An institutional ethnographic exploration of nurses' work in labour and delivery

Kelly, Paula (2022) An institutional ethnographic exploration of nurses' work in labour and delivery. Doctoral (PhD) thesis, Memorial University of Newfoundland.

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Abstract

Background: Although intermittent auscultation during low-risk labour is recommended (Society of Obstetricians and Gynaecologists Canada, 2007, 2018, 2020), nurses often use continuous electronic monitoring to assess fetal heart rate during the intrapartum period irrespective of women’s risk levels. Electronic fetal monitoring confines women to the birthing bed, thus preventing positions and movements that leverage gravity in the natural progress of labour. Its routine use also increases the risk of adverse effects of instrumental vaginal and surgical births. While some nurse researchers have examined barriers to the implementation of best practice guidelines during fetal health surveillance, research exploring the associated broader social forces to gain a deeper understanding of nurses’ work in labour and delivery, has not yet been conducted. Purpose: The purpose of this dissertation research was to gain insight into nurses’ work by examining how nurses carry out fetal health surveillance, particularly how and why nurses choose to use continuous electronic fetal monitoring. The specific research questions were: What are the everyday experiences of labour and delivery nurses related to fetal health surveillance? What social relations organize and influence how labour and delivery nurses conduct fetal health surveillance? Answering these questions is the critical first step in promoting best practices in the nursing care of labouring women. Methods: An institutional ethnographic study was conducted in a labour and delivery unit. Data sources included documents (e.g., national practice guidelines, unit policies, and patient chart forms), semi-structured interviews of inter-disciplinary practitioners, and participant observation. Data analysis included indexing, mapping, and writing accounts. Findings: Powerful textually-mediated ruling relations organize and influence nurses’ work. Notably, biomedical and medical-legal discourses infiltrate the “boss text” (i.e., national practice guidelines) and establish an ideological space that influences fetal health surveillance policies and procedures (e.g., electronic fetal monitoring). Nurses’ everyday work decisions are shaped by organizational texts (i.e., patient chart forms) that require considerable time devoted to documentation of biophysical data (e.g., fetal heart rate) and limit focus on holistic nursing care practices. Conclusions: Labour and delivery nurses are choosing continuous electronic fetal monitoring over intermittent auscultation to fulfill mandated documentation requirements that are regulated by biomedical and medical-legal discourses. Documentation reflects the influence of these discursive ruling relations—primarily the valuing of biomedical, technological interventions over supportive nursing care measures and safeguarding the institution against risk of litigation.

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