The Journal of Continuing Education in Nursing

Original Article 

Improving the Clinical Skills and Knowledge of Midwives and Nurses Caring for Late Preterm Neonates

Alannah L. Cooper, BNurs(Hons), RN; Janie A. Brown, PhD, MEd, BN, RN; Therese O'Connor, BNurs, GDip Midw, RN, RM; Siobhan Eccles, BSc Midwifery, GCert Leadership & Management, RM

Abstract

Background:

Due to changes in funding, late pre-term neonates are no longer admitted to neonatal units unless diagnosed with a specific medical condition. Consequently, neonates born at a gestational age of 35 weeks and 0 days to 36 weeks and 6 days are cared for on postnatal wards. Compared with full-term infants, late preterm neonates are at increased risk of hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulties, respiratory complications, and mortality.

Method:

An educational intervention focusing on the care of the late preterm neonate was developed, and quantitative data were collected pre- and post-intervention to assess the effect on knowledge, skills, and attitudes.

Results:

Of the midwives and nurses who participated, 65% (n = 13) strongly agreed and 35% (n = 7) agreed their knowledge and confidence had increased. The mean score increased from a range of 20 to 25 pre-intervention to 22 to 25 post-intervention.

Conclusion:

The intervention increased the self-reported confidence and self-reported competence of participants, who also felt more supported caring for late preterm neonates. [J Contin Educ Nurs. 2019;50(12):551–556.]

Abstract

Background:

Due to changes in funding, late pre-term neonates are no longer admitted to neonatal units unless diagnosed with a specific medical condition. Consequently, neonates born at a gestational age of 35 weeks and 0 days to 36 weeks and 6 days are cared for on postnatal wards. Compared with full-term infants, late preterm neonates are at increased risk of hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulties, respiratory complications, and mortality.

Method:

An educational intervention focusing on the care of the late preterm neonate was developed, and quantitative data were collected pre- and post-intervention to assess the effect on knowledge, skills, and attitudes.

Results:

Of the midwives and nurses who participated, 65% (n = 13) strongly agreed and 35% (n = 7) agreed their knowledge and confidence had increased. The mean score increased from a range of 20 to 25 pre-intervention to 22 to 25 post-intervention.

Conclusion:

The intervention increased the self-reported confidence and self-reported competence of participants, who also felt more supported caring for late preterm neonates. [J Contin Educ Nurs. 2019;50(12):551–556.]

Late preterm neonates are born at a gestational age between 34 weeks and 0 days and 36 weeks and 6 days. Research into premature neonates has largely focused on early preterm neonates, infants born before a gestational age of 32 weeks, who are at the greatest risk of morbidity and mortality (Fleming, Arora, Mitting, & Aladangady, 2014). However, it is recognized that all premature neonates are at greater risk compared with full-term infants (Machado, Passini, Rosa, & Carvalho, 2014; Medoff Cooper et al., 2012; Ognean, Boantă, & Chicea, 2016; Teune et al., 2011). Late (34 weeks and 0 days to 36 weeks and 6 days) and moderately preterm births (32 weeks and 0 days to 33 weeks and 6 days) account for approximately 75% of all preterm births (Boyle et al., 2015). The number of preterm neonates is rising, and the most significant increase has been in the number of late pre-term births (Ognean et al., 2016; Raju, Higgins, Stark, & Leveno, 2006; Teune et al., 2011). This increase has coincided with a greater number of elective deliveries by caesarean section or induced labor (Baker, 2015; Betrán et al., 2016).

Due to the increased risks for late preterm neonates, the need to identify and reduce preventable late preterm births has been acknowledged (Kardatzke, Rose, & Engle, 2017). The risks are due to the interruption of normal fetal development during the final 6 weeks of gestation in which there is critical development of the brain and lungs (Kugelman & Colin, 2013). It has been found that during birth hospitalization, late preterm neonates have a sevenfold greater morbidity risk than do full-term neonates (Shapiro-Mendoza et al., 2008). Compared with full-term infants, late preterm neonates are at increased risk of resuscitation at birth, hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulty, respiratory complications, and mortality (Boyle et al., 2015; Engle, Tomashek, & Wallman, 2007; Garcez et al., 2016; Medoff Cooper et al., 2012; Ognean et al., 2016; Teune et al., 2011). Despite the recognition of the physiological differences between late preterm neonates and their full-term counterparts, there are few data on normal vital signs in the late pre-term (Paliwoda, New, Davies, & Bogossian, 2018). It is now common for late preterm neonates to be cared for on maternity wards rather than in a neonatal intensive care unit (NICU) (Gupta et al., 2017; Medoff Cooper et al., 2012). Medhoff Cooper et al. (2012) recognized the need for an awareness of the higher risks associated with these infants, describing the need for “close(r) surveillance of Late Preterm Infants initially cared for in normal nurseries…because a significant minority will develop medical complications, and any delay in identifying these infants increases the risk of adverse neonatal outcomes” (p. 780).

Midwives and neonatal nurses, under direction from neonatologists, predominately perform the care and surveillance of late preterm neonates. Enrolled nurses deliver care under the direct or indirect supervision of RNs or registered midwives as part of the health care team. At the study hospital, changes in health funding led to late pre-term neonates being admitted to a postnatal ward rather than to the NICU, unless the infant had a specific medical diagnosis or under 35 weeks gestation. Consequently, neonates from a gestational age of 35 weeks and 0 days to 36 weeks and 6 days were cared for on postnatal wards. The nurses and midwives working on the postnatal ward lacked experience in caring for late preterm neonates. To support this change in clinical practice, a care plan was developed for use with babies in the postnatal wards, which included measures for thermoregulation, observations, hypoglycemia, feeding, and weight management. Despite the implementation of a specialized care plan, additional education and support was required to support staff to provide optimal care. As a result, an educational intervention was developed that aimed to improve clinical knowledge, clinical competence, and confidence in the care of late preterm neonates. This article describes the educational intervention and reports the outcomes for midwives and nurses who participated in the opportunity.

Method

Aim

This study's aim was to measure any change in the clinical knowledge and clinical skills of registered midwives, RNs, and enrolled nurses caring for late preterm neonates outside of the NICU, following the delivery of a targeted education intervention. The objectives of the study were to:

  • Assess the clinical knowledge, clinical skills, and attitudes of registered midwives, RNs, and enrolled nurses who care for late preterm neonates pre- and post-intervention.
  • Determine the level of clinical support nurses feel they have in caring for late preterm neonates in a postnatal ward setting.

Study Site

The study was conducted at a private hospital in Western Australia, which has two postnatal wards that can accommodate 56 mothers and their babies. During 2016– 2017, there were 3,172 births at the study hospital and 7% (n = 229) of those babies were late preterm neonates born between a gestational age of 34 weeks and 0 days and 36 weeks and 6 days.

Intervention

A targeted educational intervention was developed that focused on the care of the late preterm neonate in a post-natal ward setting. The intervention was created in collaboration with nursing and midwifery educators and senior NICU staff. The intervention focused on several aspects of clinical care, including hypoglycemia, hypothermia, feeding, weight management, respiratory, jaundice identification, and management; these aspects of care were covered in both face-to-face education sessions and an online professional development activity. The intervention consisted of small group face-to-face education sessions (repeated) lasting approximately 45 minutes and an online professional development activity. All registered midwives, RNs, and enrolled nurses working in the postnatal ward were invited to attend one of the face-to-face education sessions and were asked to complete the online professional development activity at their own convenience. The face-to-face education session was delivered three times by nursing and midwifery educators, and attendance was based on the availability of nursing and midwifery staff. Sessions consisted of a presentation on common clinical issues and challenges relevant to the care of the late preterm neonate and were interactive. The content of both the face-to-face sessions and the online professional development activity was evidence based, drew upon best practice guidelines, used clinical examples, and was related to hospital policy. It was expected to take approximately 30 minutes to work through the online professional development activity, and staff were actively encouraged to complete this by their managers and educators. At the end of the online professional development activity was an opportunity to self-assess knowledge by completing a short quiz.

Face-to-face sessions for the intervention were repeated over 8 weeks from November 15, 2016, to January 6, 2017, and the online professional development activity was available for completion during this time. Completion of both educational activities was encouraged but not required, and attendance to the face-to-face education sessions was paid.

Inclusion and Exclusion Criteria

All registered midwives, RNs, and enrolled nurses who were employed in the birth suite or postnatal wards were eligible to participate in the research. Undergraduate students and agency nurses/midwives were excluded.

Instrument

Data were collected via paper-based survey, pre- and post-intervention, to assess the effects of the intervention on the knowledge, skills, and attitudes of participants and the level of support participants felt they had in the care of late preterm neonates. Content validity for the survey was ensured with each question analyzed by panel of experts, who gave their opinion about whether the question was essential, useful, or relevant to measuring the construct under study (Heale & Twycross, 2015). The expert panel for this study included a staff development midwife, a NICU nurse manager, a postnatal ward manager, a clinical midwife, a research nurse, and a research academic. Additionally, panel members were asked to assess the face validity of the survey, which required a personal judgment of whether they thought the test was well constructed and useful (Burns et al., 2008). The assessment by the panel for content validity resulted in the addition of questions to establish whether participants felt caring for late preterm neonates was within their scope of practice. Slight changes to the wording of two questions were also made in response to the face validation.

Data Collection

Individuals were asked to rate the level of clinical support, their clinical knowledge, clinical skills, and clinical competence pre- and post-intervention. Pre-intervention surveys were completed a minimum of 1 week prior to the intervention. Participants were surveyed again from 8 weeks post-intervention, with surveys distributed beginning March 6, 2017. To assess knowledge, the survey also included a quiz. The quiz consisted of 23 questions, and the maximum score that could be achieved was 25, with the pass mark set at 80% or above. Surveys were paper based for the convenience of midwives and nurses who had limited access to computers at work (Cooper & Brown, 2017).

Ethical Considerations

Ethical approval was obtained from the study hospital's Human Research Ethics Committee, and reciprocal approval was obtained from the University Human Research Ethics Committee. Potential participants were provided with an information sheet that outlined the purpose and nature of the study. All participants were assured that they were able to decline to participate in the research without threat of adverse outcomes. Consent was inferred by the completion and return of the survey. Participants were not identifiable, and anonymity was ensured by survey return via sealed envelopes.

Results

A total of 39 individuals responded to the pre-intervention survey and 28 to the post-intervention survey. There were no exclusions pre-intervention and one exclusion post-intervention, with the respondent identifying as a student. Pre-intervention, 101 surveys were distributed, and a response rate of 39% (n = 39) was obtained. In the post-intervention period, 83 surveys were distributed, with a response rate of 34% (n = 28). Demographic data for both groups are presented in Table 1. Face-to-face education sessions were attended by 46% (n = 12) of post-intervention participants. The majority 78% (n = 21) of post-intervention respondents reported they completed the online professional development activity. Both components of the intervention were completed by 39% (n = 11) of the participants, 36% (n = 10) of participants completed only the online professional activity, and 4% (n = 1) attended only a face-to-face education session. Five respondents returned a post-intervention survey without having completed either element of the intervention. Of the 37 respondents who completed the pre-intervention quiz assessing participants' knowledge, results ranged from 13 to 24, with a mean score of 20 of 25. Post-intervention quiz assessing participants' knowledge results completed by 26 participants ranged from 19 to 24, with a mean score of 22 of 25. Participants' self-rating of clinical skills in managing hypoglycemia, hypothermia, feeding, and respiratory distress pre- and post-intervention are displayed in Table 2. Comparisons of how participants felt about clinical support, scope of practice, and competence and confidence are shown in Table 3. Participants who had completed one or both elements of the intervention were asked if their knowledge and confidence had increased, with 65% (n = 13) reporting that they strongly agreed and 35% (n = 7) reporting that they agreed since undertaking the education. Of the 11 participants who had completed both elements of the intervention, 82% (n = 9) strongly agreed and 18% (n = 2) agreed their knowledge and confidence had increased.

Survey Respondent Demographic Detailsa

Table 1:

Survey Respondent Demographic Details

Clinical Skills and Knowledge of Nurses and Midwives Caring for Late Preterm Babies in a Postnatal Ward

Table 2:

Clinical Skills and Knowledge of Nurses and Midwives Caring for Late Preterm Babies in a Postnatal Ward

Attitudes of Nurses/Midwives Caring for Late Preterm Babies in a Postnatal Ward

Table 3:

Attitudes of Nurses/Midwives Caring for Late Preterm Babies in a Postnatal Ward

Discussion

This brief educational intervention was successful in increasing the confidence and self-reported clinical competence of nurses and midwives. In particular, participants felt much more supported in caring for late preterm neonates post-intervention. Participants' self-rating in all four clinical skills focused on in the educational intervention—hypoglycemia, hypothermia, feeding, and respiratory distress—improved post-intervention. All participants agreed or strongly agreed that they possessed the clinical skills and knowledge to recognize these potential issues in late preterm neonates following the education. Of note, participants who had completed both components of the intervention reported larger gains in their confidence and knowledge in comparison to participants who attended one element. Suggesting that using more than one educational method is optimal.

Further, the knowledge and attitudes of nurses and midwives who did not complete either aspect of the intervention also seemed to improve from pre- to post-intervention. This was evident in the higher score range achieved in the quiz assessing participants' knowledge post-intervention and improvements in participants' self-reported attitudes post-intervention (Table 3). Shared learning between staff on the wards outside of the intervention was likely. Those who completed the intervention were able to help and support peers that had not, boosting the overall confidence and skills of staff working in the postnatal ward.

Limitations

The study has some limitations. This is a single-center study conducted in a private hospital. Unfortunately, the post-intervention data collection coincided with a period of low occupancy in maternity at the study hospital, which resulted in a lower survey distribution and response rate because staffing levels were reduced.

Conclusion

The authors recommend that midwives and nurses caring for late preterm neonates in postnatal settings be provided with additional education and support. Completing education on the care of late preterm neonates should be mandatory for all midwives and nurses who care for this group of patients. This may lead to higher levels of confidence and competence, which enables early detection of clinical issues, improves patient outcomes, and has the potential to prevent NICU admissions. Future research could examine whether educational interventions to improve the care of late preterm neonates in ward settings leads to a reduction in the number of babies who deteriorate and subsequently require an NICU admission.

References

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Survey Respondent Demographic Detailsa

VariablePresurvey (n)MissingPostsurvey (n)Missing
Employment part time78% (n = 29)093% (n = 24)0
Age ≥ 50 years38% (n = 14)037% (n = 10)0
Experience >10 years50% (n = 18)352% (n = 14)2
Technical and Further Education– or hospital certificate–enrolled nurse17% (n = 6)37% (n = 2)0
Bachelor's degree28% (n = 10)333% (n = 8)0
Postgraduate certificate8% (n = 3)330% (n = 8)0
Postgraduate diploma33% (n = 12)333% (n = 9)0
Master's degree6% (n = 2)300

Clinical Skills and Knowledge of Nurses and Midwives Caring for Late Preterm Babies in a Postnatal Ward

Clinical SkillStrongly DisagreeDisagreeAgreeStrongly AgreeMissing
Hypoglycemia
  Pre-intervention (N = 39)03% (n =1)43% (n = 15)54% (n = 19)4
  Post-intervention (N = 27)0050% (n = 12)54% (n = 14)1
Hypothermia
  Pre-intervention (N = 39)03% (n = 1)41% (n = 14)56% (n = 19)5
  Post-intervention (N = 27)0046% (n = 12)54% (n = 14)1
Feeding
  Pre-intervention (N = 39)08% (n = 3)50% (n = 18)42% (n = 15)3
  Post-intervention (N = 27)0046% (n = 12)52% (n = 14)1
Respiratory distress
  Pre-intervention (N = 39)0059% (n = 22)41% (n = 15)2
  Post-intervention (N = 27)0038% (n = 10)62% (n = 16)1

Attitudes of Nurses/Midwives Caring for Late Preterm Babies in a Postnatal Ward

StatementStrongly DisagreeDisagreeAgreeStrongly AgreeMissing
I feel confident and competent caring for late preterm neonates on the postnatal ward.
  Pre-intervention (N = 39)6% (n = 2)14% (n = 5)53% (n = 19)28% (n = 10)3
  Post-intervention (N = 27)0046% (n = 12)54% (n = 14)1
I feel I have good clinical support in caring for late preterm neonates on a postnatal ward.
  Pre-intervention (N = 39)6% (n = 2)19% (n = 7)50% (n = 18)25% (n = 9)3
  Post-intervention (N = 27)04% (n = 1)50% (n = 13)46% (n = 12)1
Caring for late preterm neonates on a postnatal ward is within my scope of practice.
  Pre-intervention (N = 39)09% (n = 3)49% (n = 17)43% (n = 15)4
  Post-intervention (N = 27)0056% (n = 14)48% (n = 13)0
Authors

Ms. Cooper is Nurse Researcher, Ms. O'Connor is Clinical Midwife, Ms. Eccles is Clinical Midwife, St. John of God Subiaco Hospital, and Dr. Brown is Course Coordinator, Curtin University, Perth, Western Australia, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Alannah L. Cooper, BNurs(Hons), RN, Nurse Researcher, St. John of God Subiaco Hospital, 12 Salvado Road, Subiaco, Western Australia 6008, Australia; e-mail: alannah.cooper@sjog.org.au.

Received: November 04, 2018
Accepted: July 30, 2019

10.3928/00220124-20191115-06

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