Requirements of a Labor and Delivery Nurse

Pregnancy is the gestational process compromising growth and development within a woman of a new individual from conception through the embryonic and fetal periods to birth. Pregnancy lasts for two hundred and eighty days, clinically considered forty week from the first day of the last menstrual period. Psychological changes are emotional experiences of pregnancy, as reported by a pregnant woman. Being keenly aware of the rapid and inevitable changes of the body the pregnant woman is undergoing. The nurse can help the parents in decision making about the concerns for the pregnancy. It is vital to make the mother understand the physiological processes, preparation for labour and to plan for the infant’s needs. The basic goal of antenatal or prenatal care provided by the nurses is to offer proper information to the pregnant women and the family about the current pregnancy. As well as provide emotional support, good nutritional advice and careful observation which will help the mother to achieve healthy and happy maternity period.

To begin with, there are many factors that influence pregnancy which are often diagnosed during the antenatal clinic visits. The case study discussed below highlights the factor of pregnancy induced hypertension. Hypertension mostly affects pregnant women aged less than eighteen years and more than forty years. Blood pressure ranges from 140/90 mmHg to 160/110mmHg. Recently on booking, a mother came with the history of pregnancy induced hypertension. Mrs. X is twenty-four years old with the weight of fifty-five kilograms. She lives in Seaqaqa with her husband, parents-in-law and only son who is two years old. Mrs. X’s husband is a farmer, as she stays home and does domestic duties.

Moreover, during Mrs. X’s initial visit to the antenatal clinic she presented the signs and symptoms which included nausea and vomiting. After diagnosis it was found that she had high blood pressure, however no other medical disorder. The blood pressure was 150/100 mmHg which showed a sign of pregnancy induced hypertension. Mrs. X does not consume kava or alcohol and does not even smoke. Upon history taking it was mentioned that after her first child she often took out some time for social life, whereby participated in netball training. According to Mrs. X it relieved stress and help her keep fit and healthy. Mrs. X was previously admitted in hospital during the delivery of the first child. However, Mrs. X neither encountered any complication for the first pregnancy nor went for any surgery previously whereas during the recent pregnancy antenatal clinic it has been found that she has hypertension.

Initially when Mrs. X came to the hospital she had swollen legs, elevated blood pressure, therefore her twenty-four hours urine was taken to test for protein in urine. Proteinuria was diagnosed which was more than 0.3 grams of protein in one litre of urine. However, there was no sign of vaginal discharge, blood or amniotic fluid shown for gynecological disorder. Mrs. X had her last menstrual period on the 7

^th

February, 2014 which lasted for seven days. The bleeding was heavy for the first three days and then became mild as Mrs. X used to have the menstruations every month in the same rhythm (severe to mild). The Pap smear test was done after two months from the first delivery as the results were normal. Mrs. X used condom as the family planning method. She is gravid of two and parity of one. Mrs. X delivered the first baby normally with a birth weight of 3.1 kilograms. In the second pregnancy she has pregnancy induced hypertension during the twenty weeks of gestation. Mrs. X is currently prescribed for antihypertensive drugs by the physician. Mrs. X should deliver on the expected date of delivery which is the 14

^th

of November, 2014.

Furthermore, Mrs. X’s physical examination was done. It was done to assess fetal growth and development. Vital signs were taken as follows; pulse rate 78 beats per minute, respiration rate was 24 breaths per minute, temperature was 37.2 C and blood pressure was 150/100 mmHg. The weight was sixty-two kilograms during pregnancy therefore her body mass index was calculated as it was the leading factor to pregnancy induced hypertension complication. Blood pressure was taken when Mrs. X was resting however, it was still elevated of a reading of 148/100 mmHg. Therefore, the blood pressure was taken every two hours to see for any progress which was documented. Urinalysis was performed. During the initial visit the midstream urine was collected and sent to the laboratory for culture. Results showed protein in urine due to hypertensive disorder in pregnancy. Blood test was also done on booking for full blood count. An eye examination was done to check for further retinal changes. Liver and kidney enzyme function test was also done.

The aim of antenatal care is to monitor the progress of pregnancy which optimizes maternal and fetal health. The nurse can evaluate; “physical, emotional and sociological effects in pregnancy on the women and the family” (Fraser & Cooper, 2009). Some ways to achieve antenatal care are as follows; by developing a partnership with the mother. The nurse should communicate friendly in order to know more information about the problems that the mother is facing and the nurse can help in solving the problem. Secondly, by providing holistic approach to the pregnant mother’s care that meets the individual needs. Preparing the mother physically and psychologically will help her to make the choice of either for vaginal delivery or opting for a caesarean delivery because of pregnancy induced hypertension. The nurse should provide tender and loving care to the mother. Furthermore, as a nurse provide information to the mother and the family members to enable them to make informed choices about the current pregnancy. Nurses can advocate for the pregnant mother to the family about the nutritious foods and adequate rest required by the mother cause of the current health condition. As well as providing an opportunity for Mrs. X and the family to express the views and concerns about the pregnancy. Advise the mother that breastfeeding will be the best method of feeding and nutrition for the newborn baby. Nurse can explain the advantages of breastfeeding as it will be a sensitive advice to support the pregnant mother’s decision. The nurse can show the proper positioning of the baby during breastfeeding, for example; using rugby ball method. Advice the mother on buying the baby’s clothes and other required items as it will facilitate the woman and the family to prepare accordingly to meet the demands of the forth coming child. Offer parenthood education within a planned programme or on an individual basis as it will promote awareness on public health issues for the mother and the family. Giving public health advice and pertaining pregnancy in order to maintain the health of the mother and fetus. Nurses can build a trust relationship with the mother is in part of care, love and safety for the mother.

To add on, nurses play a vital role when managing the health of the mother with pregnancy induced hypertension. Nurses should communicate effectively and sensitively. Redman (2007) suggests that: “understanding and self-confidence in a woman will develop her relationships with nurses” . The nurse should sit at the bedside of the mother and communicate with her, in order to understand the problems and difficulties the mother is facing. Nurses can find possible solution for the problems and help the mother in solving the problem, as it will help build a more therapeutic relationship between the mother and the nurse. Mrs. X should be advised on adequate bed rest. Though, rest does not prevent the development of pre-eclampsia. It is important to make the family members understand that, Mrs. X should lie on her left side since left side relieves pressure and symptom associated with pain, hence also facilitates venous return increasing the circulatory volume, renal and placental perfusion and blood pressure (Gilbert, 2007). Therefore the mother needs to have adequate rest, for at least eight to twelve hours and away from stress. If the mother has high blood pressure she can be admitted to the hospital. However, it is most preferable if the mother rests at home and visits hospital after every two weeks. Hospital visits will facilitate the nurse to check her blood pressure and compare the previous readings, check whether it is elevated, decreasing or remains the same as previous reading (150/100 mmHg).

The mother’s vital signs should be taken in every clinic. Elevated blood pressure ranges from 140/90 mmHg to 160/110 mmHg shows sign of pregnancy induced hypertension. Fluid balance can be maintained if there will be reduced intravascular compartment in pre-eclampsia and poorly controlled fluid balance may result in circulatory overload and pulmonary edema (Gilbert, 2007). The nurse can use water therapy for severe edema. Water therapy helps prevent or slow the progression of pre-eclampsia. The nurse should advice the mother which diet she should take due to hypertension, which is having low salt low fat diet. Advise the mother to consume those food which are locally available rather than foods which are imported from overseas countries or canned and junk food. For instance, locally available food includes pumpkin, cabbage, fish, bean and many more. Educate the mother on food which contains iron, fibre, vitamins and protein as it is good for the mother’s health and for the growing fetus. “Prophylactic fish oil in pregnancy may perform as an anti-platelet mediator, thereby it prevents hypertension and protein uric pre-eclampsia”. (Redman, 2007). Pregnant mother should consume at least eight glasses of water per day is important for her. Calcium supplement reduces the risk of pre-eclampsia especially of patients that have diets deficient in calcium. Exercise is also important for Mrs. X and the growing fetus. Nurse can teach the mother on some exercises which the mother can practice like kegel’s exercise. Exercise will keep the mother and fetus healthy and it will also help in contraction of uterus muscle. This will help mother feel comfortable and less painful for normal vaginal delivery. Exercise will also reduce stress and provide healthy and refreshing body and mind.

Health care professionals can also help the nurse in managing the pregnant woman in various ways. Other health specialist can get together and collaborate what kind of treatment the mother should get to reduce pregnancy induced hypertension and have a healthy baby. Firstly, the radiologist (x-ray) department, can scan and the check for gestational age of the growing fetus. They also check the health of fetus and document the fetal movement and fetal kicks. Change in the number of frequency may mean the fetus is under stress. An ultrasound scans for measurement of fetal movement, fetal kick and direction of fetal position. Laboratory technicians can do the mothers blood test and urine test. Serology department would experiment the 24 hours urine collection, to found out whether it has protein present in it. Physical examination of urine can rule out the level glucose, protein content and ketones. Microscopic examination of urine, which will show blood cells and microorganisms. The hematology department does full blood count, that includes hematocrit, Hemoglobin level, red blood cell and white blood cell count. Hematocrit is the percentage of red blood cell mass in mother’s blood volume. Hemoglobin is the main cellular component contains red blood cells.

The physiotherapist can help mother by teaching Mrs. X some exercise which will be helpful and effective for her. Bed exercises increases the blood flow, keep the muscle toned, leg exercise for example foot circles at least two times daily, kegel’s exercise and abdominal tightening exercise which keeps abdominal muscle tone. Kegel’s exercise can be done at least five times daily because it helps prevent the loss of muscle tone which occurs after child birth. This exercise involves contracting muscles around vagina holding tightly for ten seconds and then relaxing for two seconds, the woman should be work up for thirty contractions. Moreover, the dietician can also advise the mother on low salt low fat diet. Advises the mother to use salt as needed for taste, and that adequate nutrition is important for pregnant mothers eating a nutritious balance diet containing high amounts of calcium, magnesium, and iron, vitamins, less sodium, folic acid and increase amount of protein to take. As it reduces the risk of pre-eclampsia especially in patient who have diet deficit, avoid beverages containing caffeine and drink six-eight glasses of water per day is also important because it reduces the risk of dehydration and improves proper blood circulation which reduces risk of pre-eclampsia.

Hence, a counselor can also counsel the parents on the antenatal care which should be provided to the mother. The prenatal education should focus on the positive labor and birth experiences and ways in which the mother can have decreased blood pressure. Advice Mrs. X if she has any fever, rupture of membrane or leak of fluid, decrease fetal movement, vaginal bleeding, feeling of nausea and vomiting as to immediately complain to the nurse before any further complications arise. Since the mother is a non-smoker and non-alcoholic it is better to advise her to stay away from anybody smokers and not to consume alcohol so that it does not affect the growing fetus. Provide information about breastfeeding techniques which is very supportive approach. “Expected length of breastfeeding is an important prenatal factor associated with breastfeeding period”. (Pairman, Pincombe, Thorogood & Tracy, 2006). Due to increase breastfeeding duration there will be increased maternal confidence in breastfeeding and handling the child. Child birth education is also important for the mother. This provides opportunity for enhancement of family systems and can facilitate the family to empower behavior that lasts longer. Furthermore, a dentist is needed to check oral care of the mother, where the dentist can check for any decaying tooth or paining gums. This can cause pain and headache and increase the mother’s blood pressure. Treatment could be given accordingly. As the dentist can advise the mother about proper oral care, for instance; on brushing her teeth twice daily this will be healthy.

In evaluation, after the diagnosis it was found that Mrs. X had pregnancy induced hypertension. Mrs. X tried herbal medicines and followed all the nursing management which was advised to her. Though there weaknesses, which include; family members were not allowing her to come to hospital alone, mostly her mother-in-law accompanied on the antenatal clinic visits which became a hindrance for Mrs. X while expressing her views and concerns. Hence, a few times Mrs. X does not have enough money to pay for the fare since her husband was inco-operative. At certain times due to fear, anxiety and stress Mrs. X was unable to express the problems which made it difficult to exam her problems. Though Mrs. X had some weaknesses but she tried her best to co-operate with the nurses so that she has a healthy maternity period and at last to have a healthy baby. After providing successful interventions, the strength of Mrs. X was also shown as she tried to follow all the steps given by the nurses so that she can have a healthy baby.

(Approximately: 2,498 words)

References

• Cooper, M. A., & Fraser, D. M. (2009).
  
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• Gilbert, E. S. (2007).
  
  Manual of High Risk Pregnancy Delivery.
  
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• Pairman, S., Pincombe, J., Thorogood, C., & Tracy, S. (2006).
  
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• Redman, B. K. (2007).
  
  The Practice of Patient Education: A Case Study Approach.
  
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• Weber, J. C. (2003).
  
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A crucial factor dominating health organisations in NSW, Australia and the world has been identified as patient safety and quality of care. Literature indicates that in order to achieve these objectives, there is need for effective clinical leadership to occur. This essay will discuss and analyse the impact of leadership development, with a focus on transformational leadership and related matters, on both the individual and health care.

To understand how and why leadership in health care emerged as a necessity to avoid failure in health care, it is important to consider the Garling Report (2008) and the Mid Staffordshire Report (2013), of which both provided a multitude of recommendations for NSW and British public hospitals, following an inquiry into their systems after a number of high profile incidents which brought into question patient safety and quality of care.

Garling SC (2008) and Francis QC (2013) both identified that in order to overcome these endemic issues, it is necessary to make a widespread cultural change within the public hospital system and as part of that process, it is imperative to engage frontline clinicians in ongoing leadership education and training. Garling SC (2008) also indicated the need to reform and redesign traditional leadership models in order to improve the delivery of health care, which is increasingly reliant on effective clinical leadership at all levels. Focus should be on creating an inter-disciplinary team approach to patient care, which according to evidence, produces the greatest possible outcomes (Garling SC 2008). This aims to continuously provide the best level of patient-based care and patient safety.

Having considered why effective leadership emerged as a necessity, it is important to review the concept of leadership. It is an interactive relationship between the leader and followers (Kouzes and Posner 2012). For a culture shift towards a patient based care model to occur, leaders must effectively define, communicate and guide the vision for the organisation in order to ensure engagement at all levels Frampton et al. (as cited in Cliff 2012, p381).

Effective leadership is vital for inspiring, engaging and motivating others to achieve greatness. Govier and Nash (2009), highlight that is through having a shared vision that moves people towards achieving the necessary common goal of providing safe and high quality health care, that leadership can occur at all levels. Covey 2006 (as cited in Govier and Nash 2009), indicated that in order to increase the effectiveness of management, leadership needs to come first. This therefore indicates the need for management and frontline clinicians to work together to tackle the many challenges that exist within health care. Furthermore, this is indicated by Vaill 1996 (as cited in Govier and Nash 2009) who argued that there is always a need for management in order to effectively run everyday procedures, however successful handling of the constant changes and instability, begins with effective leadership.

As Kouzes and Posner (2012) suggest, to achieve this success, effective leaders must employ their Five Practices of Exemplary Leadership, including; Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act and Encourage the Heart. This incorporates leading by example, inspiring others through shared desires, making changes through risk taking and challenging oneself, whilst promoting an environment where team work, mutual respect and trust is exercised and where successes are celebrated.

Personal experience suggests that through the variety of courses and workshops now offered via NSW health, the necessary ongoing education in leadership is occurring. As Health Workforce Australia (2013, p.4) prominently state ‘capable leadership, governance, and management are cornerstones of successful efforts to improve the quality of lives and to achieve the maximum impact from health investments’. Having worked the past three years within a team leader role in Occupational Therapy, continuous education has enabled successful running of a strong, caring, hard-working, energetic team, whose primary focus is on patient care and safety. After all, these are the core values of Occupational Therapy practice.

Literature supports the ongoing education of leaders, as Kouzes and Posner (2012) state, leadership is a skill set obtainable by anyone. This is also consistent with Health Workforce Australia (2013) who highlights in their LEADS framework, that in order for successful improvement to occur and endure the ever-changing health care system, specific knowledge and skills are required to become an effective leader. As Covey 2006 (as cited in Govier and Nash 2009) emphasised, by employing a solid foundation of core values, incorporating trust, contribution, dignity, empowerment and growth, the ability to react and adjust appropriately to these changes is possible.

Garling SC (2012) emphasises that by creating individual clinical leaders throughout the health care system, patient safety and quality health care will be continuously achieved. It is through the reflection, ongoing development and improvement of one’s self, that enables this leadership to begin occur (Kousez and Posner 2012; Health Workforce Australia 2013). Health Workforce Australia (2013) have created a model which encompasses the concepts of the transformational leadership theory whereby, once self-awareness and personal development is achieved, individual leaders within the organisation are able to engage others by sharing values, communicating openly and honestly, supporting other team members in growing and developing to continue to strengthen as a department, team and organisation. From here, leaders will work closely with colleagues and patients to ascertain, guide and set achievable goals that realise the shared vision. They will continue to evaluate outcomes, celebrating successes along the way. An environment fostering the awareness and need for positive changes will be promoted and encouraged, this in turn will continue to inspire others to achieve positive outcomes and best possible care for patients.

The results of a study by Wylie and Gallagher (2009) around transformational leadership behaviours in allied health professionals revealed that one of the most significant influences on self-reported leadership behaviours is that of leadership training. Those who received training within the leadership area were able to score a significantly higher aggregated transformational leadership score, compared with those allied health professionals who had not. These results correspond with the findings of Kouzes and Posner (as cited in Wylie and Gallagher 2009), found that transformational leadership and self-awareness are more evident those who received leadership training.

To best rise to the challenge and meet the recommendations of both inquiries, there is the need for implementation of not only leadership, but more specifically transformational leadership. This because, although over time there have been many other leadership theories, they have generally concentrated on what an effective leader is, rather than how to effectively lead (Armandi et al. 2003). Transformational leadership embodies the principles that are able to combat the instability and constantly changing environment in hospitals.

Research by Halter and Bass (as cited in Armandi et al. 2003, p. 1079) and Weberg (2010), indicated that when transformational leadership is implemented within the health care setting, there is a positive impact on staff retention, job satisfaction, loyalty, burnout rates and overall staff well-being. From experience, this positive impact results in safer, improved patient care. This is supported in the article by Govier and Nash (2009), who reported that in large organisations such hospitals, there are increased levels of pressure on frontline staff to produce quality work and outcomes. If this occurs, stress levels and reduced performance also occurs and this leads to the potential harm of those being cared for. If leaders empower frontline clinicians and place ownership of care in their hands, then health care can be transformed from the bottom up, rather than top down, therefore meeting the recommendation of Garling SC (2008).

Having previously worked closely with a manager and mentor, who embodied transformational leadership principles, had open, honest communication, trust and respect for all staff, this enabled both personal and professional growth, as well as positive development as a clinician and leader. As the article by Rolfe (2011) indicates, transformational leadership is a cyclical process whereby leaders empower their followers, which in turn fosters the growth and development of these followers into leaders themselves. Having experienced this first hand, it is safe to say that this enabled better leadership of the inpatient Occupational Therapy team, empowering and inspiring them to achieve positive improvements in patient care.

Stepping into a team leader role three years ago was an enormous challenge. After gaining insight into recent times and history of the Occupational Therapy department, it was clear that instability, uncertainty and low morale had taken over. There had been a multitude of changes both within the hospital and wider organisation as well as within the department itself. Facing the challenge head on was the only way to make significant improvements. By closely building relationships with the individual team members and gaining an understanding into their driving forces, trust and mutual respect began to emerge. Through the implementation of a weekly inpatient team meeting, a structured environment was created to facilitate open communication and allow the discussion of complex cases and individual issues together in order to increase knowledge and solve problems as a team.

This further instilled a sense of trust and confidence by showing commitment to self and the organisation, demonstrating strong open, honest communication skills and being supportive with a mentorship approach, with the main purpose of ensuring best possible care for patients. As Kouzes and Posner (2012) state that when a relationship is built on mutual respect and confidence, the greatest of difficulties can be overcome and a lasting impact remains.

This is supported in the article by Govier and Nash (2009), who emphasise the importance of being a proactive leader, by solving problems with a positive approach, rather than reporting problems whilst others resolve them. They go on to say that leadership is then seen as a choice rather than a position and will therefore be focussed on ensuring that things get done in a positive way, therefore enhancing patient care.

Based on experience with clinical supervision with junior staff, the traits of transformational leadership are also carried out. Regular supervision sessions with staff have enabled growth within the leadership area as well. It has enabled ongoing education and knowledge to be imparted on staff through discussion of their practices on the ward, with attention to solving complex issues and cases. Through the method of asking reflective, open-ended questions, it has empowered the team to review their own values and performance, which has resulted in an increase in staff engagement and a stronger sense of purpose, as a direct result of a leader investing in them. Evidence supports this, for instance Porter-O’Grady and Malloch (as cited in Weberg 2010 p. 246), report that transformational leaders are not only inspiring, however also assist their staff or followers to solve problems by assisting them to be aware of issues and develop the necessary means to overcome their difficulties.

Transformational leadership looks at the relationship between the leader and followers and states that when followers are able to have input into a team or organisational vision, there is an increase in their sense of value and hence this relationship is improved (Rolfe 2011, p. 55). From personal experience as a trained Essentials of Care facilitator, this is accurate. The process involved being trained in working with frontline staff to make the necessary changes to improve patient-based care. Through working closely with multi-disciplinary staff to review their personal and professional values, a shared values statement emerged. It is through this shared value and vision, that staff became empowered to start making frontline changes to improve patient care. Daft (as cited in Rolfe 2011, p. 55) stated that when staff feel empowered and have a sense of purpose, then the workplace environment becomes more positive, with increased motivation and job satisfaction. This then has a direct impact on quality of patient-based care.

From personal experience, being the representative for Occupational Therapy on the hospital falls advisory committee has demonstrated such leadership characteristics as leading by example and being a role model for other members of the department. This committee focusses directly on patient care and is comprised of a multi-disciplinary team who guide and lead the hospital in falls prevention best practice. It is through teamwork and shared leadership and expertise that successes are generated (Ward as cited in Rolfe 2011, p. 56).

In summary, it can be seen that in order to achieve and maintain best possible patient-based care and safety, leadership must be developed throughout all areas of health care, focussing on frontline clinicians. It is through ongoing investment in training and education in the field of leadership that this can be accomplished. Through learning and practicing transformational leadership, staff at all levels are empowered, motivated and inspired to provide the best possible care for patients. This in turn has a positive impact, which affects individual staff, teams and organisations within health care and as a result, the quality of patient care.

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