Developing Nurses' Clinical Judgment in the Management of Shoulder Dystocia (SD) Patients

Shoulder dystocia (SD) is a sporadic and unexpected emergency that has up to a 24% risk of maternal and fetal morbidity and mortality. SD is more prevalent in non-white patients. Clinical judgment, competence, confidence, and awareness of implicit bias are needed to empower nurses to provide quality and equitable care during labor and delivery (L&D) emergencies. Deficiencies in any of these areas put patients at risk for poor outcomes or death. Local Problem: Nurses new to L&D units lack confidence, competence, and technical skills such as positioning and manual maneuvers. A majority of the Northern Utah L&D nurses surveyed for this project have less than two years of experience, and 97% are white. These demographics increase the potential for little or no experience with SD, poor self-confidence, and implicit bias, which may impact patient care. The skill set needed to care for SD patients is often learned on the job without proper debriefing or gap corrections. Methods: The Institute for Healthcare Improvement's Model for Improvement was used to develop and implement an evidence-based simulation experience focused on caring for racially diverse SD patients. Confidence and clinical judgment assessments were designed based on the Confidence in Managing Challenging Situations Scale and the Lasater Clinical Judgment Rubric. REDCap was used to administer the surveys. Interventions: Participants (n=32) attended a 1-hour SD simulation experience, of which there were seven offerings over four different days. The simulation experience consisted of prebrief, simulation, and debrief. Each participant was administered an anonymous linked pre/post survey before and after the simulation experience. Quantitative data gathered in the surveys were demographics, self-assessed confidence, self-assessed clinical judgment, knowledge of the care for SD patients, and implicit bias. Post-simulation qualitative data were gathered via a written open-ended question and verbal discussion. Results: Quantitative data showed that clinical judgment and competence increased overall. Confidence was increased or stayed the same in 100% of participants. Qualitative data indicates that 56.3% (n=18) of participants felt that this experience gave them the skills and preparation necessary when caring for SD patients. A qualitative data analysis software, Dedoose, was used to analyze discussion themes. Conclusion: Evidence-based simulation is a safe and effective way to improve competence and confidence and enhance awareness of implicit bias in nursing and may positively impact patient care outcomes. Additional measurements are needed to determine the impact of simulation on clinical judgment. An outcome of this project is that the simulation experience developed for this project will be a template for all future simulations within the local hospital system. A recommendation is that simulation experiences such as the one conducted in this project should be considered for all patient populations experiencing high-risk and low-volume emergencies, such as code blue, stroke, trauma, malignant hyperthermia, hemorrhage, etc.