Induction of Labor in Preeclamptic Women, Research Paper Example

Abstract

The existing controversies in the management of preeclampsia are part of the reason the hypertensive disorder has proven difficult to control. This paper aims to establish a method to create a clinical awareness session for nurses in the obstetrical units across the Northwest Territories that better reflects their unique reality as care providers. Through the transtheoretical model/stages of change approach, the creation of awareness through the sessions represents a set of steps that different experts, levels of management, and staff can be engaged through interrelated concepts, which will enhance the interventions in preeclamptic women. The intervention will take place at the Stanton Territorial Hospital in Yellowknife, the largest hospital in the Northwest Territories. The hospital has already established guidelines and policies primarily based on evidence-based research (EBR) and established best practices. However, limitations, such as the linear nature of the stages of change and the rigidity of the guidelines used in the educational sessions, present a challenge to this intervention plan.

Keywords: preeclampsia, transtheoretical model/stages of change, awareness sessions,

Introduction

Preeclampsia is a common complication in pregnancy, affecting 3-7% of pregnancies beyond 20 weeks gestation (Dulay, 2020). It is a systemic disorder affecting different maternal organs, notably presenting with visual disturbances, headache, chest pain, and shortness of breath (Brichant & Bonhomme 2014). If left uncontrolled, the disorder progresses toward eclampsia in an estimated 1 in 200 women, which can cause maternal seizures, fetal distress, fetal demise, and maternal death (Harvard Medical School, 2020). Women with pre-existing chronic hypertension are at higher risks of developing preeclampsia, yet the majority of these women remain asymptomatic in the earlier stages of the condition (Brener et al., 2020). Nevertheless, eclampsia is a preventable complication. Healthcare workers must know how to identify preeclampsia so that appropriate treatment is initiated early to reduce the risk of disease progression.

However, there is some controversy in the literature regarding which interventions preeclamptic women should receive. Some evidence suggests that early induction of labour is the best treatment (Cluver et al., 2017). Other sources are not clear as to the best method of delivery. The Northwest Territories total births in 2019 were 581 (NWT Bureau of Statistics, 2019). The territory’s health department policy requires all pregnant women to deliver in one of the hospital centers, which include The Stanton Territorial Hospital or The Inuvik Regional Hospital (Murphy, 2017). Due to the constraints of available resources and the necessity to provide prompt care to women presenting in preeclampsia, clear evidence-based practise must be available to all personnel working in nursing stations across the territory. Designing an awareness session requires a review of the current literature, along with an analysis of the available resources and the experiences of key stakeholders. This paper aims to establish a method to create a clinical awareness session for nurses in the obstetrical units across the Northwest Territories that better reflects their unique reality as care providers.

An awareness session, including different experts, levels of management, and staff, is proposed to review expert opinions, experiences, and evidence using the transtheoretical model (TTM)/stages of change (Glanz & Bishop, 2010). Using the TTM approach, the creation of awareness through the awareness sessions represents a set of steps through which the different experts, levels of management, and staff can be engaged based on interrelated concepts that enhance interventions in preeclamptic women. Due to the different levels of readiness of the various obstetric experts, factors, such as different access to online resources and different training tools, can be considered in engaging the Northwest Territories using different stages of change model (Jacobs et al., 2012). The TTM approach will address the differences in these facilities and introduce awareness sessions at an acceptable gradual process for the various experts, levels of management, and staff.

Plan of Action

Design of the Intervention

A literature review was conducted to assess the effectiveness of in-house educational sessions developed and presented by nurses. Empowering education is a newer model demonstrated by Chaghari et al. (2017). The given researchers illustrated how additional training for nurses could play a critical role in improving the quality of patient care. Secondly, involving the staff in the makeup of the training sessions improves the quality of these sessions, as the material reflects the needs of its members (Chaghari et al. 2017). These findings will be implemented in the development of awareness sessions for nurses to accommodate staff needs, encourage participation, and ultimately improve patient outcomes.

The intervention will be carried out at the Stanton Territorial Hospital in Yellowknife, which is the largest facility in the NWT. Due to its established guidelines, which are primarily based on evidence-based research (EBR), the hospital makes it a suitable choice to set up the awareness sessions. The hospital also includes established best practices (Northwest Territories Health and Social Services, 2010). For that reason, the staff is already familiar with EBR. Awareness-raising sessions should reduce any risk of resistance to change among staff (Olson et al., 2010). An invitation will be sent by email to all obstetrical nurses to participate in the development of the awareness sessions. Selected nurses will then conduct a nurse-driven awareness session, working directly with the nurse educator, obstetrician, and nurse manager. The sessions will include an introduction to preeclampsia and will cover the progression of the disease, signs and symptoms, risk factors, clinical management, and treatment.

Empowering education is a newer training model, where nurses play a critical role in improving the quality of patient care (Chaghari et al. 2017). Such models have been shown to better support employees in their practice and promote a sense of responsibility from the management to encourage successful performance by staff. Additionally, involving nursing staff to take part in the planning and implementation of educational sessions fosters more desirable learning environments and ensures that the content reflects the needs of the staff (Chaghari et al. 2017). Moreover, involving the educational model through the stages of change model will enhance the action and maintenance phase of this behavioural change theory. The given sessions will include an introduction to preeclampsia, including a discussion on the progression of the disease, signs and symptoms, risk factors, clinical management, and anticonvulsants, and other pharmacological treatment.

Applicability to the NWT and its Organizational Needs

Applicability/Transferability

Wang et al. (2006) defined applicability as the process in which an intervention can be implemented in another setting. The awareness sessions proposed can be offered to a hospital of similar size in Northern Canada, such as Whitehorse Regional Hospital or Qikiqtani General Hospital, where nurses will have basic knowledge and experience of the management of preeclamptic women. The other hospitals are ware and exposed to the challenges faced with healthcare facilities from northern Canada. Therefore, the institutional and social acceptability of applying the intervention should be possible (National Collaborating Center of Methods and Tools, 2010). Similarly, local obstetrical guidelines are likely already established in these centers; hence implementing an awareness activity should be well received. Practice guidelines are established in the hospital, so the staff is already familiar with the concept of evidence-based practice (Northwest Territories Health and Social Services, 2010). This means the awareness sessions carried out based on existing guidelines on preeclampsia will lead to ready acceptability to the engaged experts, levels of management, and staff. A lack of obstetrical training and experience among community health nurses (CHN) has been previously identified to affect awareness creation, both institutionally and to the society (NWT Midwifery Stakeholders engagement, 2017). Additionally, lack of continuity of care throughout the entire maternity process and lack of indigenous maternity supports have been identified (NWT Midwifery stakeholders engagement, 2017). Therefore, introducing an awareness session to improve best practice should be well-received if the Northwestern Territories will be engaged through incorporating existing guidelines of preeclampsia in the information being disseminated. This is mainly because the process of change is usually marked by relapse. As such, incorporating the existing guidelines on managing preeclampsia to the awareness educational sessions will help in the achievement of the maintenance in the interventions targeted by the stages of change model.

The baseline prevalence of the disease in local settings should be determined when assessing the transferability of the proposed intervention (Wang et al., 2006). The prevalence of maternal hypertension per 1000 deliveries between 2004 and 2010 was found to be 54.9/1000 in the NWT, compared to 40.8/1000 in the Yukon and 54.9/1000 in Nunavut (Canadian Institute for Health Research, 2011). Therefore, risk factors for preeclampsia are not uncommon in the Canadian North. In the NWT, the Stanton obstetrical department receives the majority of patients who deliver in the territory. However, only 52 births per year occur in the only other hospital in the NWT (Canadian Institute for Health Research, 2011). Seeing that women with worsening preeclampsia often require prompt treatment and induction of labour to reverse the disease, there is a need for nurses in the largest maternity wards to be aware of current recommendations in the assessment and management of preeclampsia. The intervention addressed in the plan will include consideration of various factors that may affect its applicability and outcomes. Some of these factors include socioeconomic status, ethnicity, educational level, and resource availability that can determine the failure or success of the intervention.

Implementation of the Intervention

Integration of a Planning Model and/or Theoretical Framework in the Intervention

“During the educational process, using the teach-back method will help verify that the staff implementing the practice change has a clear understanding of why and how the practice change is occurring and what outcomes they’ll be monitoring. Once the staff has been educated, initiating the actual practice change explored in the awareness session is the next step” (Woods, 2013). The initiated practice change will be subject to evaluation, which will determine the effectiveness in the NWT healthcare facilities.

“Products, such as UpToDate, DynaMed, and Lippincott’s Nursing Procedures and Skills give clinicians evidence-based references that can be easily used at the point of care. Many of these products can be downloaded to portable devices, such as tablets and smartphones, making access to evidence-based resources even easier for nurses and other healthcare providers” (Woods, 2013). An email sent to every obstetric nurse will ensure all of them participate in the process. Selected respondents will be trained to conduct the nurse-driven awareness session and work directly with the nurse educator, the obstetricians, and the nurse manager on the obstetrical unit.

However, the awareness sessions participant nurses will be subject to online surveys, which will assess their interest in the subject, as well as experiences and outcomes of preeclampsia. The survey will also include contemplation of the need for change in managing preeclampsia at the NWT (Glanz & Bishop, 2010). The planning for the actual awareness sessions will involve individual nurses choosing the relevant information to disseminate. The session will take place in Yellowknife, where the largest hospital in the Northwest Territories is located.

Limitations and Barriers/Challenges of the Intervention

Limitations of the Intervention

One of the biggest limitations of carrying out the awareness sessions using the stages of change among nurses includes the linear nature of the theoretical plan model. This means the model does not give considerations of the different environmental, staff, and negative social factors in the NWT healthcare that may enhance the chances of failure of the changes in the intervention of preeclampsia (Davidson et al., 2010). The linear nature of the theoretical model used leaves room for over-confidence and lack of a risk assessment and management in the process.

In addition to the linear nature of the plan, the incorporation of the practise guideline in the educational model of the awareness sessions makes the change adopted after the implementation of the plan subject to the rigidity and the various limitations of the guidelines. The rigid nature of the guidelines will mean the various individual needs of the preeclamptic patients may not be considered, making the intervention subject to questions of best practice (Farias et al., 2013). Issues, such as the validity of the intervention, arise due to the various choice of guidelines that may be used by a nurse in his/her educational awareness session.

Barriers/Challenges (and Strategies to Reduce Them)

Cost of Travel

This is the case of nurses who conduct different presentations for different preeclamptic patients of different facilities in the NWT. One of the requirements of the plan is for a nurse to prepare an educational awareness session on preeclampsia. However, this being a project, there is the cost of nurses to travel between the Stanton Territorial Hospital and the Inuvik Regional Hospital. This was a financial issue when one nurse had to facilitate different sessions in the two facilities. Also, pregnant women were not accommodated in medical travel insurance options, forcing them to cover the transport from off-pocket means (Murphy, 2017). This should be the reason for stakeholder role definitions and financing of the activities of the public health preeclampsia intervention plan (Beringer et al., 2012). The strategy in defining the roles of stakeholders, such as a financial provision in the cost of travel, can help in the running of the awareness sessions by supporting other stakeholders, such as nurses and pregnant patients.

Health Facility Barrier

“In Fort Smith, the floor nurses do no act as second attendants, only the prenatal RN affiliated with the program is a second attendant. Healthcare providers reported some tensions between nurses and midwives because the former feel nervous when a higher-risk patient elects to give birth in Fort Smith, and they do not feel that they are prepared to manage any complications that could emerge in the community. Encouraging staff and creating opportunities for education and problem-solving can be beneficial for such nurses. This also includes providing and allocating resources to support implementation and sustainability (Mollon et al., 2012). Through opportunities for education and resources allocated to facilities, the confidence levels in implementing the intervention plan will increase among the relevant stakeholders.

Strengths of the Intervention

The intervention provides standardized care for preeclampsia across the territory, increases knowledge and when to transfer patients. Through the involvement of different experts, levels of management, and staff, this intervention also provides an all-rounded, acceptable, and well-planned plan of action. Its applicability and transferability mean the intervention plan can be implemented in every other healthcare facilities in Canada while considering the various environmental, institutional, and organizational factors specific to the different healthcare facilities. Managing preeclampsia through this intervention plan provides grounds through which awareness creation can influence behavioural change on both the patient community and caregivers. Through the linear-based theoretical approach of the stages of change in applying the educational awareness sessions, stakeholders of the intervention will be engaged strategically in ensuring their maintenance of positive behaviour in managing preeclampsia.

Evaluation Plan

The evaluation plan will be based on the National Database of Nursing Quality Indicators. Through the National Database of Nursing Quality Indicators, the implementation of this plan by obstetric nurses will be reported annually and quarterly (Montalvo, 2007). The intervention plan reporting will involve its outcomes in managing preeclampsia, its structure, and the process used by nurses in implementing the awareness sessions. Also, depending on the facility, this intervention will be used; factors, such as the relationship between healthcare facility staffing and patient outcomes in preeclampsia, can be evaluated using the database in NDNQI.

Conclusion

Preeclampsia is a hypertension disorder in pregnant women, which can be fatal if left uncontrolled. One of the reasons why the disease has proven difficult to manage is the controversies that exist in its management. It is with such reason that an educational intervention model that is based on awareness sessions was suggested in the Northwestern Territories of Canada. The intervention plan utilized the transtheoretical theory model/stages of change in planning the procedure through which stakeholders, such as nurse managers, nurses, different obstetrics experts, different levels of management, other staff, and patients, are to be engaged in awareness sessions. The sessions will involve each nurse preparing information on preeclampsia and disseminating to groups in different health facilities in the NWT. Through guidelines incorporated in the intervention plan awareness sessions, it is considered applicable and transferable to various facilities in the country.

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