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Table 2 Summary of belief statements and sample responses from Birthing Unit Nurses grouped by theoretical domains identified as key to influencing fetal surveillance

From: Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses’ fetal surveillance practice using theoretical domains framework

Domains

Specific belief

Sample responses

Frequency out of 12

Nature of behaviour

IA is part of my fetal surveillance for low risk women

“If she has no risk factors for herself or the baby and there should be IA.” (N1)

11

“For me it [IA] is… part of my fetal surveillance.” (N2)

“Absolutely…IA is part of my surveillance.” (N4, N12)

I have been using IA for so long it’s just what we use.

“I think it’s just a pattern of habit that somebody is in front of you and you know if it’s an urgent situation or fast moving or a slow moving one you are talking and you are doing it at the same time so I’m just reaching for that and holding it on the belly. Like I can do that instantly without belts or wires or anything else. So I think force of habit, believing that’s what we should do and that it is the recommendation.” (N5)

4

“I think it’s experience. I think experience makes you more comfortable with IA.” (N3)

“That’s what we use and that’s what we have used for years and we’ve not had a problem with it.”(N4)

I’ll use IA if the woman is healthy and there are no complications

“I would say almost all of them unless they have an epidural like going to the hospital setting and have epidural analgesia then they need to be monitored continuously.” (N12)

3

“If a women is healthy. First baby, second baby or third baby doesn’t matter. If she has had previous uneventful pregnancies before. If she’s deemed to be low risk I mean there’s no issues with Mom or baby that warrant continuous fetal heart monitoring then I do do IA.” (N3)

There are complications with mother when IA is just not appropriate.

“So if we know what our decelerations are and everything through the fundamentals of fetal health self-learning package so we watch and listen for those okay with IA we just mostly listen. If we suspect that we’re getting decels when we shouldn’t which is post contraction then we hook them up to EFM to monitor if it’s a force of not just one, it’s just a ‘red flag’ to increase your IA surveillance." (N4)

3

“I would say almost all of them unless they have an epidural like going to the hospital setting and have epidural analgesia then they need to be monitored continuously.” (N12)

“Well Oxytocin is ordered to induce or augment labour and we do quite a bit of that and so then it is policy that they are on continuous monitoring if they are on Oxytocin.” (N8)

Some people are set in their way with respect to fetal monitoring and will always do it the way they’ve done it.

“That always fascinates me and so I think more than busyness is that people’s entrenched like the way they’ve always done it before they just think no I’ve always done it this way and I’m going to keep doing it this way and it’s the more protective conservative way to do it every half hour versus every hour, but that more conservatism we know leads to greater interventions and more surgical births and all that so it’s interesting.” (N5)

2

“There is some old school that have had difficulty giving up, and I’m old school, that initial observation strip on admission. There are some people who still do that.” (N9)

During the second stage of Labour it becomes more difficult to use IA

“The challenge becomes in the second stage and pushing for anything whether it’s IA or ESM.”(N1)

2

“The second stage of labour we usually would have them connected because you need to see every second what’s going on.” (N2)

Beliefs about Capabilities

I am comfortable using IA in healthy labouring women.

“So for me it’s more experience on both neonatal as well as the mom. I’m comfortable using it.” (N7)

10

“I’m also comfortable doing it in that I feel like I am quite competent…” (N8)

“Yes, absolutely. I’m comfortable…[using IA in this patient population]” (N9, N4)

I am confident using IA

“…so you know, I have many years of that so I can almost anticipate what the outcome is going to be. If the outcome of the infant is not where we want it to be I’m confident that I can deal with that so that’s part of my education here as well.” (N7)

11

“Well I’ve had 25 years experience so I’m comfortable and…I’m comfortable because I stay current in my practice and all the nurses do here." (N4)

“I feel reasonably confident, yes…I guess because I’ve been doing obstetrics for so long so you have some comfort level to know the rhythms and if I’m concerned about the fetal heart then you know that you can always put the mom on the continuous monitor right.” (N10)

It’s very easy/difficult to decide to use IA as my predominant method of surveillance.

“Well I think if everything goes well it’s easy to use.” (N10)

11

“Personally I find it [IA] quite easy.” (N11)

“For me personally it’s not a problem…[to use IA as the predominant method of fetal surveillance with a healthy woman having a low risk pregnancy].” (N3)

“It is very difficult.” (N12)

It’s very easy because I have the right knowledge base, my experience, and the support of my team.

“As I said before having the waterproof monitors, having support from your obstetricians that they are coming around to IA being a very adequate source of monitoring.” (N8)

4

“For me specifically it’s probably my knowledge base and my experience and I know I have the support of the physicians.” (N7)

It’s very hard to take a woman off a monitor and do IA once she’s been put on.

“I find it’s very hard to take a woman off the monitor once put on even if everything is okay.” (N11)

3

Beliefs about Consequences

Using IA is more time consuming and difficult to multitask

“Only that it’s more of a time constraint I think…[drawback to using IA].” (N8)

4

“The drawbacks I think I know sometimes again depending on the acuity of the floor I find that it’s more time consuming than EFM because EFM is easier, it’s on you look, you document, you walk away. I think for the first line nurses it can be more time consuming and it’s unfortunate but you have to…” (N3)

Using IA increases the legal concern that you can’t provide a strip printout should something go wrong.

“I guess there’s always the legal concern about you can’t prove it so there’s a thought about well if you can show a good strip then that’s very supportive of your assessment of this patient. I think that’s probably the only thing.” (N1)

5

"If something happened you don’t have that strip there that you can go back to and look at. It’s somewhat more time consuming for that reason." (N8)

“Well I am thinking immediately of a negative. If at the delivery there is an unexpected—a baby that has a longer than usual transition to—if the outgo basically is lower than one would expect there would be questions about whether the monitoring if it was just down to the experience and the reliability of the nurse to interpret reassuring the mum, reassuring her rate patterns with IA if the outgo was low then there would immediately be ‘oh heck were you really interpreting reliably?’ The question would immediately be asked and there would be no proof other than what the nurse was recording.” (N12)

Using IA provides the mother with support and a more positive experience

“Oh I think we would have more active women and more positive labours. It possibly has less observation of the woman.” (N8)

5

“Positive wise I think you know again that supportive care, not being hooked up to a monitor, feeling confident in the nurse, you know that whole positive experience." (N7)

“It’s easy because the patients have better satisfaction, they are more mobile, they can get up to the shower, they can you know use alternate methods of pain relief, they are not strapped to a monitor and stuck in a bed.” (N6)

Using IA reduced methods of pain relief or interventions.

“Well I use it predominantly and I think that it increases patient satisfaction and decreases unnecessary intervention.” (N9)

4

“… I feel anecdotally it reduces the number of requests for epidural and analgesia actually when the woman is up and moving about.” (N12)

“It’s a busy night and you are over monitoring and then you are lining up another section and the obstetrician is already busy and people are tired like it’s a win-win situation if we’re keeping things at an appropriate low level of intervention. Intervene when we need to but not when we don’t.” (N5)

Using IA encourages a more active labour where the mother is able to move and walk.

“I think the majority of the women that I have done IA on they much appreciate the fact that they are able to walk around." (N3)

4

“…continuous EFM it does commit women to be relatively still and like in the same spot and position, well we can encourage them to change position but they are committed to the bed essentially or as long as the monitor as far as the monitor can tether them.“ (N2)

Using IA allows us (the nurses) to be more focussed on the mother and baby than EFM.

“It encourages rapport and to work with the woman. It requires a contact between the nurse and the woman that isn’t required when the woman is on continuous monitoring.” (N12)

8

“…you are observing the baby’s well being and that you are taking care of the woman and not the machine and that the woman is the primary focus. So I think the best outcome is for the woman." (N5)

“With EFM you are constantly watching the monitor and you are not as in tune with your patient that’s labouring. They feel more like a patient instead of just a woman going through a process.” (N8)

If you’ve experienced a bad outcome while using IA, you are less likely to use it again.

“When you see a bad outcome it can sort of influence you with IA.” (N11)

2

Memory, attention, and decision processes

The decision is an automatic one if there are no risk factors.

“Well it’s automatic if there’s no risk factors that have been identified then it’s automatic [use IA an automatic part of your job or is it something you take time to think about with low risk pregnancies].” (N6)

2

The decision to use IA is automatic but I’m very conscious of whether or not it’s appropriate.

Well I think about it with the patient in terms of whether or not it’s appropriate for them but it’s automatic to do it if I find that they are low-risk.” (N9)

4

“No, I automatically do it but it’s not a robotic thing to do like I’m very conscious of whether or not it’s not appropriate. I assume it to be the norm but I am constantly re-evaluating to make sure it is still appropriate.” (N8)

The decision to use IA is something I think about with every patient

“Oh I think about it first. I look through all the we have indications for initiating EFM and if she doesn’t belong to one of these indications she can be IA.” (N3)

3

“With each patient….[take time to think about with low risk pregnancies].” (N10)

I can do IA without much thought …it’s a force of habit.

“you know if it’s an urgent situation or fast moving or a slow moving one you are talking and you are doing it at the same time so I’m just reaching for that and holding it on the belly. Like I can do that instantly without belts or wires or anything else. So I think force of habit, believing that’s what we should do and that it is the recommendation.” (N5)

1

 

There are not any competing tasks that would influence my decision to use IA or EFM.

“No not really..[any competing tasks or time constraints].” (N8)

3

“There are things to be done but they can be done as well you know like they can be done in between like we are only auscultating like when we auscultate for a woman in labour it’s only for a minute every 15 so that means you have 14 min every 15 min to do whatever you need to do in between so I think there is opportunity to complete all the long list of nursing things that we do.” (N2)

Time is often an issue because if we’re pressed for time we’ll put a mother on Continuous so we can multitask.

“Yes if you’ve got a really busy unit. We’re not any different than any other unit. If it’s really busy it’s unfortunate but sometimes we do use the fetal monitor as a babysitter.” (N6)

8

“…yes, if somebody’s really busy they might put a monitor on and leave it on because then they can stick their head in and listen.” (N5)

“What ends up happening is women are not supported adequately by nurses who are pressured to care for more than one patient at a time and the woman ends up having an epidural and/or augmentation of labour and they end up by default on continuous monitoring.” (N12)

“Absolutely the busyness of the floor. If it’s very busy and somehow I end up with 2 labouring patients which I understand are not the guidelines but if it’s really busy I may consider putting a woman on continuous fetal heart monitoring because I can’t get to her.” (N3)

Having the proper equipment (Hand held Dopplers & ultrasounds) available encourages the use of IA

“I think having more Doppler’s and one assigned for each room versus the monitor that is there and so prominent right beside the bed.” (N1)

7

“…we do I think the handheld ones yes. They can cut out with the batteries and that.” (N4)

“We could use more Dopplers like we have one Doptone that we can use for in the big tubs that’s safe for using in the water but if we had a few more of those then that would help us too I think. We do have monitors in each of our rooms like we do have that available to us, the big monitors.” (N10)

Having easy access to EFM technology directly next to the mothers bed decrease the nurse’s chance of using IA.

“So the monitors are hooked up to a computer and all the computers are connected and the computers are accessible anywhere on our unit…So I think like the central monitoring makes it very easy to like if you are in a room and you are having issues you are not the only one that’s seeing it.” (N2)

5

“We have portable monitors which do make it easier to do continuous monitoring because they can be up and walking around and in the shower and in the tub and then it also makes it easier because they are waterproof and you can do intermittent and you can go in there and do it that way.” (N8)

“…but all assessment areas are set up with monitors and the belts and everything you need and the drawers even have the equipment for the internal monitoring to go on the baby’s scalp so it’s easy to use the monitor but it’s also I mean you use the same equipment to do IA.“ (N5)

Missing and broken dopplers discourages the use of IA.

So there’s that and I know this sounds silly but we have handheld Doptones and they are always lost or broken.” (N11)

2

“…my unit we used to have Dopplers but for some reason all our Dopplers have grown legs and walked off the unit so we use the ultrasound as a Doppler. We don’t hook them up we just hold the monitors to their tummies so it’s the same machine we just don’t put the belts on their tummy.” (N2)

Social influences

A fellow colleague/clinical leader or physician do/do not influence my decision to use IA if they detect something I’ve missed

“I find that other nurses think if I’m taking over from another nurse like at change of shift if that nurse has had the patient on the monitor, but there has not been any medical indication for continuous monitoring it’s difficult for me to take her off in terms of the patient saying ‘well how come I needed to be on before?’ without seeming like I’m undermining my colleague’s judgment.” (N11)

9

“I would say it would be if your team members your nurse colleagues and the obstetrician that’s monitoring the progression of labour.” (N12)

“Unless it was specifically ordered by a physician no.” (N8)

I do (don’t) discuss my cases with other colleagues

“No…[don’t discuss a case with your colleagues].” (N3)

12

“Yes…[discuss a case with your colleagues before deciding whether to use IA].” (N4, N8)

“Yes we do. We look at our sheets that we get from our physicians and like often if we know they are coming in or maybe they’ll just show up we’ll pull it and between the 2 nurses there we’ll say what do you think and again you know we really there’s not all of us that are using it either right because this is a new thing right.” (N7)

“No for me I would be able to make that decision on my own but I guess if I had questions about it I could easily go to another person.” (N10)

The labouring woman’s emotions do/don’t greatly influence my decision to use IA

“For me it’s just the data, again just talking to the mom, looking at her comfort level.” (N7)

12

“I don’t think they [woman’s emotions] play into that at all.” (N1)

“Like if she was really concerned or if she was frightened or if her last baby had something happen and she felt more comfortable having the monitor on then that would be something that we would certainly try to address for her.” (N10)

“Oh yes they do. If the patient is exhausted and tired and doesn’t want to walk around because I do encourage ambulation and some patients think I’m cuckoo like I’m tired I don’t want to walk around….Because there are women who have said to me I want to try and sleep and I says yes…if they don’t want me to bother them I will put the EFM on. It’s not my first choice but if they want to sleep and they don’t want to be bothered and me looking for the fetal heart every 15 min I’ll say you know you are considered in active labour can I throw the monitors on you? With their permission and the majority of time they say yes.” (N3)

 

Having the support of the hospital policies and physicians greatly influences my use of IA

“The obstetricians here are really supportive of us using IA, most of them are very current and very supportive. Some of the family doctors that I’ve worked with in the past would want you to have them on the monitor more often and I’ve had some of my obstetricians that don’t want a monitor on and if you could manage the labour without a monitor that’s even better. So they encourage us to use IA. I guess it depends on who you are working with on that case too.” (N10)

8

“Yes. I think this is a big influencing factor especially to young, new grads that have a new nursing degree and this is their first job you know versus someone like me who has only worked there for a shorter period of time, I’ve got years of experience with it, it’s that if your team leader or your mentor the person that’s orientating you they for the most part we teach our young kind of what we know, what we do, and so you just pass it on so you just pass it on so definitely like if the team leader says ‘oh I know she’s still in that normal category but I’m not so sure put that monitor on’ you are going to cause a lot of personal, political, professional strife if you start contradicting what a leader has asked you to do." (N5)

“That is not the model if you like that is encouraged by nursing management or by obstetricians for different reasons. There’s a whole politics and a pressure put on individual primary care nurses to not be continuously in the room with one woman because if you are then you cannot look after more than one patient safely and so IA requires one-on-one nursing and the skill to support the woman in the room.“ (N12)

It’s difficult when physicians question/s-guess your decision.

‘I mean I’ve been there you know done that wore the T-shirt with continuous fetal monitoring where everything is fine and then you are pushing and then boom. We know it happens and can we predict it more with continuous I don’t think you can if everything has been fine but I think it’s that piece that really bothered me was the clinician saying to the nurse ‘why wasn’t she on the monitor?’ and the nurse just said because she’s low-risk—IA!" (N11)

3

"The biggest gap is that SOGC comes up with guidelines that are really evidence-based and clinicians go ‘yea well I’m not doing that’. Okay well it is the national organization of your colleagues or of our colleagues."(N5)

"Obstetricians can become quite concerned because they have to rely on your assessment not only of the fetal heart rate but the contraction pattern and most labours are actively managed. There is a pressure to have women in and out and delivered within a kind of unspoken time limit." (N12)

The cultural pressure to be part of the team at the nurses’ station, using IA can be isolating

“There is a culture if you like also. I’m very interested in the anthropology of you know the way nurses censor each other and if you are not sitting at the desk watching monitor screens and you are in the room with the woman you can be censored in many ways non-verbally even because you’re not involved in sitting having discussions at the nursing station rather than in the room with the woman which is a little depressing at times. You are not seen as part of the team if you are in a room all the time quote unquote.” (N12)

2

Behavioural regulation

A way to encourage IA use is review of the correct procedures to re-familiarise all staff (nurses, family physicians and obstetricians)

"Like every so often we do have, what we call, a cycle review on the procedures that are more commonly used. I think if say the policy on that is that is one of those things that were reviewed on a yearly basis that would encourage people to do it and it really makes sense." (N2)

7

"Well it’s definitely the education factor because what I’m finding now is now that we are into the more OB program and we’ve got the fetal health surveillance learning package and that the more I educate staff the more they understand. It’s getting them away from the electronic." (N4)

"Just continued education for staff around the benefits sometimes I’m not convinced that people see there’s a benefit. I think still some of my staff see continuous fetal monitoring as being more preventative and IA as being more reactive. I don’t know it’s a hard sell to be honest." (N11)

Better communication so that the team is more supportive of the nurses assessment would improve the use of IA

“I think there would have to be really very frank discussion interdisciplinary discussions and a willingness for the obstetricians who, of course, along with the hospital take on the liability risk. So the hospital and the obstetricians would have to be willing to come onboard with that and to not have this false sense of security in my view that you know a continuous readout is better and safer and more reliable than a well-trained observant nurse.” (N12)

3

“I think it’s their perception often needs to be corrected about options that are available. So for example if a resident comes in and says ‘okay is she on the monitor?’ I’ll say ‘no, no we don’t’ need to use the monitor we’re just using IA and the fetal tone has been great and I’ve heard accelerations and it’s been fine’. So I use it as an educational opportunity.” (N11)

More modelling techniques would help

"The policy is good I just think as in the previous question it’s around development of teaching tools and modelling and encouraging others to develop the confidence in it." (N9)

6

"…to make the steps necessary for that is I believe lead by example because it’s very much a culture thing in that a lot of nurses like the EFM, they strap it on and they don’t have to worry about it and they let it go so it’s very much a trend and it’s something that needs to catch on either by leading by example or having more push for IA would help in our facility." (N8)

Better communication between nurses and physicians so that Physicians are more supportive of the nurses assessment would improve the use of IA

"I think we have to change that it’s a paradigm shift right. I think we’ve got to change the mentality of people from putting them on EFM automatically and I do believe that in order to do IA successfully and get these patients walking around more we need more Doppler’s. We don’t have any." (N3)

3

"I think there would have to be a really very frank discussion, interdisciplinary discussions, and a willingness for the obstetricians who, of course, along with the hospital take on the liability risk. So the hospital and the obstetricians would have to be willing to come onboard with that and to not have this false sense of security in my view that you know a continuous readout is better and safer and more reliable than a well-trained observant nurse." (N12)