pc;u PRINCIPLES & PRACTICE
D E B O R A H J. E G A N H O U S E , RN, M A
E~ctronicFetal Monitoring Education and Quality Assurance
Although electronic fetal monitoring (EFM) bas been widely used in clinical practice for more than two decades, educational standards and competency validatton for EFM use in hospttals have been developed only recently. This article highlights a community hospital’sprogram for EFM. Basic education, staff development, and quality assurance activities involving staf nurses and managers are discussed.
lectronic fetal monitoring (EFM) was developed in the late 1960s in an attempt to reduce neonatal morbidity and mortality. The tenet that intrapartum events are responsible for adverse neonatal outcomes such as cerebral palsy is deeply ingrained in our culture. For example, in 1862, Dr. John Little wrote an article titled “On the Influence of Abnormal Parturition, Difficult Labours, Premature Birth and Asphyxia Neonatorum, on the Mental and Physical Condition of the Child, Especially in Relation to Deformities.”’ Further evidence of this theory is the current malpractice crisis. Increasingly, the clinical practice of obstetrics has become a focus for lawsuits against nurses and physicians. Malpractice suits often involve interpretation of EFM strips. Clinically, nurses and physicians began using EFM in hospitals in the United States in the 1960s. By 1978, this technology was used in more than 50% of all labors.’ Since then, medical literature investigating EFM in clinical practice has proliferated. However, nursing literature on EFM is scant, although nurses are familiar with using EFM as a tool for assessing high-risk obstetric patients. Nurses’ responsibilities when using EFM have been defined through nursing literature, education, and legal interpretation of responsibilities established by court cases.’-’ The statements of professional groups, including state boards of nursing and organizations such as NAACOG and the American College of Obstetricians and Gynecologists (ACOG), also direct practice. In 1986, NAACOG and ACOG published a joint statement that clearly provided direction for obstetric nurses involved in clinical practice, education, and management. This statement said, “Physicians and nurses who use EFM need to be able to recognize fetal heart rate patterns, beat-to-beat variability and uterine a~tivity.”~ In addition, the statement said that hospitals are responsible for verifying the knowledge base of health-care professionals using EFM in clinical practice. Unfortunately, nurse educators and managers have had little direction for achieving the goals of the joint statement. The nursing profession needs to direct and assist educators and managers in implementing effective programs that educate and evaluate nurses who use EFM. This article illustrates how available resources were integrated into a comprehensive hospital-based program for providing nurses with EFM education periodically and for evaluating the nurses’ skills through quality assurance activities.
Background
Accepted: March 1990
St. Luke’s Hospital in Cedar Rapids, Iowa, is a 525-bed community hospital that employs 40 obstetric nurses
16 J O C N N
Volume 20 Number 1
Electronic Fetal Monitoring
to provide intrapartum care for approximately 2,400 neonates each year. The hospital provides care for many women with high-risk pregnancies. At St. Luke’s,as at most hospitals, EFM became an aspect of clinical practice in the mid-1970s. Few nurses received more than cursory instruction about EFM from basic nursing curricula. Today, this trend seems to be unchanged in basic nursing education programs.*’ Until recently at St. Luke’s, EFM education for nurses varied. In the past, nurses received EFM education from providers outside the hospital and informally from experienced labor nurses. Major limitations in these methods included lack of uniformity in the type, amount, and quality of information delivered; lack of objective measures for evaluating nurses’ abilities to interpret tracings; and insufficient documentation of educational content. These limitations became increasingly problematic as the obstetric malpractice crisis escalated. Increased use of EFM for antepartum and intraparturn surveillance and physicians’ concerns, triggered by the turnover of experienced labor nurses, stimulated the development of the existing program.
Basic EFhi Education The staff at St. Luke’s began developing the EFM program in 1985 and since then has incorporated practice changes, new teaching aids, and current research findings. The program initially focused on orienting new labor nurses to the basic concepts of EFM and the associated hospital policies and procedures. The current orientation program for new obstetric nurses consists of three phases. During the first two weeks of house orientation, the nurses are required to use a computer-assisted instruction (CAI) program called FMTUTOR. This program was developed by Valerian Catanzarite, MD, PhD, and published in the American Journal of Obstetrics and Gynecology.’’The CAI consists of four sections: a fetal monitoring tutorial, “draw-a-tracing,’’tracing interpretation practice, and patient management problems. The tutorial consists of nine modules, each requiring approximately 45 minutes for completion. New nurses in the labor unit complete the “Introductory Concepts” module of the tutorial during the first few weeks of orientation. Other modules are completed as needed for review or reinforcement of EFM content. The CAI has been well received by nurses, although the computer simulations of tracings are graphic and lack the detail of real strips. Unit preceptors provide informal instruction during patient-care assignments. However, nurses do not assume responsibility for EFM interpretation until they
Januay/February 1991
The nursing profession needs to direct in implementing e$ective and and Programs that who
have attended the two-day EFM program developed and conducted by the perinatal clinical specialist. After attending this program, they are required to achieve 80% correct answers on an examination for new nurses before they independently care for monitored patients. Nurses are scheduled for the EFM program within their first three months of unit orientation. The first session consists of basic concepts, including internal and external modes of monitoring; pattern interpretation; evaluation of reassuring, warning, and nonreassuring signs; nursing interventions; patient education resources; and documentation. Nurses thoroughly review hospital policies and educational expectations related to EFM. The program focuses on placental function, risk factors for uteroplacental insufficiency, and antepartum surveillance. Unit policies are reviewed for nonstress tests, oxytocin challenge tests, breast stimulation tests, and biophysical profiles. Actual antepartum strips are reviewed during small group discussions to reinforce theory. The second session consists of advanced concepts, such as internal uterine pressure monitoring, troubleshooting, and monitoring twins. Equipmentrelated idiosyncrasies, such as double and half counting, autocorrelation, automatic gain control, and differences in arrhythmia versus artifact, are discussed using slides of actual strips. The theoretical bases for procedures such as fetal blood sampling and cord blood gas analysis are reviewed. The controversial topic of fetal distress is related to nonreassuring fetal heart rate (FHR) patterns, their etiologies, and their defining characteristics. An important aspect of the program is clarifying the ambiguous medical term “fetal distress” by discussing complementary nursing diagnoses, including impaired maternal-fetal gas exchange and altered placental or fetal tissue perfusion.
s t a f Development Activities The staff development aspect of the program is varied. Review sessions that focus on actual patient cases are presented each quarter. A case study approach was chosen to provide EFM education for experienced staff nurses, based on literature recommendations that experienced nurses learn by participation and discussion of approaches to clinical situations. High-risk obstetric cases provide opportunities to reinforce ad-
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vanced EFM concepts, such as complex FHR patterns, acid-base balance, fetal scalp sampling, cord blood gas analysis, placental pathology, intrauterine resuscitation, and amnioinfusion. Each quarter, two ll/z-hour sessions are offered for continuing education credit. These sessions include discussions of factors that regulate FHR, physiologic etiologies of periodic changes, nursing assessment of nonreassuring patterns, nursing care of high-risk obstetric patients, and risk factors related to uteroplacental insufficiency and cord compression. Reviewing a variety of high-risk obstetric case studies provides documentation of the hospital’s attempt to give nurses current information on highrisk obstetric care.
legal Concerns and Documentation Staff development also can be influenced by hospital policies, procedures, and standards of care that guide practice. Changes in nurses’ responsibilities have been defined through legal cases involving interpretation and communication of EFM data. It is imperative that nurse managers and educators provide staff nurses with directions for practice through well-written, regularly updated policies and procedures that are based on current standards. The hospital EFM educational and competency expectations should be defined by policy statements for two reasons: to keep nursing practice current and to protect the nurse and the hospital from litigation. Documentation and communication of observations are important defenses against litigation. The importance of nurses documenting care, such as medication administration, position changes, monitoring of vital signs, vaginal examinations, or any activity that alters the appearance of the monitor strip, has been described in the nursing literature.’ NAACOG has stipulated that nurses must use descriptive names, such as early, late, and variable decelerations, in documentation9 In addition, the nurse must document numerous parameters assessed on the tracing, including baseline heart rate, FHR variability, and uterine activity. Characteristics of the tracing and nursing interventions must be identified on the strip and in the chart. This requires time-consuming double documentation for nurses. To remove some of the numerous barriers in EFM documentation, nursing literature recommendations have been made for using charting guidelines and approved abbreviations to enhance communication of FHR tracingsFS6St. Luke’s implemented these recommendations in two ways. First, charting guidelines were developed to define all FHR characteristics. These were given abbreviations, such as BFHR for
18 J O C N N
An important part of the program is clarifying the ambiguous medical term “eta1 distress” by discussing complementary nursing diagnoses.
baseline fetal heart rate, FHRV for fetal heart rate variability, and L for late deceleration (Figure 1). Next, the labor flow record was revised to allow nurses to use abbreviations to document the assessment of the tracing in increments of time (Figure 2). Staff nurses have been pleased with the decreased amount of time required for documenting strip interpretation.
Quality of care The quality of care received by obstetric patients is enhanced when hospitals provide educational programs for nurses. However, another important aspect of quality of care is validation of nurses’ knowledge about EFM. NAACOG has identified this as a hospital responsibility and has recommended a variety of techniques to fulfill this task, such as examinations, case study analyses, strip chart interpretation sessions, and direct observation of skill^.^ Since 1986, St. Luke’s labor nurses have been required to take an annual written examination. This validation method was chosen because it is relatively objective and easy to administer. The examination consists of 150 items, including multiple-choice questions, matching, forced-choice strip identification, essay questions, and documentation using hospital-approved abbreviations. As mentioned earlier, a score of 80% correct answers is required for nurses to pass the examination and to continue caring for monitored patients. Nurses who do not pass the examination are counseled and required Figure 1 Kql.fbr FHR uhhretiutions usedjbr documentation on the luhor !ow record .-
I
Key For Fetal Heart Rate Abbreviations ......................................................
I-I I
~I‘
I I I I
BFHR = = D = A = I =
FHRV
Perd E V
I I
~I I i
L
Baseline Fetal Heart Rate Fetal Heart Rate Variability Decreased variability (< 6 bpm) Average variability (6-25 bpm) Increased variability (> 25 bpm) Chgs = Periodic change6 = Early deceleration = Variable deceleration (may be documented using arrows to denote nadir and duration, e.g., VJ-90 --> 30) = Late deceleration
Volume 20 Number 1
I I I I
1
I I I I I I I
I
I I
i
Electronic Fetal Monitoring
Figure 2 Rmkd labor @ow record enabling use oJ’ hospital-approtied ahhreibtionsfor documenting FHR purameters.
U B O R FLOW RECORD Pml I1
to retake the test within a specified period. In some cases, additional education is required. Initially, many nurses viewed the EFM competency examination as a major stressor. Now nurses have come to accept the examination as a job-related requirement that provides evidence of EFM skills. They find FMTUTOR to be a helpful and easy review tool. Because the examination provides a mechanism for feedback, many nurses have expressed greater confidence in their skills. Monitoring the quality of high-risk and high-volume care is a requirement by the Joint Commission on Accreditation of Healthcare Organizations. Because EFM fits both criteria, it has been incorporated into St. Luke’s labor unit audit system. Each of the 40 staff nurses is responsible for reviewing charts and EFM monitor strips to determine whether process standards or nursing actions and behaviors outlined in EFM policies and nursing standards are being met. Specific criteria related to EFM include reviewing strips with severe variable decelerations (FHR < 70 bpm > 60 seconds), because severe variable deceleration is the most common periodic change requiring nursing intervention. In each case, the nurse determines whether a spiral electrode was used, maternal position changes were initiated, and oxygen was applied. Nurses also review charts and strips from patients receiving oxytocin intravenously and having nonstress tests (Figure 3). Unit managers use the format in Figure 4 to conduct special studies for nurses who are new or cross-
Januu?y/Fehrumy 1991
trained, or who work infrequently. This process helps to validate the skills of staff nurses and to evaluate the outcome of educational activities. These studies suggest that postpartum nurses who are cross-trained in the labor unit have more difficulty meeting EFM practice standards than do new nurses. Although both groups of nurses receive the same education, crosstrained nurses have less “hands-on” experience. Nurse managers monitor nurses with deficits in documented assessments and discuss the deficits with them. Another important consideration in maintaining quality of care is the instructor’s credentials. Most nurses have not learned EFM through a formal process. Instead, EFM education has been largelyan experiential process facilitated by on-the-job training and actual patient care.’ One of the challenges in teaching EFM is to help experienced nurses correct misinformation. Nurses who teach EFM courses should receive hospital support to regularly attend EFM continuing education programs provided by nurses and physicians who are experts in the field. In addition, the Electronic Fetal Monitoring Certification Corporation (EFMCC) has developed a certification examination
Nurse managers revised the labor flow record so that abbreuiations could be used to concisely document FHR parameters.
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A N D
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Figure 3 Data collection tooljor uudit of nursing interventions related to r uriuhle decelerutions. NSTs. and Oqtocin administration
ST. LUKE'S HOSPITAL INOIVIOUAL UNIT CONCURRENT MONITORING SYSTEM UNIT 6E U n i t
SHIFT
HOSPITAL NUMBER
This a u d i t should be completed w i t h i n t h i s 8 hour s h i f t . INSTRUCTIONS:
The a u d i t should be completed on a postpartum p a t i e n t chart. Respond t o each question by checking "YES", "NO" or "N/A". Comment i n the r i g h t column about any s i g n i f i c a n t answers. MTERNAL-CHIU) NURSING O I V I S I O N
Review P i t c c i n chart and s t r i p f o r one s h i f t o f data. NO: a. Was the FHR baseline documented every 15 minutes on the labor flow sheet during I V P i t o c i n induction/augmentation? (t 5 minutes) b. Were uterine contractions c l e a r l y documented? c. I f not, was an IUPC used? d. I f IUPC used, was i t zero'd before insertion?
I I I
YES
I I
1I-1-'
1 l I I I
I
I-I-1-1
I Review one s t r i p w i t h severe variables. (FHR less than 70 BPM f o r > 60 seconds.) I NO: I a. Was f e t a l scalp lead i n place or applied?[ b. Were maternal p o s i t i o n changes I documented? I-I-1-I c. Was 02 applied? d. Was an I V i n f u s i n g or i n i t i a t e d w i t h i n 30 minutes? e. Were newborn apgars i d e n t i f i e d a t end o f
I
N/A
NO
I l I I
I
I 1 I I
I
I I
I I
I I l I I
the s t r i p ? Review one a&ission s t r i p from p a t i e n t t h a t has gone home. NO: a. I s admission s t r i p stapled t o 0-1 Part II? b. Is FHR baseline w i t h i n 120-160 range? c. Are accelerations present? d. Are decelerations present? Review one NST. No: a. Were maternal v i t a l signs documented on the monitor s t r i p w i t h i n f i r s t 15 minutes? b. Was the name o f physician i n t e r p r e t i n g the t e s t a t end o f s t r i p ?
I I
I
I * I I I
l I I
I I I
1 I I
l I
I I I I I
I I
I1--1I-1--11-1
I
I l I I 1-I-1-1 I I 1-1-
l I
I 1 I l I-I-1-1 I I I-I-I-1 1-1-1-1
I
l
I 1
I
1
lI=l-I-l 1-1-1
I 1 I I I I I I
I
I
[-!-I1- 1-
-
COMENTS
I I
1 I
I I I I
I
-1
I
I
I I I I I I
to verify the knowledge of nurses and physicians who use EFM in practice. The four-hour test covers risk factors, maternal-fetal anatomy and physiology, pharmacologic implications, anticipated outcome, and troubleshooting equipment. Two hours of the test are devoted to strip interpretation using a fill-in-the-blank approach. The allotted time for interpretation requires rapid decision making that simulates actual interpretation. This examination is perhaps the most comprehensive validation tool available for professionals. Other education programs offer posttest evaluation but do not profess to certify EFM knowledge.
effectiveness of EFM in reducing perinatal mortality and morbidity. These formal clinical studies have been unable to demonstrate any significant benefit of monitoring." In addition, the association of EFM with increased cesarean section rates and forceps use has resulted in ACOG recommending periodic FHR auscultation as an acceptable method of FHR assessment, even during high-risk labors. In discussing this latest development in the EFM controversy, Afriat stated:
Nursing Implications
The nursing profession needs to address the educational issues of EFM that contribute to problems for practicing clinicians and nurse managers.
A wealth of research has been conducted, primarily by medical investigators, about EFM interpretation and its association with various clinical outcomes. Re-
The equipment is not the weak link; the human beings using the information obtained from the
cently, numerous large studies have investigated the
20 J O G N N
Volume 20 Number 1
ST. LUKE'S HOSPITAL
Cedar Rapids, Iowa 6 EAST EFX QUALITY ASSURANCE WNITOR
Hospital Number: Nurse:
1.
I n i t i a l s t r i p documentation a. Sticker applied b.
c.
Sticker completed Reason f o r monitoring Listed
-
1-1
Clear Accurate d.
Maternal position i d e n t i f i e d
e.
Paper r a t e i d e n t i f i e d
1-1 1-1 1-1
1x1 -
IZI
-
1-1 I 1 1
1-1
1 1 1
1 1 1
1 1 1
I=I
I=]
1-1
1-1
1-1
1 1 1
Cammnts: S t r i p No. Tine 2.
to to
BFHR assessed every 15-30 (active labor) a.
Documented per u n i t guidclines
b.
D o c w n t e d assessment accurate
c.
FSE used
d.
Tracing q u a l i t y acceptable
1-1 1-1 1-1
-
1-1
-
-
1 - 1-1-1- 1-11-1
1-1
Coarntr:
3.
fHRY assessed e w r y 15-30 I F fHR i s p r FSE
a.
Docwanted per u n i t guidclines
b.
Docamanted assessment accurate
1-1 1-1 1-1
-
-
Summary
1-1
-
EFM has become a standard of obstetric nursing care.
1-1
In many hospitals, all women are monitored during labor. Despite ACOG's recent approval of auscultation for high-risk intrapartum patients, many professionals are skeptical about a major change in practice. For experienced nurses who value the wider range of data afforded by EFM, returning to auscultation may be difficult, if not impossible, especially in light of the current nursing shortage and continuing malpractice ~risis.'~-~~ This article has presented an account of the development of education and quality assurance monitoring of EFM practice in a community hospital. The process has been evolutionary and continues to improve in response to changes in standards, guidelines, research, and the acquisition of improved teaching aids. However, the task of providing EFM instruction remains challenging. The lack of EFM undergraduate education for new nurses entering the hospital work force has been identified. This discovery and the 1986 ACOG/NAACOG statement on EFM have created additional impetus for hospitals to provide well-developed EFM educational programs. In the current health-care environment, unless hospitals can document nurse competency in EFM interpretation, they could be at increased risk for litigation.*' Further information about EFMCC can be obtained by contacting Electronic Fetal Monitoring Cer-
1-1
1-1
1-1
-
1-1
tcuents:
Figure 4 Quuli(yuwrunce tool used by nurb-e managersfor evaluating nursing procl.ss during EFM.
machine must be properly educated and be specialized in the interpretation of the information. The result of an automobile accident is not to throw away the car but to evaluate the driver.13 Unfortunately, few studies have been conducted on the education or clinical decision-making ability of the professionals who are responsible for EFM. Medical interpretation of strips has been investigated.I4-l6 Only one comparable study has been reported specifically about labor nurses, who are primarily responsible for using EFM as an antepartum and intrapartum assessment Historically, nurses have learned EFM with minimal information from educators5 Education in EFM monitoring has come under scrutiny with the recent publication of a survey about the EFM skills of nursing
Januarv/Februar?/1991
students in BSN programs. Kinnick reported in her study of 50 nursing schools that only four schools provided more than two hours of EFM instruction in theory class and that limited time was available for clinical EFM instruction." Recently, a survey of 430 hospitals and 412 schools of nursing conducted by Nu-Vision, Inc., indicated that 51% of the hospital instructors and 57% of the nursing school instructors had no formal EFM education. The teaching method used most frequently by hospital instructors was patient-care experience (63% frequency), although 98.3%of nursing faculty and learners preferred workshops.'* Deficits in undergraduate nursing education and in graduate-level investigation of variables relating to EFM interpretation create a problem for practicing clinicians and nurse managers. Health-care professionals need to establish reliability and validity testing of tools used to measure staff nurses' and educators' competence in EFM interpretation. Advanced clinicians need to address practice issues involved in this important aspect of obstetric nursing and maternalchild health care.
JOG"
21
P R I N C I P L E S A N D
P R A C T I C E
tification Corporation, 7371 Sea Bluff, Suite 105, Huntington Beach, CA 92648; 714-962-7477.
References 1. Freeman, R., and T. Garite. 1981. FetalHeartRateMonitoring. Baltimore: Williams and Wilkins. 2. Afriat, C.I. 1983. The nurse's role in fetal heart rate
monitoring. Perinatology-NeonatoIo~i.7(3):29-32. 3. Applegate, J., A.D. Haverkamp, M. Orleans, and C. Taylor. 1979. Electronic fetal monitoring: Implications for obstetrical nursing. Nurs Res. 28(6):369-71. 4. Blank,J. 1985. Electronic fetal monitoring nursing management defined. JOGNN 14(6):463-67. 5. Cranston, C.S. 1980. Obstetrical nurses' attitudes toward fetal monitoring. JOGNN. 9(6) :344-47. 6. Schmidt, J. 1987. Documenting EFM events. Perinatal Press. 10(6):79-81. 7 . Snydal, S.H. 1988. Responses of laboring women to fetal heart rate monitoring: A critical review of the literature. JNurse Midwijiery. 33(5):208-16. 8. Pheigaru, J.L. 1988. Keeping staff up on electronic fetal monitoring. MCN. 13(5):334-35. 9. NAACOG. 1986. Electronic Fetal Monitoring: Nursing Practice Competencies a n d Educational Guidelines. Washington D.C.: NAACOG. 10. Kinnick, V.G. 1989. A national survey about fetal monitoring Skills acquired by nursing students in baccalaureate programs. JOGNN 18(1):57-58. 11. Catanzarite, V.A. 1987. FMTUTOR: A computer-aided instructional system for teaching fetal monitor interpretation. Am J Obstet Gynecol. 156(5):1045-48. 12. Snydal, S.H. 1988. Methods of fetal heart rate monitoring during labor: A selective review of the literature. J Nurse Midwgery. 33( 1):4-14.
I
22 J O C N N
13. Afriat, C.I. 1989. Electronic Fetal Monitoring. Rockville, Maryland: Aspen Publishers, Inc. 14. Hage, M.L. 1985. Interpretation of nonstress tests. Am J Obstet GynecoI. 153(4):490-95. 15. Hefland, M., K. Marton, and K. Ueland. 1985. Factors involved in the interpretation of fetal monitor tracings. Am J Obstet Gynecol. 151(6):737-44. 16. Larson, E.B., G. Van Belle, K.K. Shy, D.A. Luthy, D Strickland, and J.P. Hughes. 1989. Fetal monitoring and predictions by clinicians: Observations during a randomized clinical trial in very low birth weight infants. Obstet Gynecol. 74(4):584-89. 17. Chez, B.F., J.H. Skurnick, R.A. Chez, M.T. Verklan, S. Biggs, and M.L Hage. 1990. Interpretation of nonstress tests by obstetric nurses. JOGNN. 19(3):227-32. 18. Cokington, P. (January 30, 1989). Nu-Vision, personal correspondence. 19. NAACOG. 1988. Statement: Nursing Responsibilities in Implementing Intrapartum Fetal Heart Rate Monitoring. Washington, D.C: NAACOG. 20. Fields, L.M., and F.H. Boehm. 1989. Changing issues in FHR monitoring. Contemporary OB/GYN 33:145-48. 21. AIG Consultants, Inc. 1989. Fetal monitoring as a malpractice prevention tool. Viewpoint: Risk Management Advisory for Healthcare Proj&sionaIs. 2 (11.
Address for correspondence: Deborah J . Eganhouse, RN, MA, 1521 Oak Ridge Lane, S.E., Cedar Rapids, IA 52403.
Deborah J.Eganhouse is aperinatal cllnlcal spectalist at St. Luke's Hospttal in Cedar Rapids, Iowa. Ms. Eganhouse is a member of NAACOG, the Great Plains Organization, and Sigma Theta Tau.
Notice to Copiers Authorizationto photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by NAACOG, a division of the American College of Obstetricians and Gynecologists, for libraries and other users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the base fee of $00.80 per copy, plus $00.05 per page is paid directly to CCC, 21 Congress St., Salem, MA 01970. 0884-2175191 $00.80 + $00.05.
Volume 20 Number 1
D E B O R A H J. E G A N H O U S E , RN, M A
E~ctronicFetal Monitoring Education and Quality Assurance
Although electronic fetal monitoring (EFM) bas been widely used in clinical practice for more than two decades, educational standards and competency validatton for EFM use in hospttals have been developed only recently. This article highlights a community hospital’sprogram for EFM. Basic education, staff development, and quality assurance activities involving staf nurses and managers are discussed.
lectronic fetal monitoring (EFM) was developed in the late 1960s in an attempt to reduce neonatal morbidity and mortality. The tenet that intrapartum events are responsible for adverse neonatal outcomes such as cerebral palsy is deeply ingrained in our culture. For example, in 1862, Dr. John Little wrote an article titled “On the Influence of Abnormal Parturition, Difficult Labours, Premature Birth and Asphyxia Neonatorum, on the Mental and Physical Condition of the Child, Especially in Relation to Deformities.”’ Further evidence of this theory is the current malpractice crisis. Increasingly, the clinical practice of obstetrics has become a focus for lawsuits against nurses and physicians. Malpractice suits often involve interpretation of EFM strips. Clinically, nurses and physicians began using EFM in hospitals in the United States in the 1960s. By 1978, this technology was used in more than 50% of all labors.’ Since then, medical literature investigating EFM in clinical practice has proliferated. However, nursing literature on EFM is scant, although nurses are familiar with using EFM as a tool for assessing high-risk obstetric patients. Nurses’ responsibilities when using EFM have been defined through nursing literature, education, and legal interpretation of responsibilities established by court cases.’-’ The statements of professional groups, including state boards of nursing and organizations such as NAACOG and the American College of Obstetricians and Gynecologists (ACOG), also direct practice. In 1986, NAACOG and ACOG published a joint statement that clearly provided direction for obstetric nurses involved in clinical practice, education, and management. This statement said, “Physicians and nurses who use EFM need to be able to recognize fetal heart rate patterns, beat-to-beat variability and uterine a~tivity.”~ In addition, the statement said that hospitals are responsible for verifying the knowledge base of health-care professionals using EFM in clinical practice. Unfortunately, nurse educators and managers have had little direction for achieving the goals of the joint statement. The nursing profession needs to direct and assist educators and managers in implementing effective programs that educate and evaluate nurses who use EFM. This article illustrates how available resources were integrated into a comprehensive hospital-based program for providing nurses with EFM education periodically and for evaluating the nurses’ skills through quality assurance activities.
Background
Accepted: March 1990
St. Luke’s Hospital in Cedar Rapids, Iowa, is a 525-bed community hospital that employs 40 obstetric nurses
16 J O C N N
Volume 20 Number 1
Electronic Fetal Monitoring
to provide intrapartum care for approximately 2,400 neonates each year. The hospital provides care for many women with high-risk pregnancies. At St. Luke’s,as at most hospitals, EFM became an aspect of clinical practice in the mid-1970s. Few nurses received more than cursory instruction about EFM from basic nursing curricula. Today, this trend seems to be unchanged in basic nursing education programs.*’ Until recently at St. Luke’s, EFM education for nurses varied. In the past, nurses received EFM education from providers outside the hospital and informally from experienced labor nurses. Major limitations in these methods included lack of uniformity in the type, amount, and quality of information delivered; lack of objective measures for evaluating nurses’ abilities to interpret tracings; and insufficient documentation of educational content. These limitations became increasingly problematic as the obstetric malpractice crisis escalated. Increased use of EFM for antepartum and intraparturn surveillance and physicians’ concerns, triggered by the turnover of experienced labor nurses, stimulated the development of the existing program.
Basic EFhi Education The staff at St. Luke’s began developing the EFM program in 1985 and since then has incorporated practice changes, new teaching aids, and current research findings. The program initially focused on orienting new labor nurses to the basic concepts of EFM and the associated hospital policies and procedures. The current orientation program for new obstetric nurses consists of three phases. During the first two weeks of house orientation, the nurses are required to use a computer-assisted instruction (CAI) program called FMTUTOR. This program was developed by Valerian Catanzarite, MD, PhD, and published in the American Journal of Obstetrics and Gynecology.’’The CAI consists of four sections: a fetal monitoring tutorial, “draw-a-tracing,’’tracing interpretation practice, and patient management problems. The tutorial consists of nine modules, each requiring approximately 45 minutes for completion. New nurses in the labor unit complete the “Introductory Concepts” module of the tutorial during the first few weeks of orientation. Other modules are completed as needed for review or reinforcement of EFM content. The CAI has been well received by nurses, although the computer simulations of tracings are graphic and lack the detail of real strips. Unit preceptors provide informal instruction during patient-care assignments. However, nurses do not assume responsibility for EFM interpretation until they
Januay/February 1991
The nursing profession needs to direct in implementing e$ective and and Programs that who
have attended the two-day EFM program developed and conducted by the perinatal clinical specialist. After attending this program, they are required to achieve 80% correct answers on an examination for new nurses before they independently care for monitored patients. Nurses are scheduled for the EFM program within their first three months of unit orientation. The first session consists of basic concepts, including internal and external modes of monitoring; pattern interpretation; evaluation of reassuring, warning, and nonreassuring signs; nursing interventions; patient education resources; and documentation. Nurses thoroughly review hospital policies and educational expectations related to EFM. The program focuses on placental function, risk factors for uteroplacental insufficiency, and antepartum surveillance. Unit policies are reviewed for nonstress tests, oxytocin challenge tests, breast stimulation tests, and biophysical profiles. Actual antepartum strips are reviewed during small group discussions to reinforce theory. The second session consists of advanced concepts, such as internal uterine pressure monitoring, troubleshooting, and monitoring twins. Equipmentrelated idiosyncrasies, such as double and half counting, autocorrelation, automatic gain control, and differences in arrhythmia versus artifact, are discussed using slides of actual strips. The theoretical bases for procedures such as fetal blood sampling and cord blood gas analysis are reviewed. The controversial topic of fetal distress is related to nonreassuring fetal heart rate (FHR) patterns, their etiologies, and their defining characteristics. An important aspect of the program is clarifying the ambiguous medical term “fetal distress” by discussing complementary nursing diagnoses, including impaired maternal-fetal gas exchange and altered placental or fetal tissue perfusion.
s t a f Development Activities The staff development aspect of the program is varied. Review sessions that focus on actual patient cases are presented each quarter. A case study approach was chosen to provide EFM education for experienced staff nurses, based on literature recommendations that experienced nurses learn by participation and discussion of approaches to clinical situations. High-risk obstetric cases provide opportunities to reinforce ad-
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vanced EFM concepts, such as complex FHR patterns, acid-base balance, fetal scalp sampling, cord blood gas analysis, placental pathology, intrauterine resuscitation, and amnioinfusion. Each quarter, two ll/z-hour sessions are offered for continuing education credit. These sessions include discussions of factors that regulate FHR, physiologic etiologies of periodic changes, nursing assessment of nonreassuring patterns, nursing care of high-risk obstetric patients, and risk factors related to uteroplacental insufficiency and cord compression. Reviewing a variety of high-risk obstetric case studies provides documentation of the hospital’s attempt to give nurses current information on highrisk obstetric care.
legal Concerns and Documentation Staff development also can be influenced by hospital policies, procedures, and standards of care that guide practice. Changes in nurses’ responsibilities have been defined through legal cases involving interpretation and communication of EFM data. It is imperative that nurse managers and educators provide staff nurses with directions for practice through well-written, regularly updated policies and procedures that are based on current standards. The hospital EFM educational and competency expectations should be defined by policy statements for two reasons: to keep nursing practice current and to protect the nurse and the hospital from litigation. Documentation and communication of observations are important defenses against litigation. The importance of nurses documenting care, such as medication administration, position changes, monitoring of vital signs, vaginal examinations, or any activity that alters the appearance of the monitor strip, has been described in the nursing literature.’ NAACOG has stipulated that nurses must use descriptive names, such as early, late, and variable decelerations, in documentation9 In addition, the nurse must document numerous parameters assessed on the tracing, including baseline heart rate, FHR variability, and uterine activity. Characteristics of the tracing and nursing interventions must be identified on the strip and in the chart. This requires time-consuming double documentation for nurses. To remove some of the numerous barriers in EFM documentation, nursing literature recommendations have been made for using charting guidelines and approved abbreviations to enhance communication of FHR tracingsFS6St. Luke’s implemented these recommendations in two ways. First, charting guidelines were developed to define all FHR characteristics. These were given abbreviations, such as BFHR for
18 J O C N N
An important part of the program is clarifying the ambiguous medical term “eta1 distress” by discussing complementary nursing diagnoses.
baseline fetal heart rate, FHRV for fetal heart rate variability, and L for late deceleration (Figure 1). Next, the labor flow record was revised to allow nurses to use abbreviations to document the assessment of the tracing in increments of time (Figure 2). Staff nurses have been pleased with the decreased amount of time required for documenting strip interpretation.
Quality of care The quality of care received by obstetric patients is enhanced when hospitals provide educational programs for nurses. However, another important aspect of quality of care is validation of nurses’ knowledge about EFM. NAACOG has identified this as a hospital responsibility and has recommended a variety of techniques to fulfill this task, such as examinations, case study analyses, strip chart interpretation sessions, and direct observation of skill^.^ Since 1986, St. Luke’s labor nurses have been required to take an annual written examination. This validation method was chosen because it is relatively objective and easy to administer. The examination consists of 150 items, including multiple-choice questions, matching, forced-choice strip identification, essay questions, and documentation using hospital-approved abbreviations. As mentioned earlier, a score of 80% correct answers is required for nurses to pass the examination and to continue caring for monitored patients. Nurses who do not pass the examination are counseled and required Figure 1 Kql.fbr FHR uhhretiutions usedjbr documentation on the luhor !ow record .-
I
Key For Fetal Heart Rate Abbreviations ......................................................
I-I I
~I‘
I I I I
BFHR = = D = A = I =
FHRV
Perd E V
I I
~I I i
L
Baseline Fetal Heart Rate Fetal Heart Rate Variability Decreased variability (< 6 bpm) Average variability (6-25 bpm) Increased variability (> 25 bpm) Chgs = Periodic change6 = Early deceleration = Variable deceleration (may be documented using arrows to denote nadir and duration, e.g., VJ-90 --> 30) = Late deceleration
Volume 20 Number 1
I I I I
1
I I I I I I I
I
I I
i
Electronic Fetal Monitoring
Figure 2 Rmkd labor @ow record enabling use oJ’ hospital-approtied ahhreibtionsfor documenting FHR purameters.
U B O R FLOW RECORD Pml I1
to retake the test within a specified period. In some cases, additional education is required. Initially, many nurses viewed the EFM competency examination as a major stressor. Now nurses have come to accept the examination as a job-related requirement that provides evidence of EFM skills. They find FMTUTOR to be a helpful and easy review tool. Because the examination provides a mechanism for feedback, many nurses have expressed greater confidence in their skills. Monitoring the quality of high-risk and high-volume care is a requirement by the Joint Commission on Accreditation of Healthcare Organizations. Because EFM fits both criteria, it has been incorporated into St. Luke’s labor unit audit system. Each of the 40 staff nurses is responsible for reviewing charts and EFM monitor strips to determine whether process standards or nursing actions and behaviors outlined in EFM policies and nursing standards are being met. Specific criteria related to EFM include reviewing strips with severe variable decelerations (FHR < 70 bpm > 60 seconds), because severe variable deceleration is the most common periodic change requiring nursing intervention. In each case, the nurse determines whether a spiral electrode was used, maternal position changes were initiated, and oxygen was applied. Nurses also review charts and strips from patients receiving oxytocin intravenously and having nonstress tests (Figure 3). Unit managers use the format in Figure 4 to conduct special studies for nurses who are new or cross-
Januu?y/Fehrumy 1991
trained, or who work infrequently. This process helps to validate the skills of staff nurses and to evaluate the outcome of educational activities. These studies suggest that postpartum nurses who are cross-trained in the labor unit have more difficulty meeting EFM practice standards than do new nurses. Although both groups of nurses receive the same education, crosstrained nurses have less “hands-on” experience. Nurse managers monitor nurses with deficits in documented assessments and discuss the deficits with them. Another important consideration in maintaining quality of care is the instructor’s credentials. Most nurses have not learned EFM through a formal process. Instead, EFM education has been largelyan experiential process facilitated by on-the-job training and actual patient care.’ One of the challenges in teaching EFM is to help experienced nurses correct misinformation. Nurses who teach EFM courses should receive hospital support to regularly attend EFM continuing education programs provided by nurses and physicians who are experts in the field. In addition, the Electronic Fetal Monitoring Certification Corporation (EFMCC) has developed a certification examination
Nurse managers revised the labor flow record so that abbreuiations could be used to concisely document FHR parameters.
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Figure 3 Data collection tooljor uudit of nursing interventions related to r uriuhle decelerutions. NSTs. and Oqtocin administration
ST. LUKE'S HOSPITAL INOIVIOUAL UNIT CONCURRENT MONITORING SYSTEM UNIT 6E U n i t
SHIFT
HOSPITAL NUMBER
This a u d i t should be completed w i t h i n t h i s 8 hour s h i f t . INSTRUCTIONS:
The a u d i t should be completed on a postpartum p a t i e n t chart. Respond t o each question by checking "YES", "NO" or "N/A". Comment i n the r i g h t column about any s i g n i f i c a n t answers. MTERNAL-CHIU) NURSING O I V I S I O N
Review P i t c c i n chart and s t r i p f o r one s h i f t o f data. NO: a. Was the FHR baseline documented every 15 minutes on the labor flow sheet during I V P i t o c i n induction/augmentation? (t 5 minutes) b. Were uterine contractions c l e a r l y documented? c. I f not, was an IUPC used? d. I f IUPC used, was i t zero'd before insertion?
I I I
YES
I I
1I-1-'
1 l I I I
I
I-I-1-1
I Review one s t r i p w i t h severe variables. (FHR less than 70 BPM f o r > 60 seconds.) I NO: I a. Was f e t a l scalp lead i n place or applied?[ b. Were maternal p o s i t i o n changes I documented? I-I-1-I c. Was 02 applied? d. Was an I V i n f u s i n g or i n i t i a t e d w i t h i n 30 minutes? e. Were newborn apgars i d e n t i f i e d a t end o f
I
N/A
NO
I l I I
I
I 1 I I
I
I I
I I
I I l I I
the s t r i p ? Review one a&ission s t r i p from p a t i e n t t h a t has gone home. NO: a. I s admission s t r i p stapled t o 0-1 Part II? b. Is FHR baseline w i t h i n 120-160 range? c. Are accelerations present? d. Are decelerations present? Review one NST. No: a. Were maternal v i t a l signs documented on the monitor s t r i p w i t h i n f i r s t 15 minutes? b. Was the name o f physician i n t e r p r e t i n g the t e s t a t end o f s t r i p ?
I I
I
I * I I I
l I I
I I I
1 I I
l I
I I I I I
I I
I1--1I-1--11-1
I
I l I I 1-I-1-1 I I 1-1-
l I
I 1 I l I-I-1-1 I I I-I-I-1 1-1-1-1
I
l
I 1
I
1
lI=l-I-l 1-1-1
I 1 I I I I I I
I
I
[-!-I1- 1-
-
COMENTS
I I
1 I
I I I I
I
-1
I
I
I I I I I I
to verify the knowledge of nurses and physicians who use EFM in practice. The four-hour test covers risk factors, maternal-fetal anatomy and physiology, pharmacologic implications, anticipated outcome, and troubleshooting equipment. Two hours of the test are devoted to strip interpretation using a fill-in-the-blank approach. The allotted time for interpretation requires rapid decision making that simulates actual interpretation. This examination is perhaps the most comprehensive validation tool available for professionals. Other education programs offer posttest evaluation but do not profess to certify EFM knowledge.
effectiveness of EFM in reducing perinatal mortality and morbidity. These formal clinical studies have been unable to demonstrate any significant benefit of monitoring." In addition, the association of EFM with increased cesarean section rates and forceps use has resulted in ACOG recommending periodic FHR auscultation as an acceptable method of FHR assessment, even during high-risk labors. In discussing this latest development in the EFM controversy, Afriat stated:
Nursing Implications
The nursing profession needs to address the educational issues of EFM that contribute to problems for practicing clinicians and nurse managers.
A wealth of research has been conducted, primarily by medical investigators, about EFM interpretation and its association with various clinical outcomes. Re-
The equipment is not the weak link; the human beings using the information obtained from the
cently, numerous large studies have investigated the
20 J O G N N
Volume 20 Number 1
ST. LUKE'S HOSPITAL
Cedar Rapids, Iowa 6 EAST EFX QUALITY ASSURANCE WNITOR
Hospital Number: Nurse:
1.
I n i t i a l s t r i p documentation a. Sticker applied b.
c.
Sticker completed Reason f o r monitoring Listed
-
1-1
Clear Accurate d.
Maternal position i d e n t i f i e d
e.
Paper r a t e i d e n t i f i e d
1-1 1-1 1-1
1x1 -
IZI
-
1-1 I 1 1
1-1
1 1 1
1 1 1
1 1 1
I=I
I=]
1-1
1-1
1-1
1 1 1
Cammnts: S t r i p No. Tine 2.
to to
BFHR assessed every 15-30 (active labor) a.
Documented per u n i t guidclines
b.
D o c w n t e d assessment accurate
c.
FSE used
d.
Tracing q u a l i t y acceptable
1-1 1-1 1-1
-
1-1
-
-
1 - 1-1-1- 1-11-1
1-1
Coarntr:
3.
fHRY assessed e w r y 15-30 I F fHR i s p r FSE
a.
Docwanted per u n i t guidclines
b.
Docamanted assessment accurate
1-1 1-1 1-1
-
-
Summary
1-1
-
EFM has become a standard of obstetric nursing care.
1-1
In many hospitals, all women are monitored during labor. Despite ACOG's recent approval of auscultation for high-risk intrapartum patients, many professionals are skeptical about a major change in practice. For experienced nurses who value the wider range of data afforded by EFM, returning to auscultation may be difficult, if not impossible, especially in light of the current nursing shortage and continuing malpractice ~risis.'~-~~ This article has presented an account of the development of education and quality assurance monitoring of EFM practice in a community hospital. The process has been evolutionary and continues to improve in response to changes in standards, guidelines, research, and the acquisition of improved teaching aids. However, the task of providing EFM instruction remains challenging. The lack of EFM undergraduate education for new nurses entering the hospital work force has been identified. This discovery and the 1986 ACOG/NAACOG statement on EFM have created additional impetus for hospitals to provide well-developed EFM educational programs. In the current health-care environment, unless hospitals can document nurse competency in EFM interpretation, they could be at increased risk for litigation.*' Further information about EFMCC can be obtained by contacting Electronic Fetal Monitoring Cer-
1-1
1-1
1-1
-
1-1
tcuents:
Figure 4 Quuli(yuwrunce tool used by nurb-e managersfor evaluating nursing procl.ss during EFM.
machine must be properly educated and be specialized in the interpretation of the information. The result of an automobile accident is not to throw away the car but to evaluate the driver.13 Unfortunately, few studies have been conducted on the education or clinical decision-making ability of the professionals who are responsible for EFM. Medical interpretation of strips has been investigated.I4-l6 Only one comparable study has been reported specifically about labor nurses, who are primarily responsible for using EFM as an antepartum and intrapartum assessment Historically, nurses have learned EFM with minimal information from educators5 Education in EFM monitoring has come under scrutiny with the recent publication of a survey about the EFM skills of nursing
Januarv/Februar?/1991
students in BSN programs. Kinnick reported in her study of 50 nursing schools that only four schools provided more than two hours of EFM instruction in theory class and that limited time was available for clinical EFM instruction." Recently, a survey of 430 hospitals and 412 schools of nursing conducted by Nu-Vision, Inc., indicated that 51% of the hospital instructors and 57% of the nursing school instructors had no formal EFM education. The teaching method used most frequently by hospital instructors was patient-care experience (63% frequency), although 98.3%of nursing faculty and learners preferred workshops.'* Deficits in undergraduate nursing education and in graduate-level investigation of variables relating to EFM interpretation create a problem for practicing clinicians and nurse managers. Health-care professionals need to establish reliability and validity testing of tools used to measure staff nurses' and educators' competence in EFM interpretation. Advanced clinicians need to address practice issues involved in this important aspect of obstetric nursing and maternalchild health care.
JOG"
21
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tification Corporation, 7371 Sea Bluff, Suite 105, Huntington Beach, CA 92648; 714-962-7477.
References 1. Freeman, R., and T. Garite. 1981. FetalHeartRateMonitoring. Baltimore: Williams and Wilkins. 2. Afriat, C.I. 1983. The nurse's role in fetal heart rate
monitoring. Perinatology-NeonatoIo~i.7(3):29-32. 3. Applegate, J., A.D. Haverkamp, M. Orleans, and C. Taylor. 1979. Electronic fetal monitoring: Implications for obstetrical nursing. Nurs Res. 28(6):369-71. 4. Blank,J. 1985. Electronic fetal monitoring nursing management defined. JOGNN 14(6):463-67. 5. Cranston, C.S. 1980. Obstetrical nurses' attitudes toward fetal monitoring. JOGNN. 9(6) :344-47. 6. Schmidt, J. 1987. Documenting EFM events. Perinatal Press. 10(6):79-81. 7 . Snydal, S.H. 1988. Responses of laboring women to fetal heart rate monitoring: A critical review of the literature. JNurse Midwijiery. 33(5):208-16. 8. Pheigaru, J.L. 1988. Keeping staff up on electronic fetal monitoring. MCN. 13(5):334-35. 9. NAACOG. 1986. Electronic Fetal Monitoring: Nursing Practice Competencies a n d Educational Guidelines. Washington D.C.: NAACOG. 10. Kinnick, V.G. 1989. A national survey about fetal monitoring Skills acquired by nursing students in baccalaureate programs. JOGNN 18(1):57-58. 11. Catanzarite, V.A. 1987. FMTUTOR: A computer-aided instructional system for teaching fetal monitor interpretation. Am J Obstet Gynecol. 156(5):1045-48. 12. Snydal, S.H. 1988. Methods of fetal heart rate monitoring during labor: A selective review of the literature. J Nurse Midwgery. 33( 1):4-14.
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13. Afriat, C.I. 1989. Electronic Fetal Monitoring. Rockville, Maryland: Aspen Publishers, Inc. 14. Hage, M.L. 1985. Interpretation of nonstress tests. Am J Obstet GynecoI. 153(4):490-95. 15. Hefland, M., K. Marton, and K. Ueland. 1985. Factors involved in the interpretation of fetal monitor tracings. Am J Obstet Gynecol. 151(6):737-44. 16. Larson, E.B., G. Van Belle, K.K. Shy, D.A. Luthy, D Strickland, and J.P. Hughes. 1989. Fetal monitoring and predictions by clinicians: Observations during a randomized clinical trial in very low birth weight infants. Obstet Gynecol. 74(4):584-89. 17. Chez, B.F., J.H. Skurnick, R.A. Chez, M.T. Verklan, S. Biggs, and M.L Hage. 1990. Interpretation of nonstress tests by obstetric nurses. JOGNN. 19(3):227-32. 18. Cokington, P. (January 30, 1989). Nu-Vision, personal correspondence. 19. NAACOG. 1988. Statement: Nursing Responsibilities in Implementing Intrapartum Fetal Heart Rate Monitoring. Washington, D.C: NAACOG. 20. Fields, L.M., and F.H. Boehm. 1989. Changing issues in FHR monitoring. Contemporary OB/GYN 33:145-48. 21. AIG Consultants, Inc. 1989. Fetal monitoring as a malpractice prevention tool. Viewpoint: Risk Management Advisory for Healthcare Proj&sionaIs. 2 (11.
Address for correspondence: Deborah J . Eganhouse, RN, MA, 1521 Oak Ridge Lane, S.E., Cedar Rapids, IA 52403.
Deborah J.Eganhouse is aperinatal cllnlcal spectalist at St. Luke's Hospttal in Cedar Rapids, Iowa. Ms. Eganhouse is a member of NAACOG, the Great Plains Organization, and Sigma Theta Tau.
Notice to Copiers Authorizationto photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by NAACOG, a division of the American College of Obstetricians and Gynecologists, for libraries and other users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the base fee of $00.80 per copy, plus $00.05 per page is paid directly to CCC, 21 Congress St., Salem, MA 01970. 0884-2175191 $00.80 + $00.05.
Volume 20 Number 1
