Improving Nurse Confidence and Competence of Speculum Exams Through Enhanced Training and Available Resources in the Labor and Delivery Triage Setting

Background: Pelvic exams with a speculum are often necessary to evaluate patients and complete medical screening exams in the obstetric triage setting. Labor and Delivery nurses often lack confidence and competence when performing speculum exams due to the infrequent and limited training, the absence of various speculum sizes, and the lack of mentorship from experienced providers. Thirty- eight percent of RNs at a local hospital reported their last speculum training was over five years ago. Best practice indicates that those performing sensitive exams should receive training when hired and renewed regularly to maintain competency. This project aimed to improve best practices competencies with speculum exams by increasing nurse competence and confidence through enhanced training and resources. Methods: This quality improvement project was carried out at a busy regional labor and delivery unit in Ogden, Utah. Surveys were used to pre-assess RNs' confidence, competence, and knowledge surrounding vaginal speculum exams, as well as their attitudes towards caring for obese patients. This project included developing and implementing several online PowerPoint presentations, hands-on simulation training, and performance of patient exams with trained provider support. The unit's equipment and workflow were improved by increasing speculum size selection and stocking all pelvic exam supplies in triage rooms. Finally, a feasibility, usability, and satisfaction survey was conducted approximately 1 to 2 months after implementation. Results: Confidence scores statistically increased in two of the five areas of interest: patient positioning (p=.010) and specimen collection (p=.020). Confidence levels increased but were not statistically significant in patient education before an exam, obtaining consent, and properly handling and inserting a speculum. Pre and post-knowledge assessments showed improved RN recollection of proper specimen collection (p=.003). There were increased competence scores for visualizing the cervix during speculum exams, but this was not statistically significant. Attitudes toward caring for obese patients remained unchanged from pre to post-intervention. One hundred percent of respondents agreed or strongly agreed that the program helped improve their confidence in performing speculum exams and their ability to do their job, a clinically significant finding. Conclusions: A training program explicitly focused on speculum exams for labor and delivery RNs appeared valuable for increasing their confidence and competence. Replicating this quality improvement project at similar labor and delivery units would help determine if consistent findings would ensue. This program should be considered for future use as it complies with best practice guidelines concerning training for sensitive exams.