention to my assumption that all labour and birth nurses would think that c-section births should be avoided when possible. I worked to be conscious of how this assumption may act to influence my analysis, and also acknowledged this was my professional experience and context from which I undertook the study. Being critically conscious of the influence of my assumption 42 was my reflexive commitment, while also recognizing the impossibility of removing bias from qualitative and engaged inquiry. It was my assumption when starting this research that all nurses working within maternal care would likely show some concern about the rate of c-section births and recognize high c-section rates as a systemic problem, possibly shaped by social and practice discourse. My assumptions were challenged as I listened to participants speak about this not always being the case. None of the nurses interviewed indicated that the number of c-section births on their unit were too high; however, I did not explicitly ask participants if they viewed high c-section rates to be problematic. In retrospect, this question could have added depth to the data. Yet, by not inserting my assumptions into the study, space was created for the participants to point to how dominant societal discourse influences how nurses perceive vaginal versus operative birth as equally good ways to birth a newborn. The data highlighted the role of this social discourse and how nurses navigate the in-betweens of their practice context and the interpersonal dynamics and medical hierarchy. A study on a larger scale sample may have yielded more diversity in ideas and more in-depth data. However, for a master’s thesis, n= 9 was appropriate. This study is a starting point, that can give rise to further research, rather than an end point to influence practice. With qualitative research, one dives deeply into the subjective truths and experiences of participants with the goal to yield rich data. While there may be limitations for transferability, this data has potential to motivate further inquiry and raise questions for intrapartum care, particularly in relation to how interprofessional collaboration brings about more positive birth outcomes. In summary, this exploratory ID study contributed to the groundwork for further research, as this was one of the first studies conducted to generate knowledge about how nurses perceive their influence on birth mode. 43 Finally, recruitment was a challenge in this study and may have contributed to the limitations. This lengthened the timeline and, at times, led me to question the legitimacy of this study and its importance that somewhat undermined my confidence. While recruitment was challenging, in the end I don’t believe it undermined the quality of the data which aimed to bring visibility of nurses’ work within the birthing context. Recommendations: Using the Findings to Bring About Positive Change Practice Recommendations Nurses providing labour and birthing care are uniquely placed to practice in the “in-betweens” spaces, working with patients, their family and support people, and the healthcare team at large. They are often the liaison between all these parties, working with and for everyone in tandem. They navigate the nuances of interpersonal and interprofessional work and are driven by societal discourses of women’s empowerment and autonomy within the context of pregnancy and birth. Nurses need to be valued for their insight, expertise, and input relating to patient outcomes. They are not neutral caregivers, they have influence on the patients they care for, in large part because of their close proximity to patients. As such, their practice should be studied and optimized. In the labour and birth practice setting, where nurses spend most of their time one-on-one with labouring patients, they need to be an active participant in decision-making about labour and birth care. Expertise in nursing practice is necessary for optimal birth outcomes and nurses need to be recognized for their ability to coordinate care that is patient-centered and collaborative to ensure quality care. 44 Policy Recommendations The nurses in this research study explained how they perceived they were rarely consulted during the decision-making process when it came to operative births. Research discussed above suggests that decisions made in an interprofessional way can lead to better outcomes for labouring patients and their newborns. Policy changes to reflect this need for interprofessional collaboration, and those that give nurses greater autonomy in decision making, are critical for increasing birthing peoples’ positive experiences. The practice recommendations above cannot be implemented without policy changes and leadership buy-in. These need to be synergistically linked, to ensure that nurses are supported from the top down, to practice to their full capacity, which includes being active members of the birthing decision making process. This change would entail an entire shift in the hierarchical structures and the culture of medical practice. This would go beyond simple policy changes and require the current policy and decision makers, who are usually physicians, to relinquish some control, and adopt a more collaborative model of care. Future Research Recommendations As discussed in the above chapters, there is an overall lack of research on this topic of nurses’ influence on modes of birth, and the wider context of nurses’ influence on labour and birth in general. Given that this is an understudied area, with the majority of research looking at other medical care providers, more research and knowledge on how nurses contribute to healthy and optimal birth is needed. This research project can point to more in-depth research assessing how nurses’ practice within the social, practice, and interpersonal contexts. For example, research could also be undertaken to assess the difference in expertise levels of labour and birth nurses, and how that knowledge is translated, garnered, and passed down to younger nurses. 45 Preforming this study on a larger scale, perhaps using a survey method for more mass data collection would be helpful to add to the body of knowledge surrounding nurses influence on birth modes and decision making. Also, using nurse sensitive patient outcomes to research labour and birth care is an area that could further this line of research. Education Recommendations Nursing education requires integrating the points made above relating to nurses’ roles in decision making and interprofessional collaboration. A goal within educational institutions should be to teach nursing students that they have a defined care role, and they have importance. Starting in the first year of nursing school, it is important that the role of a nurse as a care provider, and an important interprofessional team member is taught. Once in the upper years, perinatal nursing education needs to reflect how vital nurses are to patient outcomes, and how their expertise in liaising and collaborating with the healthcare team and the patient reflects better outcomes for birthing people (Provost et al., 2015, Wise and Jolles, 2019). It is also critical to teach nursing students how to become conscious of hierarchy and power relations, and how to navigate those relationships and teach nurses to assert their agency, voice, and authority in labour and birth care. Nurses need to be educated to understand how critical their expertise is as members of the interprofessional team. The curriculum in maternal health courses could be enhanced by understanding the importance of interpersonal skills and awareness on how nurses can positively influence patients and optimize positive social discourse. More active engagement in interprofessional learning environments may help to teach these practices and give nurses the confidence to engage with other professions within the hospital setting. 46 Conclusion In conclusion, this study contributes to knowledge about nurses and their interpretation on their influence on modes of birth and relationship to years in practice. While this study was undertaken with the goal of contributing to a reduction in cesarean sections, this study highlights and shows the everyday spaces within which nurses navigate and practice to support people giving birth. As noted in previous chapters, we know that cesarian births increase morbidity and mortality for both the birthing person and the infant and creates increased demands on the healthcare system. Yet, the nurses in this study navigated social, practice, and interprofessional contexts to ensure birthing people feel supported within their birth experience. The current societal discourse that surrounds women’s empowerment, which pushes for freedom of choice above all else, was highlighted in this study. The participants felt it a top priority to navigate this social discourse and ensure that birthing people felt fulfilled and happy with their birth, regardless of the mode. The findings highlight nurses’ perceptions of the need to navigate what they know to be evidence-based care with these societal pressures, and the nurses that participated in this study demonstrated how this can be hard at times. Nurses recognize the need for empowerment of the birthing person, as well as interprofessional collaboration as a cornerstone to quality care that is safe for mother and newborn and builds up the birther rather than making them feel less than or like they have no control. These nurses noted that their work is about ensuring that birth is within the domain of choice and control, and that the birther was healthy, safe, and content with their eventual birth outcomes. The nurses in this study expressed interprofessional and practice context struggles that often contributed to nurses and patients feeling like they had limited control and contribution to birth mode decisions. Within this context, nurses navigate this in-between space from the 47 medical team to the patient, and attempt to bridge that gap to ensure birthing patients feel autonomous and empowered. Nurses with more experience noted this ability to navigate these spaces more readily, and were more likely to understand their abilities to do so. Finally, nurses utilized skills learned over time, to develop the art of nursing. These interpersonal skills were learned via while watching and working with more senior nurses and developed and honed overtime. These skills are what nurses need to be able to navigate the social and practical aspect of patient care in the birthing room. While paternalism in healthcare persists, within maternity care specifically, the nuanced care that nurses provide is understudied. This study depicted that care, and how nurses navigate the different contexts, is critical to assert agency and contribute to knowledge for optimal labour and birth care. 48 References Adinma J. (2016). Litigations and the Obstetrician in Clinical Practice. 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Nurse-sensitive outcomes in district nursing care: A delphi study. PloS One, 16(5), e0251546-e0251546. https://doi.org/10.1371/journal.pone.0251546 54 Wise, G., & Jolles, D. (2019). Promoting effective care: Reducing primary cesarean births through team engagement and standardization of care at a community hospital. Nursing Forum (Hillsdale), 54(4), 601-610. https://doi.org/10.1111/nuf.12384 World Health Organization Human Reproduction Programme, 10 April 2015. (2015). WHO statement on caesarean section rates. Reproductive Health Matters, 23(45), 149. 55 Appendix 1: Interview Questions Open-ended interview questions will include: 1. How long have you been a nurse? 2. How long have you worked in labour and birth? 3. What are your feelings relating to a woman’s ability to give birth? 4. What comes to mind when hearing the term “a woman’s capacity to labour and birth naturally”? 5. What are your feelings relating to vaginal vs cesarean birth? 6. Do you feel like you influence your patient’s mode of birth, why or why not? 7. What knowledge and skills do you use most when preforming your job as a nurse during labour and birth? 8. What do you think most influences an operative birth? 9. Have you ever given birth? If yes, do you feel this affects your nursing care on the labour and birth unit? 56 Appendix 2: Codes • C-section is a major surgery/comes with increased risk/healing • C-sections called due to unit conditions • C-sections can be necessary/beneficial • C-sections need indication • C-sections w/out indication are not good • Communication • Fetus/efm influences mode of birth • Induction • Lack of role clarity for nurses • Medical staff actions/words affect the woman’s psyche • Natural labour/birth • Need experience/expertise to be an effective l&b nurse • Nurse the way you want to/were nursed • Nurse/hcp relationship/hierarchy • Nurse’s advocate • Nurses affect the four p’s (direct discussion) • Nurses build trust • Nurses influence the pt.’s mindset with their words and actions this may also be just in yellow with no grey highlight. • Nurses learn from their peers • Nurses need passion for birth learning • Nurses need support from management • Nurses need to have compassion for pt.’s • Nursing skills influences birth • Ob making the ultimate call for section • Psyche of birthing woman affects birthing outcomes • Societal perception of c-sections • Teamwork w/ co-worker • Too many interventions 57 • True informed consent • Two ways of accomplishing the same goal • Upright and active or not affects birth • Vaginal birth has better health outcomes for moms and babies • Vaginal birth should be the goal • Vulnerability of birthing women • What even is natural birth • Woman body is made for birth • Woman’s ability to cope with labour affects their capacity to give birth • Women made to feel bad/guilty/failure for labour/birth choices/outcomes by society • Women need l&b education • Women should have choice in labour
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Brown, Helen
Nurses’ perceptions of their influence on modes of birth : an interpretive description study
Text