“Self Enrichment: A Maternal &

Child Nurse’s Quest Towards

Excellence”

DR. MARIA TERESITA SY-SINDA

Professor & Dean
College of Nursing & Allied Health Sciences
Silliman University, Philippines

28th Founding Anniversary & 27th Annual Convention

Maternal – Child Nurse Association of the Philippines
July 18, 2008 – Great Eastern Hotel, Quezon City
 Compared with many other highly
technical endeavors, health care
activities – despite many advances are
inexact procedure based upon
incomplete knowledge and are
performed in a rapidly changing world
on an increasing aging population.
• Uncertainty is large and
error margins are small.
• Health care professionals
and their patients both
possess medical
knowledge as one surgeon
recently noted:
“We look for medicine to be
an orderly field of
knowledge and
procedure.”
• But it is NOT!
IT IS:
• an imperfect science,
• an enterprise of constantly changing
knowledge,
• uncertain information
• Fallible individuals
• lives on the line

There is a science in what we do, Yes.

However it is also a habit, intuition
and sometimes plain old guessing.

The gap between what we know and

what we aim for persists and this
gap complicates everything we do
(Gawande, 2002).
In this time & age, health
care professionals are
expected to evaluate the
care they provide and
show evidence that care is
not only clinically
effective but also cost
effective and satisfying to
the patients.
In light of these challenges, the
term best practice has emerged
as a descriptor of clinical
practice that result to the best
outcomes as well as the
process used to select these
clinical practices.
Best practice is often
associated with
benchmarking which
involves identifying
the most successful
institutions, using
their approach,
replicating and
refining their
methods
 Perlith, Jakubowski & Busse
(2001) describe best practice as
an approach organizational
process, improvement that
involves using research findings
to change organizational
policies, to improve the delivery
of health care
Santos (2002) describes best practice
guidelines as evidence – based
statements that assist practitioners
and patients in making decisions in
specific health care situations.
 Sigma Theta Tau International
define evidence - based practice
as the integrating the best
evidence available, nursing
expertise, & the value &
preferences of individuals,
families, & communities whom we
serve.
This assumes that optimal nursing
care is provided when Nurses and
health care decision makers have
access to a synthesis of the latest
research, a consensus of expert
opinion, & are thus able to
exercise their judgment as they
plan & provide care that takes into
account cultural and personal
values & preferences.
 Both best practice & evidence
based – practice though with
slight differences in their
definitions have one goal:

To provide optimal patient care that

is based on reliable evidence with
the goal of enhancing practice &
in turn improving patient or
system outcomes.
Contemporary health care
consumers are
knowledgeable &
demanding.
They expect the most
current; effective and
efficient interventions.
In our quest to promote excellence
for our patients, we are challenged
to stay abreast of new
developments in health care even
within the limits of our own areas
of specialization.
Similarly with the growth of health
care knowledge, health care costs
increase and patient’s
satisfaction, takes on greater
importance.
Administration expects health care
providers to satisfy their
customers and do it in the most
clinically effective & cost –
effective manner.
Control of health care cost
was one of the initial
drivers of the best practice
movement (Larafee, 2004)
 In today’s health care
environment, Nurses are
increasingly accepted as
essential members & often as
leaders of the
interdisciplinary health care
team.
To effectively participate & lead a health
care team, Nurses must have
knowledge of the most effective and
reliable evidence based approaches to
care.
And as Nurses, increase their expertise
in critiquing research, they are
expected to apply the evidence of their
findings to selecting optimal
interventions for their patients.
 In recent years, the
implementation of evidence –
based, best practices have
been identified as a priority
across nearly every nursing
specialty.
During the late 1990’s Sigma Theta
Tau International conducted a
strategic planning process to
establish future directions for the
organization.
They found out that the most
frequently cited request from
practicing Nurses was a desire for
support systems & resources to help
them implement evidenced based
practices.
• The feedback was consistent across
Nursing specialties and across Nursing
roles & positions.
• For e.g. Obstetrics & Neonatology, Malon,
Albrech & Thomas, et. al. (2003) have for
their research, the title or theme,
“Implementing evidence – based practice:
Reducing risk for low birth weight
through pregnancy smoking cessation.
• The type of report is to describe
implementation process for evidence -
based protocol.
In women’s health, Mason (2002) had
the research title,
“Who says its best practice.”

The type of report is discussion of

changes in prescribing hormone
replacement therapy.
• Craig & Smyth (2002) asserted that best
practice begins by asking good
questions.
• Nurses must be empowered to ask
critical questions in the spirit of looking
at opportunities to improve Nursing
practice & patient outcomes.
• In any specialty or role, nurses can
regard their work as a continual series
of questions & decisions.
For e.g. in the area of Maternal &
Child Health, we can ask
these questions:
1. What particular health
education methods can
decrease the incidence of
teenage pregnancy in the
Philippines?
2. What demographic factors
relate to incidence of fetal
death?
3. What obstacles are in the way
for women to access
reproductive health services?
In general, qualitative, descriptive
quasi – experimental studies are
much more common methods of
inquiry in Nursing research rather
than randomized clinical trials
(RCTs) or Meta analysis.
 Optimal professional practice
can occur when practitioners
take all kinds of sources of
knowledge into account in the
clinical situation & make use of
then wisely for their specific
goals.
 In practice settings, much of the work
of successful encounter rests on how
practitioners actually utilize the
knowledge produced through hypothetico
– deductive processes.

This include how they take the extant

knowledge of books & research papers &
use it in the different modes of
application they select for patient care
situations.
• General observations of policies aimed
to increase patient’s, involvement in
their health care, of moves to increase
physical activity in societies, & other
strategies to increase community
participation in health lifestyles, calls
into questions many of the passive
treatments & interactions in health care
that are labor intensive, of high cost and
tending to create patient dependency
A dilemma for the practicing
nurse is the time, access &
expertise needed to search &
analyze the research literature
to answer clinical questions.
In the light of the challenges of
providing best practices,
Nurses must consider some
alternative support
mechanisms when searching
for the best evidence to
support their practice.
The following strategies are:
• Keep abreast of the evidence –
subscribe to professional
journals & read widely.
• Use and encourage the use of
multiple sources of evidence.
• Use evidence not only to support
clinical interventions but also for
teaching strategies.
• Find established sources of
evidence in your specialty.
Don’t reinvent the wheel.
• Implement & evaluate nationally
sanctioned clinical practice
guidelines.
• Question & challenge nursing
traditions, promote a spirit of risk
taking.
• Dispel myths & traditions not
supported by evidence
• Collaborate with other nurses, locally
& globally
• Interact with other disciplines to
bring nursing evidence to the table
Other ways to support best practices are:
1. Garner administrative support, it is needed to
access resources, provide support personnel
and sanction necessary changes in policies
and procedures.
2. Collaborate with a Research Mentor Advance
Practice Nurses, Nurse researchers or
Nursing faculty are examples of Nurses who
may provide consultation & collaboration to
support the process of searching, reviewing &
critiquing research literature and data bases
to answer clinical questions & identify best
practices.
3. Search already reviewed or
summarized research –
For e.g. Some journals such as
Evidence Based Nursing and
Worldviews on Evidence Based
Nursing specifically focus on providing
summaries, critiques, & practice
implications of existing research
studies.
 For e.g., In the 2004 issue of
Worldviews on Evidence Based
Nursing is the research on
Elastic Compression Stockings
for prevention of post –
thrombotic syndrome.
4. Access Resources from professional
Organizations
Professional Nursing Organizations also
provide a wealth of resources to support
evidence based practices.
For e.g. the Association Women’s Health
Obstetrics Neonatology Nursing
(AWHONN) provides multiyear projects
focusing on the management of women in
the second stage labor, urinary
continence for women, Neonatal skin
care, & cyclic pelvic pain & discomfort
management.
 They also fund a project on
guidelines for care in topics
such as Breastfeeding support,
regional Analgesia/Anesthesia
in labor, promotion of
emotional well being during
mid-life and cardiovascular
health for women.
5. Benchmark with high performing teams,
units and institutions.
Although evidence based practices
are being discussed and pursued by
Nurses around the world, there are
obstacles that inhibit the movement.
These are:
a. Accessibility of research findings
b. Anticipated outcomes of using
research (concerns about discomfort
with change)
c. Support from others & lack of
organizational support.
• Yet challenges continue. Organizational
cultures may not support the Nurse who
seeks and uses research to change long
standing practices rooted in traditions
rather than science.
• In addition, a stronger connection needs to
be established between researchers &
academicians studying evidence based
nursing & best practices & staff Nurses who
must translate those findings into the art of
nursing practice over the science.
Both are critical in making sure that patients
received the highest quality of care
possible.
Some studies which are evidence – based
that Maternal – Child nurse specialists can
apply to practice are the following:
A study to examine Nurse’s knowledge,
attitude and practice in positioning healthy
newborns for sleep in the hospital setting
revealed that Nurses no longer place infants
on the prone position for sleep, but almost
75% of those answering the survey used
either the side lying position or a mixture of
side & back positioning even though 96% of
the Nurses said that they were aware of the
guideline recommending “back to sleep”
• The clinical implications would be that
Nurses are the role models for new parents
regarding newborn sleep position, & are in a
unique position to influence parents’
decisions about how to put their infants to
sleep at home.
• Because Nurses continue to worry about
aspiration when newborns are placed on
their backs, it is clear that more education is
needed for hospital nurses about newborn
sleep position. Practice is difficult to change
as evidenced by this study.
Strategies need to be developed
to help change the knowledge,
attitude and behavior of
hospital newborn nursery
nurses in relation to the
guideline.
 Another study to provide evidence –
based practice is a descriptive and
replicate study of Nursing ambient sound
levels associated with nursery equipment
and care activities in a Level III Neonatal
Intensive Care Unit (NICU).

Measurements were obtained

using sound level meter and
evaluated in the light of
previous findings.
• The results revealed that contrasted with 16
years ago, room sound levels were reduced.
However, sound levels associated with care
giving equipment and activities continue to
be high.
• Implications state that sound levels
continue to be a clinical challenge for NICU
Nurses.
• This study suggests some modifications of
care practice & equipment selection that
could reduce sound levels and conclude
that sound reduction is a continuing need in
neonatal care.
Suggested clinical implications include:
1. Awareness of ambient sound level and
ongoing control is an important aspect
of neonatal care.
2. Certain sound levels in incubators are
high, including opening/closing
porthole and plastic porthole sleeves,
using the incubator hood as work
surface (writing, tapping, & closing
incubator cabinet) Incubator hoods
should not be used as work surface
3. Be aware that noise caused by IV &
cardiopulmonary alarms & ventricular
tubing bubbling is high. Prompt response
to alarms & removal of fluid from tubing is
warranted.
4. Nurses should be aware that dropping the
head of the incubator mattress was the
loudest sound measured.

Levers should be used to gently raise or

lower the mattress.
5. Assessment of sound levels
associated with specific care
activities may help the care provider
modify infant exposure to loud
sounds.
6. Equipment selection should include
evaluation of sound levels criteria.
• A study on the controversy of neonatal
exposure to plasticizers in the NICU was
explored by Pak, Victoria et. al in 2007.
• Critically ill infants in the NICU undergo
medical procedures & treatments that
require extensive use of medical
devices. As a result these infants maybe
exposed to di – (2 ethyhaxy) phthalate
(DEHP) levels much higher than
exposure of the general population.
• The study explores the extant literature
that informs our current understanding
of the effects of DEHP exposure and
how DEHP enters the bloodstream and
how it is metabolized.
• DEHP is a major component in the
manufacturing of polyvinyl chloride
devices commonly used in the health care
setting such as blood bags, IV tubing,
ventilator, enteral and parenteral feedings,
O2 & suction equipment.
• Because maintaining a DEHP free NICU
environment requires teamwork, Nurses
should begin discussing with their co –
workers & managers the research
evidence cumulative exposure & adverse
effects that result from infant exposure to
DEHP.
 Check the supply room in the NICU & list
the medical equipment & supplies that may
contain DEHP devices that may contain
DEHP plasticized PVC such as:
1. IV Bags & tubing
2. Umbilical artery catheter
3. Blood bags & infusion tubing
4. Enteral nutrition feeding bags
5. Nasogastric tubes
6. Peritoneal dialysis bags & tubing
7. Tubing used in cardiopulmonary by pass
procedures.
8. Tubing used in hemodialysis
• Identify alternative devices & equipment
that are DEHP free
• Advocate that the purchasing
department of the hospital consider
purchasing only DEHP free equipment &
supplies.
• More human studies are needed to
explore health outcomes in infants
exposed to DEHP & to look for
relationships between exposure &
subsequent outcomes.
• Further studies are
needed to
demonstrative efficacy
of alternative materials
in the manufacturing of
medical devices.
• The authors of the study
believe that a
conservative approach
to their use involving a
reduction of exposure to
infants is warranted.
• In recent nursing literature,
mothers of newborns have been
shown to associate satisfaction in
breastfeeding with behaviors of
their infants related to state
organization.
• This suggests a positive
relationship between newborn
behavioral state management &
breastfeeding success.
• Nurses who work with postpartum
women are encouraged to learn more
about newborn states & breastfeeding
in order to assist new mothers in their
breastfeeding efforts.
• Prenatal nurses are daily witnesses to
the hightened sensitivity mothers
have with their newborns, & can use
this maternal awareness & interest to
assist them.
• The Nurses are entrusted with
support of breastfeeding through
teaching the mother during the
hospital stay, in the home & often in
primary care.
• Nurses are often the healthcare
providers who advocate keeping
mothers & babies in physical
proximity to each other during the
postpartum period when separation
of Mother & baby is a significant
barrier to successful breastfeeding.
• Because Nurses are critical to its
success, they must constantly refine
their practice of passing on the art and
science of breastfeeding of mothers.
• A strong Nursing role model is that of a
facilitation around with the knowledge
about newborn states, the Nurse can
explain how the newborn organize
themselves in preparation for
breastfeeding and how the mother can
help the newborn.
• Finally, the nurse shows the mother how to
create a physical environment for
breastfeeding, accurately express her
baby’s position and latch the baby.

A study by Clemmens, Donnacues et. al

in 2004 described in greater depth the profiles
of the dimensions of the Postpartum Depression
Screening Scale (PDSS) with a focus on those
women identified with postpartum depression
(PDD) and to provide a discussion of the
implementations of early detection in the
community.
• 150 new mothers completed the PDSS and
an interview with a Nurse
psychotherapist.
• Date analysis focused on exploring the
profiles of women who were diagnosed
with PPD as well as those who were not.
• Results revealed that the group with PPD
averaged scores twice as high as those in
the non – depressed group and described
more profound emotional responses to
the maternal role transition.
• PPD should be conceptualized as occurring
in a continuum with symptoms worsening
overtime for some women. Nurses working
across all health care settings can use the
PDSS to identify women with PPD.
• All health care provides who are in contact
with postpartum women should be open to
discussing those women’s emotional
needs, & should assess women on an
ongoing basis. They can help identify
women who require treatment for this
curable illness.
• Spaulding, Deborah et al in 2007 asked
the question “How does postpartum
Depression affect breastfeeding?”
• The purpose of the study is to examine
patterns of exclusive bottle feeding
among a sample of women identified at 2
– 4 weeks postpartum with positive PPD
symptoms.
• The sample include 122 women who were
part of a larger study. Data were collected
during the three postpartum home visits.
• Results revealed that the severity of
depression was not related to
breastfeeding.
• Older Maternal age, living with a
partner and high income were
positively related to breastfeeding.
• Compared to a random sample the
level of exclusive breastfeeding was
significantly lower in the sample than
the level of combination feeding.
Nurses should be involved in
screening all prenatal &
postpartum women for PPD
Symptoms particularly when
they present breastfeeding
difficulties & refer to treatment
when appropriate.
Weinhard, Orpha 2007 wrote an
article in the
Development of the Perinatal
Concerns Program: Care of
Mothers after Diagnosis of
Fetal infant anomalies.
• Care of the grieving mother in the labor and
delivery setting is a complex phenomenon
requiring collaboration of professionals and
designing sensitive care based on theory
and compassion.
• This article describes the Perinatal
Concerns Program, which was
developed to make available
a complete range of care for
women whose pregnancies
are complicated by
fetal abnormalities.
• Development of this program required
collaboration of several services,
coordination of protocols, and
establishment of a clear lines of
communication.
• It was born after a particularly difficult
case in labor and delivery that alerted a
staff nurse to the fact that coordination
of care for this patient could have
resulted in enhanced ability of all the
staff to meet this woman’s physical and
emotional needs.
The development of this
program demonstrates
that a motivated staff
nurse, with effective
leadership skills can
make major changes in
an institution which
can make a difference
in the care of
grieving patients.
Conclusion:
The successful development of
the Perinatal Concerns program
was dependent on the ability of the
staff nurse at this institution to
move forward to solve a difficult
problem.
This staff nurse acted as an
empowered leader in order to
accomplish this task.
An effective, empowered
leader must possess
specific characteristics
including
(1) Effective communication
skills,
(2) Integrity, and
(3) Vision.
Effective communication
skills include
the ability to express
thoughts and be
understood, the ability to
motivate people, the skill
to listen clearly and
understand shared
thoughts, and the
capability to effectively
communicate messages
as a leader.
• In addition, an effective communicator
will also have other qualities such as
enthusiasm, empathy, self-regulation,
wisdom, and the ability to empower.
Integrity means being honest and
forthcoming, and is motivated by
intention (Dye, 2003).
• Vision means having the ability to see
beyond the moment, to know where you
want to be, and how to get there (Dye).
• The staff nurse in this case study was motivated to
address the issues discovered in the care of her
patient, and then to collaborate with nursing,
medicine, and other staff to better meet the
complex needs of this grieving mother, leading to
major changes for similar patients in the future.
• Nurses who are educated in leadership skills and
experts in patient care can use the information
provided in this article
to develop similar programs in
their institutions, thus enriching
their own professional lives
and enhancing the care givers
to parents in their most
desperate hours.
 I like to end this talk
with the definition of a
Nurse by the theorist
Virginia Henderson
which spells excellence in
the Nurse
 THE NURSE
The NURSE is the Consciousness of the
Unconsciousness
The NURSE is the Sight of the Newly Blind
The NURSE is the Leg of the amputee
The NURSE is the Confidence of the New
Mother
The Nurse is the LOVE OF LIFE of the
Suicidal
The NURSE is the Mouthpiece of those who
cannot Speak
We can only be this Nurse if we diligently
seek for current knowledge to guide our
practice that should result in:
Positive Client Outcome at the least Cost.
REFERENCES:
1. Higgs, Joy, Richardson, Barbara & Dahlgram, Madeleine. Developing Practice
Knowledge For Professionals. Butterworth & Heinmann 2004 edition.
2. Keeping Patients Safe: Transforming the Work Environment of Nurses.
National Academy of Sciences. 2004 edition.
3. Huston Carol. Professional Issues in Nursing Challenges & Opportunities.
Lippincott, Williams & Wilkins 2006 Edition.
4. Bullock, Linda et. al “Are Nurses Acting as Role Models for the Provider of
SIDS?” Journal of Maternal & Child Nursing, May – June 2004.
5. Thomas, Karen et al. “How the NICU Environment to a Preterm Infant” Journal
of Maternal – Child Nursing. Vol. 12 July/August 2007
6. Park, Victor & McCauly, Linda. “Controversy: Neonatal Exposure to
Plasticizers In the NICU”. Journal of Maternal – Child Nursing. Vol. 12
July/August 2007
7. Karl, Dona. “Using Principles of Newborn Behavioral State Organization to
Facilitate Breastfeeding.” Journal of Maternal – Child Nursing. Vol 29 ________
Oct 2005
8. Clemmence, Donna et. al. “ Postpartum Depression” Journal of Maternal –
Child Nursing. Vol. 29 May – June 2004
9. Spaulderg, Deborah & Horowitz, June Andrews. “How does Postpartum
Depression Affect Breastfeeding?” Journal Maternal – Child Nursing. Vol. 12
January – Feb. 2007
10. Weinhold, Orpha. “Development of the Perinatal Concerns Program: Care of
Mother after Diagnosis of Fetal Infant Anomalies” Journal of Maternal – Child
Nursing. January/Feb. 2007