WSU REPOSITORY MSN/DNP Alternative Positions During Labor Project Title by Molly Dalebout Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 4/26/2024 Date Molly Dalebout BSN, RN, MSN Student 4/26/2024 Student Name, Credentials Date (electronic signature) Jamie Wankier Randles EdD(c), MSN, RN 04/26/2024 MSN Project Faculty Date (electronic signature) 04/26/2024 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Alternative Positions During Labor Molly Dalebout, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aims: This project aims to educate labor and delivery nurses about the benefits of alternative laboring positions and increase their knowledge and comfort level in initiating alternative positions, which will improve patient outcomes. Rationale/Background: The supine position is widely used in labor and delivery but can lead to significant risk factors. The benefits of alternative positions in labor and delivery are wellresearched, yet the supine position is routinely used as the birth position to deliver. This MSN project discusses various factors established in research, such as the physical risks of the supine position, the benefits of alternative positions, and nursing culture and preference. Research showed that implementing alternative positions during labor and delivery can decrease labor length, perineal pain, and perineal intactness. Methods: Educational materials were developed to provide education and comfort about the use and benefit of alternative positions during labor. Materials created for this project that will be presented to stakeholders include pre- and post-surveys, slideshow presentations, and infographics. Results: The project will benefit nurses by cultivating confidence and knowledge to decrease the use of the supine position during labor. Likewise, patients will have the opportunity to give birth in alternative positions, leading to an overall decrease in labor length, perineal pain, or perineal intactness. The implementation and results of this project will be continually evaluated to ensure its success. Feedback methods from The Iowa Model provide a foundation to showcase project progress to stakeholders. Conclusions: As nurses become more confident in implementing alternative positions, the associated risks of the supine position, including prolonged labor and increased perineal pain and 3 lacerations, will decrease. Nursing education is essential to decreasing the risks that patients can encounter in the labor and delivery areas. Evidence-based research shows the benefits of alternative positions, nurses must implement best practices in clinical settings. Keywords: alternative birth positions, supine position, evidence-based practice, nurse culture, nurse education Alternative Positions During Labor 4 According to the American College of Obstetrics and Gynecologists (ACOG), labor is defined as contractions that come at regular intervals and patterns lasting for about 60-90 seconds and cause the cervix to dilate (2020). The second stage of labor is a significant part of labor that includes the pushing and delivery of the baby. During this stage, the patient's cervix is fully dilated and effaced to begin pushing. The most common position mothers in the United States deliver is semi-sitting or lying flat on their backs, known as the supine position (Satone & Tayade, 2023). The supine position is widely used in the second stage of labor and, compared to alternative positions, has been shown to have an increased risk of perineal trauma and a longer length of labor (Hofmeyr & Singata-Madliki, 2019; Huang et al., 2019). While many factors can influence the use of alternative labor positions, one common theme is workplace culture, including a lack of knowledge of alternative positions by the healthcare team and the preference for supine positions due to ease and convenience during delivery (Mselle & Eustace, 2020; Muse et al., 2019). When healthcare providers receive education on the benefits of alternative pushing positions, the patient can have a lower risk of perineal trauma and pain and a shorter length of labor (Musie et al., 2019). Perineal tears can include first, second, third, and fourth-degree tears and contribute to unsatisfactory patient outcomes (Ramar & Grimes, 2023; Souza et al., 2019). Alternative laboring positions can be safer due to an associated decrease in the severity of perineal lacerations, perineal pain, and shorter length of labor (Kurnaz et al., 2022; Souza et al., 2020). The framework used in this MSN project is The Iowa Model, which provides a specific roadmap for implementing evidence-based research into clinical practice (Chiwaula et al., 2020). This framework includes the formation of a team, which consists of various stakeholders in this implementation process, including the unit manager, educator, nurse preceptors, and chief 5 obstetrician. These individuals provide a unique skill set and knowledge of labor and delivery, which will be crucial to implementing alternative positions. Statement of Problem Nurses and midwives are not well educated on the benefits of alternative positions and, consequently, use the supine position for laboring patients, causing increased perineal trauma, pain, and length of labor (Musie et al., 2019). Nurses and midwives in the Labor and Delivery setting should receive additional education on using alternative positions during labor (Yadav et al., 2021), including skills and training on upright birth positions (Irvin et al., 2022). Nursing education and implementing alternative positions can help decrease the risks of perineal lacerations, pain, and length of labor (Berta et al., 2019). Therefore, this MSN project aims to educate labor and delivery nurses on alternative pushing methods to improve patient outcomes. Using alternative pushing methods helps to decrease the risk of perineal tears and length of labor and improve fetal heart rate (Huang et al., 2019; Mtatina et al., 2022). The MSN project goal will be accomplished by examining the current literature to determine the extent of this problem and identify best practices to develop and implement an educational program for nurses on alternative pushing methods and the associated benefits. Significance of the Project Without well-educated nurses and midwives, mothers will continue to give birth supine, leading to perineal trauma, pain, and prolonged labor. An evidence-to-practice gap persists in midwives' education on the benefits of adopting upright positions (Irvin et al., 2022). The effectiveness of alternative positions can lead to a shorter duration of pushing and less risk of tearing during birth (Mtatina et al., 2022). Using alternative positions in the Labor and Delivery setting can increase patient outcomes and satisfaction. 6 The workplace culture, including the birth provider's skills and opinions, substantially impacts the woman's birth position. (Kjeldsen et al., 2022). Due to the workplace culture in labor and delivery areas, many nurses promote using a supine position because of comfort, knowledge, and historical practice (Musie et al., 2019). Despite some midwives acknowledging that they are taught about optimal birth positions, midwives say they do not promote alternative birth positions (Irvin et al., 2022). According to the research, there are also barriers to labor and delivery nurses utilizing alternative laboring positions despite the benefits (Irvin et al., 2022; Musie et al., 2019; Satone & Tayade, 2019). Exploring these barriers and providing nursing education in the labor and delivery setting supports positive patient outcomes and increases satisfaction with the labor process. Review of the Literature A Literature Review was conducted to gather the most up-to-date research and evidence about using alternative positions, benefits, and implementation in Labor and Delivery. The project PICOT question was used as a guide for exploration and covers the following: In Labor and Delivery Nurses, does comfort in initiating alternative pushing versus supine pushing for delivering mothers improve with education versus no education? Various search sources were used to locate pertinent evidence and to determine the best evidence-based framework for this project. The Iowa Model was chosen as the framework as a foundation for the implementation of this research project (Hanrahan et al., 2019). Framework 7 The framework used in this MSN project is the Iowa Model, which incorporates a problem-solving approach that utilizes evidence-based practice and research for healthcare improvement (Hanrahan et al., 2019). The Iowa Model is a roadmap for evidence-based practice that helps providers know if the approach or change is heading in the right direction and allows for troubleshooting (Duff et al., 2020). This model helps nurses translate research evidence into clinical practice to prevent the delivery of unstandardized and poor-quality care (Chiwaula et al., 2020). The Iowa Model has several steps, including identifying triggering issues/opportunities, assembling relevant literature and evidence, designing and piloting the change in practice, and integrating and sustaining change in practice (Chiwaula et al., 2020). The Iowa Model is a feasible framework because it implements and evaluates change and allows the project to be continually assessed for progress and revision if needed (Duff et al., 2020). The MSN project problem of nurses' lack of education on alternative positions and the consequences of increased perineal tears, pain, and prolonged labor is identified as the triggering issue. It follows the course of the framework to assemble sufficient evidence that can be easily explored with the first step of the Iowa model (Chiwaula et al., 2020). The MSN project's PICOT question follows this model's second and third steps. Identifying and forming a team of stakeholders encompasses the fourth step, which will be discussed in depth later in this paper. Designing and piloting change supports introducing evidence-based research into clinical practice (Chiwaula et al., 2020). The gathering and appraisal of evidence-based research about alternative positions are included in steps five and six (Bell et al., 2022). Once labor and delivery nurses are educated on the importance of alternative positions and how to assume them, they can implement them with their patients in step seven of the Iowa Model (Irvin et al., 2022). Then, the project lead can survey nurses' comfort levels using alternative positions, and data will be 8 collected and reported to management for evaluation, as stated in step eight (Bell et al., 2022). The Iowa Model allows for revisions, and changes can be made depending on the data results (Duff et al., 2020). Integrating this change into the workplace is the final step of this model (Chiwaula et al., 2020). Monitoring and engaging with the nurses to sustain the evidence-based practice of alternative positions will continue to be integrated into the workplace. Strengths and Limitations The Iowa Model has strengths and limitations in the healthcare setting. Strengths to using this model include its ability to help make and sustain evidence-based practice changes (Hanrahan et al., 2019). The Iowa Model promotes excellence in healthcare by guiding clinicians in problem-solving through the dissemination of information (Chiwaula et al., 2023; Dent et al., 2023). The design of this framework offers a straightforward and easy-to-use practice to implement improvement in healthcare (Chiwaula et al., 2023; Dent et al., 2023). The framework guides clinicians from problem identification to sustaining changes in practice using the principle of evidence-based change practice (Chiwaula et al., 2023). Some limitations of the Iowa Model also exist, such as needing a thorough patient perspective in the framework (Cullen et al., 2022). Patient perspective is vital in understanding what is most important to them (MJH Life Sciences, 2018). When the patient's feedback is valued, it can lead to better health outcomes and adherence to their care plan (Southwick, 2023). In addition, work is needed to implement strategies for patients to drive evidence-based practice improvements and implementation (Cullen et al., 2022). However, despite these limitations, this model can successfully implement evidence-based change in this project (Dent et al., 2023). Analysis of Literature 9 The PICOT question, In Labor and Delivery Nurses, does comfort in initiating alternative pushing versus supine pushing for delivering mothers improve with education versus no education, was used as a guide for the literature review. Information about alternative and supine positioning during labor, the importance of nurse education, and other relevant topics were explored. From the literature review, the following three themes were identified and explored further: 1) the supine position is the most common position (Hofmeyer et al., 2020; Huang et al., 2019), 2) the benefits of alternative positions (Musie et al., 2019; Satone & Tayade, 2023), and 3) nurses lack knowledge about alternative positions (Atsali & Russell, 2018; Mselle & Eustace, 2020). Search Strategies A literature review was conducted to identify current evidence using various search engines, including Google Scholar, Weber State University's Stewart Library's OneSearch and Advanced Search (which span multiple databases), and CINAHL to direct initial exploration. Search terms included alternative positions, supine positions, nurses' education, supine risks, alternative positions risks and benefits, and labor and delivery positions. Various Boolean combinations were created with the abovementioned keywords to create a broad search. Articles from 2018-2023 were only included in this literature review. Synthesis of the Literature A rigorous literature review was completed with three identified themes identified and explored. The themes included: 1) the supine position is the most common position (Hofmeyer et al., 2020; Huang et al., 2019); 2) the benefits of alternative positions (Musie et al., 2019; Satone & Tayade, 2023), and 3) nurses lack knowledge about alternative positions (Atsali & Russell, 2018; Mselle & Eustace, 2020). 10 Supine Position is the Most Common Position Research has shown that the supine position is the most common and widely used position among nurses and midwives (Irvin et al., 2022; Hofmeyer et al., 2020; Huang et al., 2019; Mselle et al., 2020). The midwife and nurse commonly decide what position the patient will deliver a baby in, which can lead to physical risks for the patient from the supine position (Irvin et al., 2022; Kjeldsen et al., 2022; Kurnaz et al., 2022). Nurse Culture and Preference Midwives and nurses work in a culture that prefers supine positioning due to its convenience (Irvin et al., 2022; Yadav et al., 2021). Research has shown that the type of assistance and preference of midwives are instrumental in determining a patient's position during labor (Kjeldsen et al., 2022; Kurnaz et al., 2022). According to Mselle et al. (2020), most women (68%) give birth lying on their backs or in a semi-sitting position. Atsali & Russell (2018) also concurred that in a study of 2,400 women in the USA that had a vaginal birth, 74% did so in a supine position. Workplace culture has been noted to be a barrier to facilitating alternative positions (Irvin et al., 2022). In an interview about workplace culture, one nurse stated, "I never practice alternatives [positions]; I guess we just…adopted the [routine] culture" (Musie et al., 2020, p. 8). Although some midwives appear to know the normal physiological process of birth, they tended to comply with hospital culture and policies, which did not facilitate alternative birth positions (Atsali & Russell, 2018). Hospital policies are meant to mitigate risk; however, the strict policies and procedures around labor positions can cause midwives to be unable to promote upright positions during the second stage of labor (Atsali & Russell, 2018). 11 Yadav et al. (2020) enquired further and found that preference and refusal of certain birth positions are common reasons for selecting particular birth positions. The choice of birth positions is guided more by the midwife's advice than the women's personal preference (Kjeldsen et al., 2022). Midwives and nurses prefer the supine or lithotomy position rather than upright positions (Atsali & Russell, 2018) because it is more accommodating and convenient for fetal monitoring and intravenous treatment (Kurnaz et al., 2022). In addition, nurses and midwives preferred the supine position because it allowed them to continuously monitor the progress of labor and assist in the delivery more efficiently (Mselle & Eustace, 2020). Midwives are most likely to support a patient giving birth in the supine position because of the ease of monitoring and delivering the baby (Astali & Russell, 2018). Although the supine and lithotomy positions offer midwives and obstetricians convenience in monitoring the progression of labor (Huang et al., 2019), the risks and concerns previously stated in this literature review persist. The convenience and culture surrounding the supine position can be a barrier to facilitating the use of alternative positions. Physical Risks of the Supine Position Childbirth can have increased physical risks when supine positioning is used (Berta et al., 2019; Satone & Tayade, 2023). Approximately 53-89% of women will experience some form of perineal laceration at the time of delivery (Ramar & Grimes, 2023). In a study by Souza et al. (2019), 72.7% of 226 normal-risk normal risk primiparas who had vaginal deliveries in a semisitting position sustained third-degree tears. Current literature stated that the supine position increased the risks of perineal lacerations, perineal pain, and longer length of labor (Berta et al., 2019; Mtatina et al., 2022; Ramar & Grimes, 2023; Satone & Tayade, 2023). Women who assumed the supine position had a longer duration of second-stage labor and perineal trauma 12 (Mtatina et al., 2022; Musie et al., 2019). Childbirth in the supine position was found to correlate with delayed delivery of the baby compared to upright positions (Mtatine et al., 2022). Studies suggested that delivering in the supine and lithotomy positions increased perineal pain compared to alternative positions (Irvin et al., 2022; Satone & Tayade, 2023). The lithotomy position can increase pain during contractions, whereas upright positions have psychological advantages like decreased pain perception (Kurnaz et al., 2022; Satone & Tayade, 2023). The supine position carries physical risks that can be mitigated using alternative positions (Kurnaz et al., 2022; Satone & Tayade, 2023). Benefits of Alternative Positions Upright positions, such as squatting or standing, aid in the descent of the fetus by gravity and reduce the length of the second stage of labor (Satone & Tayade, 2023). A systematic review found that X-ray results showed an increase in pelvic diameters leading to shorter labors when a woman adopts upright positions compared to lithotomy (Musie et al., 2019). In addition, Berta et al. (2019) found that using a flexible sacrum position, such as an upright or lateral position, can reduce the duration of the second stage of labor by 21.12 minutes compared to the supine position. Using upright or lateral positions is recommended and preferred to shorten the second stage of labor (Irvin et al., 2022; Kurnaz et al., 2022). Vertical and lateral positions are known to prevent perineal trauma and increase the rate of perineal intactness (Mselle & Eustace, 2020). Mtatina et al. (2022) found that perineal tears can be mitigated if the woman shifts to an upright kneeling position. According to Ramar & Grimes (2023), the results of 16 studies on the effects of positions in labor on perineal trauma revealed that vertical positions used during labor exacerbate the development of first-degree 13 lacerations but have no impact on intact perineum, perineal lacerations of the second, third, and fourth degree, anal sphincter injury. According to a literature review by Irvin et al. (2022), mothers who assumed an upright birth position experienced a significant reduction in pain during labor and birth. A meta-analysis of upright and lateral positions in birth reported less intense perineal pain than in supine or lithotomy positions (Satone & Tayade, 2023). Using alternative positions can significantly affect the intensity of perineal pain; although regional block analgesia can be effective, it will restrict the patient's ability to assume different positions (Satone & Tayade, 2023). In other positions, such as standing or kneeling, 50% of this sample did not experience perineal trauma (Souza et al., 2019). Physical trauma is lessened and even avoided by using upright alternative positions compared to the supine position. Nurses' Lack of Knowledge about Alternative Positions A key reason why laboring patients are not assuming alternative positions is due to nurses' lack of knowledge about alternative positions and their benefits (Atsali & Russell, 2018; Mselle & Eustace, 2020; Musie et al., 2019; Yadav et al., 2021). The birth position midwives are most exposed to during education and training influences what position they choose to have the patient deliver in (Healy et al., 2020). In a cross-sectional observational study of 52 nursing officers, knowledge about different positions like standing, squatting, lateral, sitting, and handknee was extremely poor (Yadav et al., 2021). Only 50% of respondents knew about squatting, 23% knew about hand and knee positions, and 23.1% knew about lateral positions (Yadav et al., 2021). Research showed that midwives' knowledge and experience in upright birth positions varied, but a clear gap in training and confidence was evident (Irvin et al., 2022). Kurnaz et al. 14 (2022) found that the most significant barrier to midwives' preference for vertical positions is the worry that the mother may not be protected against perineal trauma. This finding is in direct contrast to what was previously researched on this topic. Mselle and Eustace (2020) concluded that nurses and midwives did not assist or advise women to use alternative positions because they did not know about alternative birthing positions. Atsali and Russell (2018) discovered that midwives with skills and experience facilitating upright positions were likelier to adopt the practice compared to those without experience. Nurses and midwives significantly influenced the positions women adopt during labor; therefore, the lack of skills and knowledge nurses and midwives have about alternative birth positions led to the use of more frequent supine positioning (Irvin et al., 2022; Kjeldsen et al., 2022). In a study by Kjeldsen et al. (2022), 554 null- and multiparous women were surveyed on their knowledge of alternative birth positions. Most women indicated having sufficient knowledge about which positions to use during the second stage of labor, but only 30% specified they had sufficient knowledge about which optimal positions could be used during the different stages of labor and birth (Kjeldsen et al., 2022). Nurses are highly influential in patients' positions and require additional knowledge of alternative positions (Kurnaz et al., 2022). Summary of Literature Review Findings and Application to the Project The review of current literature conducted for this MSN project identified several themes and factors of why the supine position is the most used. The literature confirmed that the supine position is the most used in labor and delivery but carries several disadvantages, including increased risk of perineal trauma, perineal pain, and length of labor (Huang et al., 2019; Mselle & Eustace, 2020; Musie et al., 2019). The literature found that upright positions can avoid or lessen these risks (Berta et al., 2019). Using alternative positions instead of the supine position 15 can lead to decreased risks of perineal trauma, perineal pain, and shorter length of labor (Berta et al., 2019; Huang et al., 2019; Mselle & Eustace, 2020; Musie et al., 2019). For these reasons, nurses and midwives should be educated about alternative positions and their benefits. Several studies highlighted nurses' essential role during labor and delivery and that the nurse and midwife determine the patient's position (Atsali & Russell, 2018; Healy et al., 2020; Irvin et al., 2022). Research suggests that the nurse or midwife can avoid the supine position with adequate support and knowledge (Irvin et al., 2022; Kjeldsen et al., 2022). Nurses and midwives should be educated on alternative positions and the physical benefits they possess; furthermore, due to the existing workplace culture, nurses are uncomfortable suggesting positions other than the supine position (Mselle & Eustace, 2020; Musie et al., 2019). The information discovered has helped validate this project's potential to explore and carry out evidence-based education for labor and delivery nurses to implement alternative birth positions in labor. The literature suggested that nurses and midwives will feel comfortable implementing alternative positions with patients as they become more knowledgeable about alternative positions (Dent et al., 2023; Kjeldsen et al., 2022; Kurnaz et al., 2022). Furthermore, this will mitigate the physical risks associated with the supine position. As nurses become more knowledgeable about the benefits of alternative positions, their level of comfort in initiating these positions will increase. Project Plan and Implementation This MSN project aims to educate labor and delivery nurses and midwives to assist laboring patients with delivery in alternative positions to decrease the length of labor and perineal tears. Various essential stakeholders will be needed for this goal, including the nurse 16 manager, unit educator, nurse preceptors, and the chief obstetrician, who all have labor and delivery experience and leadership influence. Educating these stakeholders about the benefits of alternative positions will require the use of deliverables to ensure that optimum knowledge is met to promote this project's implementation and goal. These deliverables will include the following: (a) a pre-survey for labor and delivery staff that asks them to rate their level of comfort and education using a Likert scale about implementing various pushing methods (side-lying, squatting, and hands and knees), (b) a PowerPoint presentation that targets stakeholders by detailing various alternative positions, including their benefits and risks and how to assist patients in getting into these positions, (c) a pocket-side handout that includes key points from the presentation that the nurse can refer to while on the job. A larger referral handout will also be stationed at the nurse's desk. (d) a postsurvey that will include the same questions as the pre-survey to gauge learning. Since the Iowa Model will be used during this implementation, revisions and changes can be based on staff members' feedback and learning (Duff et al., 2020). Plan and Implementation Process This MSN project, specifically the PICOT question, In Labor and Delivery Nurses, does comfort in initiating alternative pushing versus supine pushing for delivering mothers improve with education versus no education, will be addressed. The Iowa Model framework will be utilized to provide a framework for clinical practice. The Iowa Model guides clinicians to evaluate and connect research findings into clinical practice (Bell, 2022). The Iowa Model guides clinicians through systematic steps to identify a triggering issue, state its purpose and priority, locate organizational support, synthesize evidence, pilot the practice change, and evaluate and redesign the change if needed (Cullen et al., 2023). 17 An initial meeting will be set up with stakeholders for this MSN project. This meeting will include essential information presented in a PowerPoint format to gain cooperation and assistance in its implementation. During this meeting, information will be presented about the project's importance and current evidence-based research on the topic. As mentioned, the project deliverables will be presented to the unit manager and educator. An open discussion will be encouraged throughout the meeting so that participants can ask clarifying questions and make further suggestions. Once approval of the project has been gained, an email will be sent to the labor and delivery nurses detailing the overall goal of the MSN project and include the pre-survey for staff members to take. A reminder of the pre-survey should be discussed during the staff huddle each day. A two-week deadline will be given for staff members to complete the pre-survey. Staff members can sign up for an in-person in-service where the unit educator will utilize the PowerPoint presentation to educate nurses about the benefits of alternative positions. Due to the nature of nursing schedules, it is understood that some staff will be unable to attend in person, and the presentation will also be emailed to those for review. A post-survey will be emailed one month after the in-service to gauge staff learning and implementation. Based on the data following the pre- and post-survey, modifications will be made to the implementation of this project and its development and will be regularly evaluated according to The Iowa Project (Bell, 2022). Interdisciplinary Team A team of healthcare workers with different backgrounds and specialties is essential for efficient teamwork and collaboration. Creating an interdisciplinary team of healthcare workers is an early investment to create collective learning and action needed to promote the adoption of 18 evidence-based practice in the process (Cullen et al., 2023). For this MSN project, the interdisciplinary team will include the project lead, unit manager, unit educator, nurse preceptors, and the chief obstetrician. These healthcare professionals share knowledge, skills, and expertise that contribute to improved patient outcomes. This project can be executed using these various roles to achieve the best possible results. Project Lead. The project lead will oversee the project process from beginning to end. The project lead is responsible for creating the deliverables and presenting them to the interdisciplinary team for buy-in and implementation. The lead facilitates open discussion between stakeholders and can answer questions that may come up during the planning and implementation process. The project lead will be an additional resource to the unit educator during the in-service educational session. The lead will follow through at the end of the project by analyzing the pre- and post-survey data to determine the effectiveness of the project. Labor and Delivery Unit Manager. The labor and delivery manager is a nurse with previous labor and delivery experience and holds the necessary leadership to guide staff members during new changes. The unit manager oversees the day-to-day aspects of patient care and is a source for staff members to ask questions regarding implementing alternative birth positions. The unit manager sees that staff members adopt new procedures and guidelines that improve patient care outcomes, which will be important in ensuring staff members implement new birth positions. Labor and Delivery Unit Educator. The unit educator provides unit-specific knowledge and skills for nurses in labor and delivery. For this project, the unit educator will conduct the inservice for staff members. The educator will ensure that staff members feel comfortable using alternative positions and provide vital feedback on how staff members are doing in executing 19 alternative positions. In conjunction with the unit manager, the unit educator will be a source for questions regarding implementing alternative birth positions. Nurse Preceptors. Nurse preceptors are designated nurses who provide guidance and knowledge to new graduates and newly employed nurses on the unit (Duquesne University, 2020). Nurse preceptors have specific training on how to teach nurses best and work under the role of the unit educator. They can teach nurses on the floor by utilizing hands-on experience. The role of nurse preceptors will be vital in the transition of using alternative birth positions, and they will be able to establish this transition in new hires from the beginning of their training. Labor and Delivery Nurses. The role of the labor and delivery nurse in this project will help to gather information before, during, and after the implementation process to improve the project's success. These nurses form a relationship and build rapport to gain trust among patients. This relationship will be meaningful in implementing alternative positions. The labor and delivery nurses will be educated to provide knowledge and training to patients about the different positions in which to deliver. These nurses are essential to the success of this project because they will be working directly with laboring patients. Certified Nurse Midwives. A certified nurse midwife is a registered nurse with additional education to manage and provide holistic care during labor and birth (WGU, 2020). It will be important that nurse midwives are involved in the stakeholder meeting because they provide one-on-one care with laboring patients. Nurse midwives assist patients throughout their labor and can provide suggestions, including position changes for support. Education about alternative positions for this specialty will be imperative. Chief Obstetrician. A chief obstetrician is a doctor who specializes in obstetrics and serves in a supervisory capacity (CA.gov, n.d.). The chief obstetrician ensures that fellow 20 obstetricians comply with hospital and safety standards and follow best practices. The role of the chief obstetrician in this project is to ensure that doctors follow evidence-based research about the benefits of alternative positions and allow laboring patients to choose the birth position they wish to deliver in rather than what is convenient for them during the delivery process. Patients. Laboring patients is central to this project, and this project can only be successfully carried out with their cooperation. Patients should have buy-in as the nurses will implement alternative positions during labor. The labor and delivery nurses will be responsible for educating patients and gaining their approval before implementing different positions in their labor. Description and Development of Project Deliverables Four deliverables were developed to aid in the buy-in and implementation of this project. This section will discuss the deliverables in detail and how each one contributes to the success of the MSN project. Pre- and Post-Survey Knowledge The first deliverable is a pre- and post-survey (Appendix A). The pre-survey aims to establish a baseline of knowledge and understanding at the beginning of this project. It will include a list of alternative birth positions and ask how comfortable and knowledgeable the nurse is with each alternative position. Following the in-service and implementation, the same survey will be used as a feedback loop to gauge nurses' knowledge and comfortability and provide opportunities to evaluate and revise the project (Duff et al., 2020). Benefits of Alternative Birth Position Presentation The second deliverable (Appendix B) is an Emaze presentation targeting the stakeholders on alternative positions' benefits. This presentation will introduce the current practice: the risks 21 of birthing in the supine position. It will highlight evidence-based research about perineal trauma, increased length of labor, perineal pain, and nurse culture and preference. The presentation will then detail the benefits of various alternative positions, including squat, sidelying, hands and knees, and upright. In addition, the presentation will outline the project process, including the pre-survey, in-service, implementation, and post-survey. Following this, there will be time for open discussion, including a Q&A session. This deliverable aims to gather buy-in from essential stakeholders to increase the project's education and success and utilize evidencebased practice in the labor and delivery setting. Implementation and Benefits of Alternative Positions Presentation The third deliverable is a guided presentation about the benefits and implementation of alternative positions for labor and delivery nurses (Appendix C). This presentation will be given at an in-person in-service and emailed to those unable to attend. It aims to educate nurses about why the supine position should be avoided and how alternative positions should be implemented (Irvin et al., 2022). The unit educator and project lead will oversee this presentation and can give additional insight and clarification throughout the in-service. Alternative Birth Position Quick Reference Infographic The fourth and final deliverable is an infographic that provides quick reference information about alternative positions (Appendix D). It will provide an overview of the information from the presentation at the in-service. This infographic will be printed and available for reading at the nurse's station. It allows for easy references and reminders about alternative positions while providing direct patient care. Timeline 22 The timeline for this project is estimated to be approximately three months for the approval and implementation of this process (see Appendix E). The implementation requires buy-in and collaboration with the stakeholders. First, a meeting will occur to present the current issue of the supine position and promote the benefits of alternative positions. Once buy-in is achieved, a pre-survey will be emailed to labor and delivery nurses, who will have two weeks to complete. The unit educator and project lead will conduct an in-service for nurses about the benefits and implementation of alternative positions. This in-service will help nurses become comfortable using alternative positions in clinical practice. Implementing alternative positions within the work environment will span approximately three weeks, with a post-survey for nurses at the conclusion. The unit educator and project lead will assess the post-survey results and discuss any changes that should be made. These changes will be implemented by week eleven and will continue to improve the project and implementation process. Project Evaluation The success of any project must be evaluated to determine its effectiveness and if changes should be made. Evaluation examines, collects, and analyzes information and outcomes (Zint, n.d.). The evaluation process allows for better communication of the project's impact on staff morale and stakeholders (Zint, n.d.). The effectiveness of this project will be determined by comparing and evaluating the results of the pre-survey and post-survey. Answers on the postsurvey that reflect an increase in knowledge and comfortability indicate that the education project was successfully implemented. A rating of four or higher on the post-survey indicates that the project was effective. The project lead will identify trends and themes from the surveys and closely evaluate qualitative feedback from the project participants. Based on information 23 from the survey results and individual feedback, the project lead will disseminate the information to be shared with all the participating stakeholders. Feedback from nurses about the project's implementation is necessary in the project evaluation process. The nurses are responsible for implementing the project and will provide vital information about its implementation process. The nurses' perceptions and education play a critical role in patient care (Kjeldsen et al., 2022). Ensuring that nurses feel heard and validated in their thoughts will be necessary for the unit educator and project lead to gain feedback and understanding. The unit educator and the project lead will hold a meeting to gain nurses' thoughts and perspectives about the project, including the effectiveness of surveys, in-service, and infographics. This meeting will provide vital information to improve upon and ensure the project's success as part of the Iowa Model feedback loop (Duff et al., 2020). At the conclusion of the project, a meeting will be held with stakeholders to educate them about the effectiveness of the project and provide areas for improvement. The pre-and postsurvey data and feedback from the labor and delivery nurses will be presented. Nurse midwives will also be encouraged to share their thoughts since they played a significant role in the implementation process. Communicating and evaluating the data will be an ongoing process to improve the project's productivity and effectiveness (Zint, n.d.) Constant evaluation and revision can encourage success and help reach the project's goals. Ethical Considerations Multiple ethical considerations must be considered when implementing changes in patient care. Ethical considerations allow for accountability, transparency, and confidentiality in research and decision-making (Resnik, 2020). All nurses will be sent a pre-survey, but participation in the project will be voluntary, with ethical factors considered. Survey answers 24 will be kept anonymous to ensure honest responses. To ensure the project's success, deliverables that reflect many learning styles will be created. These considerations will help implement this project to ensure that ethical standards are met. Research indicated that nurses are unaware of the benefits of alternative positions; consequently, the supine position is the most widely used in labor (Atsali & Russell, 2018; Hofmeyer et al., 2020). Therefore, introducing new positions poses ethical considerations of personal preference, consent, and privacy. Some patients may have particular position preferences, and the nurse should respect the patient's choice of whichever position she wants to deliver. Patient confidentiality and diversity should also be safeguarded by keeping patient identifiers anonymous. It is also essential that personal bias is avoided throughout the project to ensure the project's integrity and success. The project lead is a registered nurse at the hospital where this project is being conducted. During the project's implementation and evaluation process, it will be vital that the nurse remains impartial to avoid any bias that could distort results. Awareness of personal values and thoughts is essential to avoid implementing them into the project (Resnik, 2020). Ethical considerations at the forefront will allow for the validity and reliability of the project to ensure its success and outcomes. Discussion The supine position can lead to complications, including increased perineal pain, perineal trauma, and longer length of labor (Berta et al., 2019; Huang et al., 2019; Musie et al., 2019). Labor and delivery nurses commonly use the supine position due to a lack of knowledge about alternative positions and their benefits (Atsali & Russell, 2018; Satone & Tayade, 2023). This MSN project aims to educate labor and delivery nurses about the risks of the supine position and 25 the benefits of alternative positions through an educational in-service with adjunct materials to assist nurses in implementing alternative positions. This section will discuss the dissemination of the project's results, its significance to advancing nursing practice, implications, and additional recommendations. Evidence-based Solutions for Dissemination Following the implementation of the project, data will be collected and analyzed from the post-survey. These results will also be compared to the pre-survey nurses filled out at the beginning of this project. The information will be compiled and disseminated electronically to nurse managers, educators, and the chief obstetrician. The information provided will help leaders in administration and education evaluate the project and any changes that may be necessary for improvement. The project lead and unit educator will disseminate the results to labor and delivery nurses via a staff meeting. The project outcomes will be presented in a PowerPoint format with an open discussion with nurses to understand the strengths and weaknesses of the project and facilitate improvement. An additional poster presentation with the project's results will be developed and presented to peers and faculty at the Annie Taylor Dee School of Nursing at Weber State University. Significance to Advance Nursing Practice Through education of the Labor and Delivery nurse on alternative positions for labor, patient safety will improve, perineal pain and trauma can decrease, and the length of labor could potentially decrease (Mselle & Eustace, 2020; Musie et al., 2019; Satone & Tayade, 2023). The research suggested that nurses and midwives have an influence in determining a patient's position during labor (Kjeldsen et al., 2022). Consequently, the supine position is widely used 26 (Irvin et al., 2022). This project aims to address the workplace culture and preferences of using the supine position and educate nurses to prevent the associated risks. Educating nurses about the supine and alternative positions will increase knowledge and confidence in implementing alternative positions to prevent physical injury and decrease the length of labor (Irvin et al., 2022 & Souza et al., 2019). Implications Several strengths and limitations have been identified throughout this project. The MSN project provides various materials to assess knowledge and provide education for all learning types. The evaluation method and framework are beneficial for ensuring the project's success. Using the Iowa Model guides the project in searching for relevant literature and integrating it into practice (Chiwaula et al., 2020). Feedback loops allow for assessment and revision to achieve desired outcomes. (Duff et al., 2020). The framework allows for easy problem identification to sustain the change in practice (Chiwaula et al., 2023). Additionally, the project deliverables have various electronic and hardcopy options to learn and refer to throughout the implementation process. These include surveys, presentations, and infographics. There are various evaluation methods, including open discussions and data consolidation, to determine the project's effectiveness. Limitations of the project exist and have been identified, including patient buy-in and sample size. Due to the nature of labor and delivery, implementing alternative positions may not always be feasible in such cases as epidurals or patient preference. To reduce this barrier, nurses will be educated about how to initiate position changes with numbing analgesia and educate the patient on the benefits of alternative positions so that they have a well-rounded knowledge to decide. The project is implemented on a single unit in a mid to rural hospital, thus limiting the 27 sample size. Pending the project's implementation, however, it may be possible to integrate it throughout various cohorts as new labor and delivery nurses are hired within the hospital system. Overall, the project can help reduce perineal pain, trauma, and the second stage of labor by educating nurses on using alternative positions (Mtatina et al., 2022; Satone & Tayade, 2023). This project can help nurses become more comfortable initiating alternative positions via various educational platforms and decrease the associated risks of the supine position. Recommendations The project explored the risks of the supine position and the use of alternative positions, including nurses' knowledge and comfortability. The literature review showed extensive research comparing various positions and their associated risks and benefits. However, only the risks and benefits associated with perineal pain, trauma, and the second stage of labor were addressed. Additional research should be conducted and reviewed to determine other risk factors associated with the supine and alternative positions. This research would be beneficial in improving and expanding upon this project. Another recommendation for this project is to educate the entire obstetrical department in the hospital. Due to the large number of OB physicians who practice, this would improve project buy-in and collaboration among stakeholders. This project is focused on educating labor and delivery nurses; therefore, expanding this to the OB physicians could improve adherence to alternative positions and benefit patient outcomes. Conclusions Alternative positions have been shown to decrease perineal pain and trauma and reduce the second stage of labor (Berta et al., 2019; Ramar & Grimes, 2023; Satone & Tayade, 2023). The nurse's role is integral in initiating different positions and determining the patient's position 28 (Kjeldsen et al., 2022). This project strongly recommends that labor and delivery nurses be educated on the benefits of alternative positions to reduce the above-stated complications associated with the supine position. 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Meera. https://meera.seas.umich.edu/evaluation-what-it-and-why-do-it.html 34 Appendix A Pre- and Post-Survey https://forms.gle/Gf5PHHA6RG19ZeSz6 35 36 Appendix B Benefits of Alternative Birth Position Presentation https://www.emaze.com/@ALLFZRTOL/alternative-birth-positions Presentation includes eight-slides detailing the current practice of supine position and its risks. Alternative positions are discussed, including squatting, side-lying, hands and knees, and upright. Benefits of the alternative positions are included with each position. A brief implementation timeline and a slide dedicated to questions and answers are outlined. References are included at the end. 37 Appendix C Implementation and Benefits of Alternative Positions Presentation 38 39 40 41 42 43 44 45 46 Appendix D Alternative Birth Position Quick Reference Infographic 47 48 Appendix E Timeline