key: cord-0926438-ow3j6uvu
authors: George, Erin K.; Weiseth, Amber; Edmonds, Joyce K.
title: Roles and Experiences of Registered Nurses on Labor and Delivery Units in the United States during the COVID-19 Pandemic
date: 2021-08-26
journal: J Obstet Gynecol Neonatal Nurs
DOI: 10.1016/j.jogn.2021.08.096
sha: 44da45eb01006e8c2433f6cc4bdc3887a4624001
doc_id: 926438
cord_uid: ow3j6uvu

Objective To examine the roles and experiences of labor and delivery (LD) nurses during the COVID-19 pandemic. Design Cross-sectional survey. Setting Online distribution between the beginning of July and end of August 2020 Participants Labor and delivery nurses (N = 757) responded to an open-ended question about changes to their roles during the COVID-19 pandemic as part of a larger national survey. Methods We calculated descriptive statistics on respondents’ characteristics and their hospitals’ characteristics. We applied conventional content analysis to free text comments. Results We derived four major categories from the responses: Changes in Roles and Responsibilities, Adaptations to Changes, Psychological Changes, and Perceived Effects on Labor Support. Nearly half (n = 328) of respondents reported changes in their roles and responsibilities during the COVID-19 pandemic. They described adaptations and responses to these changes and perceived effects on patient care. Infection control policies and practices and the stress of a rapidly changing work environment affected the provision of labor support and personal well-being. Conclusion The experiences described by respondents conveyed considerable changes in their roles and subsequent direct and indirect effects on quality of patient care and personal well-being. Policies and practices that can facilitate the ability of LD nurses to safely and securely remain at the bedside and provide high-touch, hands-on labor support are needed. The findings of our study can help facilitate the provision of labor support during times of disruption and foster the resiliency of the nursing workforce.

addressing disparities in perinatal health. In the international literature, Kang et al. (2021) 52 conducted a qualitative study of 24 labor and delivery nurses in South Korea to explore their 53 experiences of providing care during the pandemic. Understanding these experiences is vital to 54 informing emergent policy and practice that can support high-quality LD nursing care during and 55 after times of disruption. 56

Background 58

Concerns about the transmission of SARS-CoV-2 and COVID-19 infection among health 59 care providers and patients prompted hospitals across the United States to enact controversial 60 policies to restrict external labor support to one person per woman in labor. In the early stages of 61 the pandemic, New York City and other locales banned any labor support people external to 62 hospital staff (Diamond et al., 2020) . Limited evidence suggests that these restrictive policies 63 may have detrimentally affected women's childbirth experiences and birth outcomes. In a study 64 of 1,978 pregnant women in Canada, women who reported receiving less labor support 65 experienced increased symptoms of anxiety and depression during the COVID-19 pandemic 66 (Lebel et al., 2020) . Media outlets highlighted increases in elective labor inductions and cesarean 67 births at the start of the pandemic (Gantz, 2020) and restrictions that prevented women in labor 68 from leaving their hospital rooms (Gao, 2020) , which can minimize the physical movement 69 necessary to facilitate physiologic labor. A key concern is that these visitor restrictions, changes 70 in birth practices, and limitations of space for labor negatively affect the quality of patient care, 71

particularly the provision of labor support. 72 nurses, compared to other healthcare professionals. Our purpose was to examine the roles and 87 experiences of labor and delivery (LD) nurses during the COVID-19 pandemic. 88

Design 90

We used a cross-sectional, self-administered survey that was delivered online. The study 91 was approved by Harvard School of Public Health Institutional Review Board. 92

We collected data on respondent, hospital, and LD unit characteristics via a researcher-94 design survey. The survey included a measure of factors that are associated with the low-risk 95 cesarean birth rates and is entitled the Labor Culture Survey (Vangompel et al., 2018 We disseminated recruitment materials through social media and professional 113 organizations. We posted study advertisements with an electronic link to the survey and quick 114 response code on Facebook, LinkedIn, and Twitter. We also distributed recruitment materials to 115 leaders of state AWHONN sections and the Perinatal Quality Collaborative and requested wide 116 distribution among members. Our purpose was to achieve regional distribution. Information 117 about the purpose of the study, participation in the study, and data use was available upon arrival 118 at the survey site. Consent was implied when respondents clicked on the "agree" button and 119 started the survey. To maintain respondent anonymity, we used a separate survey to collect the 120 J o u r n a l P r e -p r o o f email addresses of respondents who opted to register for the study incentive, which was a 121 drawing for one of 45 $100.00 gift cards. 122

We calculated descriptive statistics on the respondent and hospital characteristics and 124 used content analysis to analyze the qualitative data provided by the 757 respondents who 125 answered the open-ended question. Content analysis is one research method used to 126 systematically and objectively describe words and phrases in communication text by creating 127 categories or a group of content that shares a commonality (Krippendorff, 2018) . We used a 128 conventional or inductive approach, in which responses were analyzed to allow meaning to 129 emerge rather than fitting responses into preconceived categories (Hsieh & Shannon, 2005) . 130

Using an iterative approach, the first (EKG) and last authors (JKE) repetitively read the verbatim 131 written comments about role change during the COVID-19. The first author (EKG), a certified 132 nurse-midwife and nursing PhD student read the responses to gain general insight and an initial 133 understanding of similarities and differences. The responses were then re-read to condense their 134 meanings and construct an initial list of codes. The last author (JKE), a nurse scientist with more 135 than 10 years of experience in mixed methods research, reviewed the codes with their associated 136 meanings. The first and second authors developed the code list and refined the codes iteratively 137 until they reached consensus. The first author then applied the corresponding code or codes to 138 each response, checking samples of the coding with the second author to ensure consistent 139 application of the coding schema. After the initial coding, we merged similar codes and 140 abstracted them into four main categories. We coded each response with one or more of the main 141 categories, calculated the frequencies of the categories, and identified exemplar quotes. 

The responses to the open-ended question varied from single phrases to several lengthy 159 sentences. We developed four major response categories, Changes in Roles and Responsibilities, 160

Provision of Labor Support, though content analysis. Table 2 Nurses are expected to carry out additional roles. After delivery, we mop the floors, 177 because housekeeping isn't expected to come into a COVID + room. Also, lab technicians 178 are refusing to come into the rooms and asking the nurse to go in and perform the draws 179 (associate degree in nursing [ADN], 6-10 years of experience working at a suburban 180 community hospital). 181

While acknowledging the need to reduce infection risk on the unit, respondents reported 182 that these additional responsibilities increased demands on their time, took them away from the 183 bedside and distracted them from providing direct patient care, including labor support. As one 184 respondent described, reductions in staffing due to task shifting influenced care provision: "Our 185 staffing has dramatically been decreased so that our labor nurses can help throughout the rest of 186 the hospital. This has placed an immense strain on our ability to perform labor support" (BSN, 6-187 10 years of experience working at an urban academic medical center). 188

Respondents also reported being assigned to other hospital departments to provide care 189 on COVID-19 units during a surge or to conduct COVID-19 screenings on other units, requiring 190 them to join unfamiliar teams. As one respondent discussed, "On this unit it's now mandatory 191 that we float to other units if needed, including COVID units. We are all expected to take on 192 more responsibilities in an effort to help other team units within our hospital system" (ADN, 15 years of experience working at a suburban community hospital). 194

In addition, respondents frequently commented on changes in their roles and 195 responsibilities that affected the staffing and nurse-patient ratios on their units. When nurses took 196 on ancillary responsibilities or were rotated away from their units, the nurses remaining on the 197 unit faced an increase in patient care demands: "Staff has been taken from unit to screen temps in 198 hospital lobby, so we are working with less staff but now just as busy as before COVID" (BSN, 199 11-15 years of experience working at an urban academic medical center). Another respondent commented on PPE as a barrier to even enter a patient room: "If a patient is 210 suspected of having COVID-19 or tested positive, it is much more difficult to care for them due 211 J o u r n a l P r e -p r o o f to clustering care and the time spent donning and doffing PPE" (BSN, < 2 years of LD 212 experience working at an urban academic medical center). Finally, one respondent reported that 213 clustering care became policy on their units in order to preserve PPE: "It takes a long time to 214 enter a COVID room, and we are told by management to cluster care to avoid excessive use of 215 supplies" (BSN, 6-10 years of experience working at an urban academic medical center). 216

Respondents discussed the additional expectation that they "police" patients and support 217 people to enforce infection control practices, including monitoring adherence to proper mask 218 wearing, ensuring proper hand washing, and conducting signs and symptoms assessment "We 219 now have to screen/monitor and temp check the support person(s) and 'police' proper masking 220 protocol for patient and support person" (MSN, greater than 15 years of experience working at a 221 suburban community hospital). Respondents recounted feeling particularly responsible to assess 222 for COVID-19 signs and symptoms among their patients' support people, who did not have to 223 submit to required COVID screening at their hospitals: 224

We do still allow one support person to stay in attendance and I find that has been one of 225 our issues is to ensure they are wearing their masks at all times and not symptomatic as The most difficult aspect of this pandemic has been the lack of adequate PPE. Reusing 255 surgical masks and N95s, having to order off-brand gowns and shoe covers, and using 256 house-made hand sanitizer has had a toll on all providers. Unfortunately, there is no end 257 J o u r n a l P r e -p r o o f in sight for us, even as the state opens up and the public thinks the pandemic is behind 258 them as indicated by respondent's (BSN, less than 2 years of experience working at an 259 urban academic medical center). 260

Respondents recounted being forced to re-use PPE and expressed concern about the 261 diminished effectiveness of reused PPE in protecting them from COVID-19 infection. They 262 reported feeling personally unsafe and worried about becoming infected: "Also the emotional 263 stress of not having the testing we need, the PPE that we need, and worrying that you will catch 264 the virus" (BSN, less than 2 years of experience working at an urban academic medical center). have constant COVID changes and extra duties plus additional "normal" hospital 282 changes. It feels like too much. Our hospital has been short-staffed and far from 283 AWHONN staffing guidelines, but we keep getting more and more demanded of us at 284 work. If our night shift crew didn't stay over, we would have ratios of three labor patients 285 to two nurses many days. But managers and admin refuse to get us staff because they 286 claim they are not making budget. So nurses are leaving in droves, and our code whites 287 (maternal hemorrhages) and other codes are skyrocketing (BSN, 2-5 years of experience 288 working at a suburban academic medical center). 289

Respondents (n = 262) consistently commented on how COVID-19 related changes 291 affected patient care, particularly the amount of time they had available to spend at the bedside 292 providing labor support. In some cases, respondents reported an increased opportunity to provide 293 labor support. Among these responses, a common sentiment of personal responsibility emerged, 294 in which respondents focused on patient well-being in the context of visitor restrictions, 295 widespread patient anxiety, and constraints on movement outside the labor rooms: 296

We [the nurses] have become more of the emotional support because of the prohibitive 297 rules on visitation. We are also actually in the patient rooms more because of the new 298 rules. We have to provide anything and everything for both the patient and her support 299 person as we no longer allow them to leave their room to go for food or drinks and 300 such. We are the patients' partners, their moms, their doulas, and in the end their friends. 301

We encourage and cheer them on. We also commiserate and cry with them when things 302 J o u r n a l P r e -p r o o f don't go as planned (ADN, < 2 years of experience working at an urban community 303 hospital). 304

In some cases, respondents commented that visitor restrictions, which resulted in fewer 305 external support people present in a labor room, reduced distractions and improved their ability 306 to focus on patient-centered care: 307 I feel as though I am able to provide better patient care and give a safer and more 308 excellent experience because of the visitor allowance being only 1 person at the bedside 309 for non-COVID patients. It allows me to focus on the patient instead of the support 310 people and all of their requests and needs (ADN, 6-10 years of experience working at a 311 suburban community hospital). 312

Several respondents detailed hospital policies that mandated continuous blocks of time be 313 spent in patient rooms. This required time at the bedside was an attempt to preserve PPE and to 314 diminish cross-staff and cross-patient contact, particularly among patients known or suspected to 315 have COVID-19 infections: "With suspected or confirmed COVID-19 laboring mothers, we are 316 required to stay at bedside with the mother in 4 to 6 hour increments to decrease use of PPE" 317 (BSN, 11-15 years of experience working at a suburban community hospital). 318

While enabling one-on-one patient care, this mandated or dedicated time in one room 319 reduced the availability of nurses to work as a team providing hands-on labor support: "Would 320 be more available to help other nurses with hands on labor support but now try to limit time 321 spent in more than one patient room to decrease cross-contamination" (MSN, 11-15 Having to think about protecting ourselves with PPE before entering a patient room 327 during an emergency. It is not in our nature to pause and don PPE before entering a 328 patient room to assist in resuscitation efforts…We are also limiting how many people 329 rush into a room for a deceleration. Prior to COVID, all available nurses would go 330 running. Now, only 2 to 3 will go in depending on the situation just to limit staff 331 exposure to potential COVID patients" (MSN, 2-5 years of experience working at a 332 suburban community hospital). 333

Respondents also emphasized that PPE hindered their ability to communicate and form 334 connections with their patients, which they believed affected the provision of labor support: "I 335 nurse the monitor more than I do the patient. I am unable to build the rapport with my patients 336 that I did before having to wear a mask all the time. Can't get a full communicative picture" 337 (BSN, 2-6 years of experience working at a suburban community hospital). One respondent 338 summarized her perceptions of how these barriers affected patient care: "I think patient care has 339 suffered because most nurses who would normally stay at the bedside are now leaving their 340 patients more frequently" (ADN, 2-5 years of experience working at a suburban academic 341 medical center). Schroeder et al., 2020). A fundamental concern is that nurses who experience the strains of the 362 COVID-19 pandemic will leave the profession, which will further exacerbate the nursing 363 shortage in the United States, and an estimated half-million nursing jobs will go unfilled by 2030 364 (Zhang et al., 2018) . Note. ANCC = American Nurse Credentialing Center. 569 J o u r n a l P r e -p r o o f 

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