Nurs1591 Leading Complex Care for Women, Newborn Infants and Families Assignment Sample 2026

Introduction

In 2016, there was a national maternity review set out called Better Births conducted as part of a healthcare wide improvement scheme by the National Health Service (NHS). The aim was to improve outcomes for both mothers and neonate in England across a five-year plan through a safer, patient centres, professional and approachable system. It details changes proposed for both staff and patient environments, how the organisations and the multidisciplinary team each have their place to make the change (National Health Service, 2016).

Service improvement projects in the maternity unit are evolving and as research is developed research projects are a key part of improving services (National Health service, 2011) The taskforce on the front line often have the best insight into what is working well in the organisation and what would need to change, staff are often encouraged to suggest changes (Jones et al, 2021). Using the staff at the forefront to propose change also extends to the knowledge of how these beneficial changes can be implemented and sustained through time (National Health Service, 2014).

This service evaluation will propose a change for a local maternity unit (this will be referred to as trust X due to anonymization) exploring the need for this change. Adapting the Lewin change model will also detail the key three stages of implementation of the service improvement. As a final part there will be a short reflection on personal leadership skills and how going forward post graduate this module has influenced my practice.

This is an evaluation of the labour room environment and the promotion of physiological birth for low-risk women within the obstetric unit.

Rationale for change

The rationale for change is to reduce intervention rates for low-risk women in an obstetric led unit and promote low risk physiological birth, thus improving maternal and neonatal outcomes via enhancing the low-risk rooms to be more oxytocin friendly (Nilsson et al, 2020).  The World Health Organization, 2018 made recommendations for intrapartum care for a positive childbirth experience. In this paper they touched on the increasing intervention rates in obstetric led units of which do not have a clear clinical indication suggesting routines and personal preference of professionals have become a new lower standard of practice.

Below (Figure 1) is a recent visual of the mode of deliveries within the obstetric unit at trust X. Whilst factoring in that this is a high-risk unit in relation to the detailed current situation this also is including the low-risk women that opt for the geographical option of the hospital. Looking at improving safety and outcomes is an ongoing necessary part of the health care system (Royal College of Midwives, 2021).

Research shows that having an adaptable, calmer, more oxytocin friendly labour room reduces intervention rates for low-risk women, improving the rates of vaginal births and overall patient service satisfaction (Berg et al., 2019 and Nilsson et al., 2020). The definition and changes that make a room oxytocin friendly is detailed later in this paper. There is a multitude of research globally on the effects of the birthing environment and the relation to the outcome of delivery. Despite this, not all hospitals have a high standard of oxytocin friendly low risk labour rooms within obstetric units, including trust X.

The Royal College of Midwives made a summary of better births in 2015, understanding experiences in hospital based maternity settings. In discussion of women birthing in an obstetric unit but are clinically low risk from anecdotal research it was found obstetric teams are not focused on the environment as a priority of care. It was found the high risk focused role they carried out such as theater sisters, operating department practitioners, doctors and anesthetists have been so climatized to a clinical environment they do not factor in environmental factors into their assessments and resolutions (also discussed by McGowan, 2022). In terms of differences between birth centres and obstetric units welcoming women in the anecdotal experiences from this paper were similar practice to trust X.

The code, 2018 sets out professional standards for nurses and midwives. Priorities people, practice effectively and preserve safety can all influence and relate to this improvement change. Prioritising better outcomes for the mother and neonate by improving the service to reduce the rate of intervention and better the satisfaction of the hospital experience. Preserving safety, again reducing the rate of intervention which is including the use of synthetic hormones to encourage faster labour, kiwi and forceps and emergency section deliveries which each come with furth risk complications, having a domino effect of reducing adverse outcomes. Thus, in turn practicing effectively, reducing obstetric team workload, using evidence-based care and enhancing the midwives (students and maternity support workers) knowledge and care of caring for this group of women.

Current practice

At the current Labour ward at trust X is made up of 2 high dependency maternity rooms and 15 labour rooms, 6 of which are classed as low risk rooms and 7 rooms are for high-risk women.  There are two independent birth centres under the trust of which are around a 25-minute blue light ambulance drive, these birth centres are midwife led for low-risk women. In order to attend the birth centre women, need to be risk assessed from 32 weeks and ‘booked’ to deliver at the birth centre, they are unable to birth here without prior contact and acceptance. If geographically the birth centre does not suit a low-risk woman, or they do not find it appropriate to birth in a midwifery led unit with pain relief options being restricted their only option is to attend the obstetric led unit. Because of the geographic location of the birth centres it restricts low-risk women’s choice of their birth settings which is not giving them the best chance of their birth preferences being met (Hollowell et al, 2016).

If low risk at time of labour they will be placed in a ‘low’ risk room on labour ward if acuity allows. These rooms visually do not differ from the higher risk labour rooms they are just located further away from emergency theatres and midwives’ desk. In terms of an optimal birthing environment for physiological low risk birth (Hastie, 2020) these rooms are not necessarily as oxytocin friendly as the birth centre low risk rooms.

In terms of differences between birth centres and obstetric units welcoming women in again the anecdotal experiences from this paper were similar practice to trust X. Women being welcomed into the birthing centre are encouraged to bring home comforts such as pillows and scents, are left to make their room more homely and encouraged to adapt their surroundings to their taste and comfort. Whereas the obstetric unit is set up for a specific purpose and as commonly women are not introduced to these rooms prior to labour they are unaware to bring in home comforts and are often discouraged to move items and nest into the room.

Within the obstetric it is often practice for doctors to introduce themselves to patients on the ward round or on admission even if low risk and feedback has reported women to feel like this is ‘writing’ them off, like the doctor is waiting around the corner to intervene at the earliest convince and puts pressure on them to perform which often leads to failure (Stohl, 2018). The practice found in this Royal College of Midwives Report, 2015 heavily reflects the practice in trust X and nationally.

Proposed Change

A minimum of 4 of the 6 ‘low risk’ rooms on labour ward to have an enhanced low risk environment. Rearranging the furniture in these rooms such as a lounge sofa. A change of layout including the bed to be routinely stored in the lowered down position and in the corner opposed to the current layout of it being raised and in the centre of the room upon entry. The addition of fairy lights and mood lighting and facilities to play music. Encouraging the patients and partners to nest in these rooms, moving furniture and feeling able to ‘unpack’ belongings is essential to women feeling safe in childbirth and owning the space they are in (Harte, 2016 and Mondy, 2016).

At current trust X has two birthing pools available on labour ward, due to current trials and a surge in water births and use of them in labour due to these trials and encouragement from the consultant midwife these two pools are often in use. This means that women do not always get the opportunity to use the pool when they want to, therefore, an additional pool is added into this proposed change. Not having a pool available upon admission for a woman when that is her chosen method of pain relief or choice of delivery can be very upsetting and can have a mental impact on that women, slowing down their labour and possible leading to adverse outcomes (Milosevic et al, 2020).

The space envisioned is based upon the Snoezelen room. A Snoezelen room is based upon the idea of creating a space that stimulate senses but does not overwhelm them and is adaptable to the purpose of the room. Hauck, 2008 researched the Snoezelen room in association with labour and birthing. They found that the optimal birthing space included: polished floorboards, earth colour theme paint and furnishings, soft rugs, fiber-optic lighting systems that are colour changing and dimmable. As well as visual prompts they also touch on the use of relaxation music, calm, soft ambience and aromatherapy that compliments the journey the woman is on and meets their needs (Ayerle et al, 2017). Community midwives would be to discuss with women in antenatal appointments the importance of bringing in home comforts such as scents and pillows, ensuring women are aware they can bring in items to nest and feel ownership of the room (Horton, 2022).

As well as, this a curtain that separated rooms 1-6 (low risk rooms) from the remains of the ward to show a boundary and visual change for staff entering the corridor. Stickers on the handover board so doctors are aware of the patient being low risk and not requiring intervention at current so not to enter room unless emergency, this includes no entry or introducing at ward round or on admission unless clinically indicated – to be discussed with midwife prior (NHS Improvement, 2017). These signs are also to be placed on the doors of the patients when in use, so staff are more aware and a further visual prompt.

Due to the acuity of the obstetric unit the proposed number of rooms to be changed is currently four. Whilst the environment of the rooms can be changed and adapted to be as homely as possible, they can still be used by high-risk women if needed due to acuity due to the medical equipment still being in the rooms, just hidden in cupboards/behind curtains.

Stakeholders

As part of a multidisciplinary team there is a multitude of stake holders in this project in order to initiate the change as well making it a sustainable change. It is important to make each stakeholder aware of the vision behind the change, in order for them to be inspired and be onboard, actively making the difference to meet the set-out objectives (Locock et al, 2020 and NHS improvement, 2011).

Table 1 demonstrates how each stake holder has an involvement and the motivation for them to assist with this change.

Table 1 above.

Below Table 2 is a cost breakdown of different interventions mode of delivery. It is clearly a financial motive to reduce intervention and emergency caesarean section rate in exchange for the minimal cost of extra furnishings to the room. The cost implication of a service change is a huge incentive given the financial situation of the national health service, so this is a key selling point for this improvement (Burgess and Randor, 2015).

Table 2 as above

Service improvement plan

The Lewin change model, 1951 seems the most appropriate to adapt and carry out this change.

1. Unfreeze

– Need for change: Birthing environment prohibiting physiological birth and increasing intervention rates (previously discussed at length prior).

– What needs to change: (previously discussed).

– Encourage and replace old behaviors and attitudes: encourage staff who are on the forefront of the change such as the MSWs and midwifes for changes and give the reasons behind change, all staff, domestic, MSWs’, midwives and doctors attitudes and behaviors of routine rooms. – Think about culture of change in the unit, the culture of being high-risk obstetric lead and making a distinctive difference when looking after low risk women within the setting.

– Strong managerial support: Make them aware of research, feedback and the need for change. How it will positively reflect in patient feedback and experiences, giving the unit a better image to the public. As well as a reduction in cost implications of interventions and reducing intervention rates to come in line with other local and national trusts, meeting goals.

– Manage doubts and concerns: A suspected concern or doubt from staff could be the acuity on the ward in order to redecorate rooms, financial change and ability to be sustained. Ways to overcome this would be slow change, taking one room at a time for it not to affect the workflow of the ward. The cost implication is minimal in the scheme of things as it has a good potential return in terms of reduced costs of intervention.

2. Change

– Plan change: when, how long will it take, financial side, details of decoration, who will carry out these physical changes to the rooms. In reflection of taking into acuity and ensuring maximum rooms are available at a time the changes proposed will not take more than a day per room, the pool installation as advised by a delivery suit matron would take around 3 days. The addition of furniture can be done at any appointed time after delivery of items and would not affect availability.

– Implement

– Help employees to learn new concept: Use a demonstrative room to show idealic set up, take photographs of this staged room and send a generic email to all suitable staff with the update. Also offer contact for any questions or further advice/critiques – open the line of communication with service users and staff (Institute for Health Improvement, 2019).

3. Refreeze

– Reinforce and stabilize, Make it the new normal

– Sustain: random checks on room layouts, possible weekly audits? Ask staff what is working, any changes they suggest.  Being available for staff to contact with worries.

-Celebrate success: Thank you group emails, personal ‘thanks’ for supportive members of staff who are on board and actively making change. As feedback and interventions improve make staff aware and celebrate the change. The positive patient feedback available and visual to staff to encourage positive reinforcement.

Conclusion and Reflection on own Practice

To conclude this essay a short self-reflection on my own knowledge and skills in relation to the module will be discussed.

Following the last module, I understand better about the different models of change and the roles in which the multidisciplinary team play in these changes. Personally, a weakness of mine is confidently delegating and taking on a leader role. My confidence has dramatically got better across the three-year degree, and I am now more confident in decision making and independent working but still struggle when it comes to acting as an authoritive figure. I believe this will come with time and experience. Therefor if I came to the point of implementing a service change, I would need to act on this, however I do believe it is not only a weakness, being less authoritive I believe makes me approachable and an active part of the team. I am always of others’ opinions of myself and aim high when it comes to performance in practice.

Having worked within the maternity unit of the national health system for over six years now in various roles, I have seen various clinical trials and service improvement projects, some that have worked and some that have not. I realised early on the importance of evaluating the system regularly and all levels of staff putting forward ideas when they see room for improvement. I have previously been involved in improvement projects when it came to enhancing the role of the band 3 maternity support worker and was used as a band 3 lead in this.

Service improvements and changes excite me, I feel they are an important, critical way of delivery the safest, most effective care and environments for women, families and staff (Care quality commission, 2020).