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Evidence-Based Practice Project: Improving Nursing Documentation of Evidence-Based Practice Used to Manage Second Stage Labor Denise S. VanderWeele Ferris State University, NURS 324

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION A recent audit of labor charts in my unit indicated that most nurses are apparently not in compliance with current EBP standards in regard to the management of the second stage of labor. In particular, a patient who has received an epidural anesthetic may not be allowed to labor down (encouraging passive fetal descent) after complete dilatation is achieved. Current research indicates that patient-controlled pushing (both in initiation and duration of pushing), frequency of pushes (every contraction, every other contraction, or every third contraction), and open-glottis pushing resulted in better fetal and maternal outcomes (Mahlmeister, 2008). What are the barriers present that prevent nurses from implementing EBP to their bedside care in this unit? The reason I chose this topic is because I believe there is more than one reason why normally competent, intelligent and gifted nurses seem to be choosing to ignore EBP that is readily available for them to apply to their practice. Are they using EBP and not charting it? Is

the use of the EMR (Electronic Medical Record) impairing the nurses ability to chart when EBP is followed? By identifying these barriers, could a plan be implemented to follow and acknowledge that current EBP is being used? I will explore these and other questions using EBP using the elements of reasoning on the following pages.


Evidence-Based Practice Project: Improving Nursing Documentation of Evidence-Based Practice Used to Manage Second Stage Labor The purpose of this project is to improve the documentation of evidence-based practice (EBP) interventions performed by the Registered Nurses in Labor and Delivery during second stage labor. The specific documentation that would improve as a result of the interventions explored in this paper would be allowing the patient to labor down when completely dilated but the fetus remains high in the pelvis, patient-controlled initiation of pushing, patient-controlled frequency of pushing, open-glottis pushing and position changes to aid in fetal descent (Mahlmeister, 2008) . Questions As noted in recent chart reviews, there is little charting completed during second stage labor. In speaking with the nurses who wrote the charts, EBP is often being utilized, with the exception of open-glottis pushing. Open-glottis pushing is actively opposed by the physicians in the institution studied. If the physician is not present during pushing, the nurse may use this method but not chart it. If EBP is integral to the nursing care, why does the charting not reflect the actions of the RN? Is there a need for staff education on how to include EBP in their documentation? Is there a mechanism already in place for documenting EBP? How does the presence of electronic medical records (EMR) affect the frequency and completeness of documentation during second stage labor?

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION Point of View Nurses as a whole are committed to professionalism and strive to give the best care available to their patients (ANA). They are taught to document in nursing school, and desire to keep accurate records of what transpires in the course of their care of the patient. Three main barriers are involved in completing the documentation of second stage labor: the inability of the nurse to chart in real time due to the acuity of care needed at this stage of labor, the availability of the EMR at the bedside (there is a lengthy log-in process that automatically times-out after a

few minutes), and the skill of the RN to put the information onto the proper electronic flowsheet. A drop-down checklist may be helpful for documenting routine EBP nursing interventions such as turning patient to improve FHR or facilitate descent, laboring down, patient-initiated pushing and open-glottis pushing. A narrative of unusual events should be placed in the Progress Notes (Green & Thomas, 2008). Many nurses who are over 50 years old are reluctant to chart in the Progress Notes because progress notes were frequently labeled as Physicians Notes in their early training years (Rewerts, personal communication, 2012). Evidence, Information and Research Review of the EMR at this institution reveals that some of the mechanisms for detailed second stage labor charting are in place. There is a drop-down box in which you can select the following information on the Labor Flowsheet, under the Second Stage Labor tab: RN at bedside continuously monitoring FHT and uterine activity Laboring down Urge to push Non-coached pushing Pushing efforts limited to 3-4 per contraction Pushing efforts limited to every other contraction Pushing efforts limited to every third contraction Stopped pushing Open-glottis pushing Special Care Nursery nurse at bedside

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION Neonatal Nurse Practitioner at bedside Reviewed vacuum checklist in progress note Physician at bedside Set up for delivery Clearly, there are many EBP interventions that are represented in the drop-down box

(Mahlmeister, 2008), but the part of the nursing process that is missing is the evaluation of these actions (ANA). For example, if the patient was laboring down and the head descended, how long did it take and how far down did it descend? This question is answered in the EMR but on a different flowsheet, which takes valuable nursing time to locate and document accurately. Sequential logic is also missing in this process, because the problem, intervention and evaluation of actions taken are not on the same page. A possible alternative is to use the checklists during second stage labor and then later write a narrative Progress Note that shows the nursing process at work, such as a note using SBAR Situation-Background-Action-Results or Recommendation (Lyndon, Zlatnik, & Wachler, 2011). Physicians view (sic) detailed assessments and well-described interventions of nurses as critical to their ability to effectively practice medicine, such narratives may not be available to the physicians during the labor process if it needs to be written later due to the acuity of the situation (Green & Thomas, 2008). Concepts Quality of care, patient safety, service to the community, professional growth and customer satisfaction are the pillars of the organization studied (Metro). Each staff member bought into these ideals when becoming a part of the organization. EBP embodies the best of all these concepts and needs to be evident in the documentation of care, especially the concepts of quality and patient safety. According to Debra Rewerts, RN, BSN, Nurse Educator for the

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION Childbirth Center, We nurses are really good at taking the appropriate steps to treat a patient, but we fail to take credit for what we do (personal communication, 2012)

Assumptions It is the goal of every nurse to provide the best care s/he is able, while applying the latest knowledge available. Most nurses are aware of the current best practice standards in their discipline (ANA, 2010). The documentation of EBP should be a priority because it reflects that care that each nurse must provide for their patients.

Implications and Consequences Given that physicians rely on good documentation by nurses (Green & Thomas, 2008), and the nursing code of ethics demands competent documentation, ignoring the necessity of documenting the application of the nursing process in a responsible, accountable and ethical manner (ANA, 2010) is not an option. If the barriers to documenting second stage labor could be exposed and eliminated, documentation would improve in quantity as well as in reflecting the EBP care that was given.

Inference and Interpretation Complete and accurate documentation will lead to better collaboration between physicians and nurses during the laboring process and result in less conflict in opinion regarding the patient care management (Lyndon, Zlatnik, & Wachler, 2011). Patient satisfaction would also be higher because their needs could be addressed by all members of the health care team, not just their nurses (Simpson & Lundon, 2009). Nurses who are able to translate their EBP care

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION into the EMR are promoting a safe care setting for the patient (Lyndon, Zlanik, and Wacher, 2011) and will ultimately improve their performance evaluation by documenting their use of EBP (Metro).

Reflection on the EBBP Overall, the thought process for this paper was exhausting, time-consuming, interesting and rewarding. It was a new experience for me to evaluate my thinking process and collaborate with peers in the framing of solving the clinical problem I chose. I believe that I can use this information to initiate real change in the workplace. I have already suggested to my Nurse Educator that I prepare a brief (5-7 page) PowerPoint presentation reinforcing the importance of accurate, complete documentation and how to achieve it. Screen shots from our EMR could show the tools that are available to accomplish this improvement in charting. Samples of an SBAR note may help relieve anxiety about writing in the progress notes. By first providing education, a higher standard of performance is placed on everyone, and compliance is expected to follow the education. It would be unreasonable to expect a change in documentation by all those involved without first presenting the corresponding education necessary to understand the expectation. The barrier of availability of the EMR at the bedside is eliminated because there are workstations on wheels in all labor rooms. The difficulty of logging on to the EMR and maintaining an open window will need to be addressed with the Information Technology Department, however. The barrier of nurses being reluctant to chart in the Progress Notes can be addressed by simply stating what needs to be placed there and that appropriate, concise notes are the expectation when additional information needs to be communicated. The objection that time

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION is not available to do this much charting should be framed in the medical-legal world in which

we practice: if you do not chart it, how can you prove that EBP was used? Once the information has been brought forward, it is up to the integrity and professionalism of the individual nurse to see the value of incorporating that into their practice.


References American Nurses Association. (2010). Standards of professional nursing practice in Nursing: Scope and standards of practice (2nd ed.). ANA: Silver Springs, MD: Author. Green, S. D., & Thomas, J. D. (2008). Interdisciplinary collaboration and the electronic medical record. Continuing Nursing Education Series (report ) in Pediatric Nursing. 34(3). Retrieved from =lom_ferrisu&it=r&p=ITOF&sw=w. Lyndon, A., Zlanik, M.G., & Wacher, R.M. (2011). Effective physician-nurse communication: A patient safety essential for labor and delivery. American Journal of Obstetrics and Gynecology. doi: org/10.1016/j.ajog.2011.04.021 Mahlmeister, L. R. (2008). Legal issues and risk management: Best practices in perinatal nursing. Journal of Perinatal & Neonatal Nursing. 22(3). doi: 10.1097/01.JPN.0000333917.15081.62. Metro Health Hospital (2012). Pillars of Excellence. Retrieved 6/21/2012 from Simpson, K .R. and Lundon, A. (2009). Clinical disagreements during labor and birth: How does real life compare to best practice? Maternal Child Nursing, 34(1)

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION Reflective Questions on Writing this Paper How did the planning process, where you thought about what you wanted to change, prepare you for your EBP?


The planning process was helpful in framing the problem to be addressed. In retrospect, I had two separate issues that I was attempting to explore. Using the elements of reasoning clarified and narrowed my topic to just one of the issues which lead to modifying the central issue addressed. Exploring the stakeholders point of view enlightened me to possible barriers in using the EBP at the bedside. Gathering information on specific EMR documentation of second stage of labor was difficult. Instead, I used what research was available for good documentation and the results obtained by clear communication through concise, accurate charting. My assumption that nurses really want to perform to the highest standard possible was reinforced by reading the book on the scope and standards of nursing care. The consequences of not using EBP were highlighted in the article on legal issues and risk management. How did the peer evaluation process prepare you for the EBPP? At first, I was skeptical that there would be any value in having my thoughts reviewed by my peers. I was proven wrong, however. The insights from the two people who did respond to my posting were instrumental in the changing of the direction of this paper. Their probing questions highlighted the folly of trying to address two questions in one assignment. By narrowing my topic to just the documentation of EBP, I was able to dig deeper into the topic than if I attempted to address the use of EPB along with the documentation piece.

Do you feel you are prepared to elicit change in your practice with your proposal? How does it fit into quality health care? I believe I answered this in my conclusion to my EBBP when I stated that I would be creating a PowerPoint in-service to be emailed to all RNs in my department. By presenting evidence of improved outcomes and examples of better charting practices, the quality of care will be improved, probably at the same rate as the interdisciplinary communication improves. One cannot expect change or be held to a higher standard without the education to support the rationale of the change expected. Nurses are intelligent and driven people, and when presented with a higher standard of care that will improve patient outcomes and enhance team collaboration, change will happen! What could you have done better? I would have liked to have submitted this paper with the rest of the class, but the circumstances of my service learning project to Haiti prevented that from happening. I am glad, however, that my initial research and peer reviews were completed prior to my departure for Haiti. I enjoyed doing this project, but would have probably enjoyed it more if I were not under pressure to catch up in this and another class that I am presently taking.

Running head: EBPP: IMPROVING SECOND STAGE LABOR DOCUMENTATION How well do you think you are using the EOR? Do they make sense to you?


I believe the elements of reasoning were helpful in writing this paper. Each one made me stop and think more deeply and critically about the problem I was trying to solve. By answering each of the eight elements, my paper had more thought behind it and more depth was given to the subject matter. It has not been easy to think about my thinking (as you put it), but the rewards are in producing something of which I can be proud and feel that I have explored the question completely.

Reflection on the EBPP

Points 0-6 Planning Process Peer Evaluation Process Ready for Change Improvement Use of Critical Thinking TOTAL 6 6 6 6 6 30