 All right. It's my pleasure to introduce our speakers today. Pamela Abbott has had a career in nursing spanning over 30 years. Her nursing experience includes various areas of nursing, such as cardiac intensive care, telemetry, and post-anesthesia care, but she found her passion in labor and delivery. She's worked in labor and delivery most of her career as a bedside nurse and a charge role. She's a member of the Association of Women's Health, Obstetrical and Neonatal Nursing, and is a registered nurse clinician, OB certified. Pam started her education career as an adjunct faculty member at St. Xavier University in the role of clinical instructor and lab educator. Dr. Zapir Samawi is a tenured full professor and a Fulbright scholar who has served as associate dean of the undergraduate nursing program at St. Xavier University. She has over 35 years teaching experience in the Middle East and the United States. She completed her bachelor degree in nursing from Arab colleges of medical professions in the Palestine West Bank and a master's degree in nursing in maternal child health from Arizona State University. Her doctorate is from Weidner University. Her areas of teaching expertise include undergraduate maternal child health, pediatric nursing, nursing research, community nursing, and nursing ethics. Mary Murphy Smith is a tenured associate professor of nursing at St. Xavier University in Chicago. She graduated with a bachelor degree in nursing from St. Xavier, a master's degree in nursing from the University of Illinois, Chicago, and a doctorate in nursing practice from Rush University. Additionally, she's an advanced practiced registered nurse with board certification in midwifery, lactation, and fetal monitoring. She's an active member of the American College of Nurse Midwives, International Lactation Consultant Association, and the Association of Women's Health Obstetrical and Neonatal Nursing. I saved Mary's introduction to the last because Mary and I have known each other since 1980 when we were in labor and in delivery working as registered nurses on the night shift, hoping to become midwives. I use that as a segue to say that labor and delivery nurses are pretty unique to the United States and Canada. Anywhere else in the world, labor and delivery nurses are midwives. So with that, I'm so glad to be back with Mary and I am going to make her the presenter so that our presenters can tell us about their study. All right, we'll see you. Thank you for that wonderful introduction. I'm happy to be here with you again. Okay, so I just want to emphasize that we have nothing to disclose. And moving on here, we will begin our presentation. Alrighty, so certainly we want to talk about the aim of our project. How many of you have observed in the clinical setting students standing against the wall trying to get a glimpse of a baby being born? No matter what your role is in childbirth study, whether you're a midwife, doula, nurse, most of us have seen nursing students assigned to a nurse caring for a laboring patient. Because they are students, they typically have minimal involvement with the patient. And it's not uncommon to see them holding up the wall, rather than being at the bedside, holding a leg or a hand. I have noted this when I was practicing as a full-school midwife. And again, when I returned to the bedside as a labor and delivery nurse, the teaching side of me would try to include those students in the birthing process and keep them engaged. Now that I have switched gears and I'm teaching in the university level, I want the nursing student to be active participants with the birthing process. On a typical labor and delivery unit, it's not uncommon for the nurse to have two patients. This prevents the nurse from finding the time to provide the needed labor support to her patients. To complicate things further, the recent pandemic placed restrictions on the number of people a woman could have when she was in labor. For short while here in Chicago anyway, significant others were not allowed to be present. Even in some places today, the significant other is the only person allowed in the labor and delivery setting. Recognizing these factors, one of the ways I found to keep students engaged with the labor and patient is to have them provide labor support. I wanted the students to take on an active role in doing more in the way of labor support for their patient. One of the ways students could safely provide labor support is by implementing non-pharmacological pain measures in labor. So this brings us to the aim of our presentation which is to disseminate our research findings of nursing students' interactive clinical experience with implementing non-pharmacological pain management techniques, thereby decreasing that theory to practice gap. Just to give you a little background of why we decided to do this project, what is the significance to pain management and why we decided to do this project? First of all, we all know that pain is one of the most prevalent problems nurses encounter with their patients. It is often considered the fifth vital sign. Previous studies identified a lack of knowledge among nursing students in regard to pain management. Recognizing this factor, Shimorde developed a software tool for teaching nursing students about pain management. The quality and safety education for nurses acknowledged the importance of having students demonstrate a comprehensive understanding of pain and comfort concepts to support patient-centered care. We also know that the pain for the laboring woman is one of the major focus of nursing care and labor and delivery. Bowren, in a copy review, documented the value of providing continuous labor support during the birthing process. To summarize, we felt that if nursing students were provided with the knowledge of non-pharmacological pain management, they could promote and optimize the midwifery philosophy in the birthing outcomes. We did a review of the literature, which reminds us how we can educate students on pain management. When Shimorde and his colleagues developed their teaching tool on pain management techniques, they utilized the input of physicians, nurses, and nursing professors. The U.S. Department of Health and Human Services developed a task force looking at pain management. They recognized the problems associated with opiate abuse and misuse. Additionally, they identified the lack of clinical practice guidelines for non-pharmacological pain treatment for the pregnant and postpartum women. The task force recommended a need for improved management of pain options during childbirth and postpartum. Furthermore, they recognized the benefits of including pain management in the curriculum of healthcare providers, specifically nurses. A consortium task force was also developed due to the mismanagement of pain control and the opiate crisis. Their suggestions included implementing non-pharmacological measures for pain management across all healthcare settings. When one considers non-pharmacological pain management in labor, we are reminded of the works completed by Penny Simkin. She was a classic in childbirth education and is indirectly referenced here. Simkin identified the importance of pain management during labor rather than pain control. Her teachings on pain management are supported in the literature by ACOG, A1, and of course the AC&M with their pearls of midwifery. Together, they recommend continuous one-to-one labor support and identify this support as a process that can shorten labor duration, decrease the need for analgesics, and improve FGAR scores. Additionally, they suggest intermittent fetal monitoring and non-pharmacological pain management. Some of the non-pharmacological pain management that they discuss include rhythmic breathing, movement and positional changes, hydrotherapy, application of hot and cold compresses, massage, touch, and acupressure points. Finally, they recommend that providing personnel trained in labor support will improve outcomes and in the long run be cost effective. So teaching nursing students non-pharmacological pain measures is a recent phenomenon that has been investigated in other studies. There are several authors who have completed studies on nursing students' knowledge of pain and have found the students' knowledge of pain to be inadequate. When teaching nursing students, Gisemi acknowledged that nursing student engagement was essential for their learning. Desan illustrated that using simulation created an environment conducive to learning. Kipness in summerness utilized different approaches when teaching nursing students about labor support. Kipness taught nursing students about labor support using prenatal classes and education. While summerness implemented a quality improvement study, teaching nursing students how to become do-less. In conclusion, our review the literature supports teaching nursing students non-pharmacological pain measures that can be used in the labor and delivery setting. So now I'm going to turn this over. The significance of our research is going to be turned over to disappear. So the significance of this research study, the clinical setting as we know where students can apply the theory that they learn in their classroom into the skills in the clinical setting with real life experiences with patients. These skills can assist the midwife and the patient with promoting the physiological birth using non-pharmacological measures. Important as well that when nursing students learn those measures, they can as well be role modeling to assist the whole team to support non-pharmacological pain management measures. There is a limited research that investigated the nursing students role in providing non-pharmacological pain management for women in labor. So the significance of this study was timely. So having students participate with implementing non-pharmacological pain techniques when family members' presence were restricted during the pandemic of COVID, the nursing students played an important role in providing support to the women. And by this the nursing students were part of the healthcare team. An important significant as well continuous labor support provided by nursing students and having a role in patient-centered care also contributes to patient satisfaction and outcome of care. The purpose of this research study was to identify how providing instructions in a didactic environment as well as simulated scenario using non-pharmacological labor support techniques would impact nursing students' engagement in the clinical setting. In addition, participation within the clinical setting may assist the nursing students in the acquisition of learning of all the knowledge that they have gained in relation pain measures and promoting patient comfort. A secondary gain of this research was to measure the sub-confidence level of the students in applying those measures in the clinical setting. And not only that they have established confidence, but what were the opportunities of experiences that provided them to increase their self-confidence? We did a qualitative response for that. So continuous labor has been proven to be beneficial to facilitate physiologic birth and students can be instrumental in providing the support. The research setting. This research was conducted in a Catholic private university located in the Midwest. IRB approval was obtained from the University IRB. The setting where the research occurred was in the classroom, in the nursing simulation lab, and part of the students' practicum, the students took those skills and applied it in their clinical settings. And of course, important to mention that they applied those skills on their clinical faculty supervision. Important to mention that our university has contracts of agencies and the research setting for the students who did clinical and applied those skills were exposed to midwives. Only one hospital that had not a full scope of midwifery. This is important that students had direct observation of the midwives in their own clinical setting. And of course, Dr. Murphy is as a midwife that provides experience for the students as well. The design of this research study included qualitative and quantitative descriptive design. The sample of this study consisted of senior one baccalaureate nursing students who were enrolled in a holistic course which had a practicum component. The survey that we used to collect the data was developed by the research investigators. And the outcome of the survey was to measure the knowledge and the comfort level achieved by the nursing students as well as from the pain management techniques. What were the techniques that the students applied in the clinical setting? In addition, the measuring students' self-confidence increase and knowledge increase. So the implementation of the intervention occurred in a classroom setting with the use of PowerPoint presentation and which will be discussed by my colleague in a simulation lab environment with a guided simulation scenario with a guided demonstration and return demonstration by the students. And in the clinical setting, part of their practicum, the students had the opportunity to apply those skills while providing care to their patients in the clinical area. Now I will move to Dr. Murphy to continue presentation. Okay, so this was the fun part of our project. The focus first was on the didantic construction and it was threefold. First, we wanted to teach the students the mechanism of the labor process and to find labor pain. As we all know, it's pretty unique. Second, we utilized the gate theory of pain control to illustrate how the non-pharmacological measures worked. Finally, we identified various types of non-pharmacological measures and the benefits of using them in labor. In the simulation lab, we divided the students into smaller groups and demonstrated the various non-pharmacological pain measures used in the bird setting. Students had the opportunity to practice these techniques on each other. They practiced counter pressure, acupressure, massage. They facilitated physician change, promoted movement, and manipulated the birding ball for comfort. Having the simulation mom actively progress through the different stages of labor and delivery gave the students the opportunity to provide our SMM with emotional support in breathing techniques. We almost broke her when we tried to change her position, but the students were very much involved and they demonstrated ways that they could involve the significant other for that labor support. The non-pharmacological pain measures practiced most are illustrated here. I think you need to, thank you. Nursing faculty first obtain the non-pharmacological pain measures techniques are practiced most are illustrated here. Note that we did not implement the aromatherapy, the hydrotherapy, or the music therapy, but it was discussed. In the clinical setting, nursing faculty obtained permission from the patient, the nurse, the midwife, or healthcare provider to work with the laboring patients. The instructor and the nurse role model to the students, the various measures most commonly used to support the patient in labor. They encouraged the students to implement these measures as well. What we found is that students not only provided the labor support, but they implemented the techniques that they learned in the simulation lab. And in some instances, they became role model for the nurses. I'm turning it over to Pam, who's going to disappear, who will discuss the research. Pam will discuss our research. Hi. So of the of the students we researched, 156 were given the opportunity to to convey to indicate in the survey. There was 75% of those surveyed answered the surveys. Of those surveys, 70% were able to apply non-pharmacological techniques that we were teaching. The students that answered no to applying these techniques were correlated with limited patient senses or acuity. Of those 117 answered 100% felt that the instruction improved their knowledge regarding labor support and pain management. Of those surveys, 94% felt that the instruction approved their self-confidence. And that was very important to us. In the research findings, we wanted to know the percentage of how much of the interventions were used by the students. We felt that if more than two or more were greater were used, then that student felt more comfortable in applying those techniques. So we have an in total 61% of those students did have to apply two or more techniques. So some of the so majority of the students felt comfortable. In the research findings, we also wanted to know like what techniques were the students comfortable in applying. So that was like encouragement and emotional support was turned out to be number one. Pressure points and counter pressure points were turned out to be number two. Number three, there was a tie between movement and repositioning and breathing exercise, which that was very surprising to me. I thought breathing would have been higher up in that category. We also wanted to have the students actually tell us in their own words how this would increase the knowledge. So one of the students said, it reinforced my knowledge and helped me carry out techniques with confidence. Another student replied, I wouldn't be able to comfort my patient if I didn't have the knowledge of how to perform breathing techniques. Positioning of a patient was also emphasized, so it allowed me to remember and assist her in moving. I now know that there are more to labor labor support, not just pharmacological options. Also that we need to listen to our mothers and let them choose the support techniques she wants. The lastly on knowledge, it taught me a lot of non pharmacological, I'm sorry, non pharmacological ways to of pain relief can be achieved, which may be forgotten by the unit nurses. It was a great tool for us students to utilize during our experience with laboring mothers. For self-reflection of self-confidence, of course 94% of the students said they were confident. Some of their comments were I was timid to step in and help, but trying to apply techniques that I knew could help me, help me feel confident in participating. It helped me feel involved and useful rather than a background shadow student. I was nervous to start breathing techniques, but I noticed that she was in pain because she didn't have an epidural. So I took a moment, remembered some techniques and helped her. I felt as if I was contributing as a member of the health care team as well as the supporting the mom. I felt like I was able to help the mom relax a bit and not feel alone knowing I was making a difference. It was very exciting and rewarding. I felt like I had the ability to guide her through confidently. I felt more prepared. That's exactly what we wanted to accomplish. So we wanted to also, the patient is the center of everything we do in nursing and so it's so and this was our center, but we wanted to see how the students reflected on how the patients, how receptive they were to giving them giving instructions. So when we looked at the at the surveys, we looked at words for like appreciative, receptive, thankful, grateful, and 42% of the students conveyed that the patients were receptive to what they were teaching them. Of the students, when we asked them how the pain assisted, did the pain techniques that we that they were using, did they notice that the patient felt more relief or was able to better cope with laboring? And so we used, we looked for words like assisted help, more comfortable coping and 62% of those students conveyed that this patient did get some sort of relief. One noteworthy was although during her active pain, she verbalized pain worsened, was not approving after delivery, she emphasized she couldn't have done it without me and what I did for her and aided it aided her in having successful birthing experience. The patient was better, better coped with pain. Patient was better able to work through her contractions. So they helped the patient. And I'm going to turn it over to Zepir talking about the discussion. So from the analysis of our study, it is clear that students felt that they played a significant role in providing labor support. I would like to mention that looking at the analysis of our findings is that the students were able to apply the techniques used. However, we see that the students were more comfortable in providing encouragement, doing pressure points, movement positioning, breathing. And we see that touch, massage, comfort measures, hot and cold therapy, which is more hands on, would lower. This can be contributed to the environment that the student that in labor and delivery, where the environment is tense and nursing students need more practice and guidance to be able to apply those hands on skills in relation to pain management and comfort. And I think that as a nursing faculty, this gives us a great insight that we need to continue to have simulated lab environments to provide to students hands on experience more and more through the curriculum. In addition, faculty and students perceive that they played a role model to the nurses. And especially when faculty were so dedicated in providing comfort measure and including the students in the practice, this gave the students the experience that they felt they were really part of the health care team. And as my colleague, Dr. Murphy said that it wasn't that they were standing against a wall just observing what was happening, but they were having an active role in being engaged. So what does this teach us as educators? This teaches us that in clinical setting, faculty should continuously encourage and support students to apply the skills that they learned whether in class or in lab into the clinical setting. And the important part of this research was that we learned how important it is for partnership and collaboration not only with the nurses, but the acceptance of the nurse midwives that nursing students can play a role in promoting and providing comfort to laboring moms. And this would give them more insight into thinking about midwifery. Yeah, these are the things that I have done in my clinical. And this could be a driving force for them to think about a specializing in midwifery and so on. So as the students reported that they felt part of the laboring process, and this was very important because we want our nursing students to be actively involved in patient-centered care. And this is what this research affirmed that the students felt that they were part of the patient-centered care. And it was important that we, when we wanted to look at this data, the increased knowledge to students' self-confidence was critical. And for the students to reflect on their own learning and on their own self and communicate to their inner thinking how the knowledge that they have gained, whether it was in the clinical set, in theory, and applying it to the lab and taking it to the clinical setting, they saw how knowledge acquisition was transformed to the clinical in which gave them confidence in their skills. And now I will pass it to my colleague for synthesis. So in synthesis, nursing education, learning, and nursing practice should all be overlapping. We provided nursing education to our students regarding pain and non-pharmalogical management of this pain and also a patient-centered approach. With doing that, the students were able to find engagement, they were engaged, they gained knowledge, they gained understanding, and they also gained self-confidence at the bedside, which is always very hard to do as a new grad and as a new nurse. It also incorporated all this study, also incorporated nursing practice by providing labor support to the mother. And it promoted the physiological birth that we all want in labor and delivery. And then I turn it over to you for implications. So the implications and recommendations of our research study. So the first thing is that for nursing education. It is so important as educators that we teach our nursing students, as my colleague Dr. Murphy said, that pain is the fifth assessment. And nursing students, while they are in the program, should be able to learn how to alleviate pain in their patients, whether being for the laboring mom or even for any patient across setting. So this gave the students how to be actively involved. So it is important that we continue to teach in our classrooms and integrate the concept of pain and comfort measures through the curriculum. And it was important as well for nursing education to document interventions and teaching pedagogies that we as faculty use in our program and evaluate effectiveness of teaching and learning. And it is clear that by the findings of our study that the intervention we used in class, in the lab and in the clinical setting promoted student learning in relation to the concept of pain, management of pain, patient centered care and collaborative practice. So contributions and indications to the nursing practice. We as faculty believe that nursing students, while they are in the nursing program, should learn how to apply concepts such as pain and comfort level and comfort measure while in the program. As they transition to their role to nursing profession, it is important for them to take into consideration the level of pain their patients have. And those non-pharmacological measures are measures that makes a significant difference in alleviating pain and suffering in their patients across settings in healthcare. In addition, one of the important outcomes of our research was again, as we mentioned, is the collaboration between nursing faculty and midwives and how we can bring nursing students to be part of the healthcare team in labor and delivery and in mother baby as well. And finding other means for patient support during the pandemic where family members are restricted because of COVID. Implications to nursing research and recommendation. One of the recommendations for our research is to continue data collection in doing the intervention that we did in this course but also extended to other courses that have didactic as well as practicum setting because those non-pharmacological measures nursing students can do not only for moms who are in labor but can be to any patient who is experiencing pain. And overall through our plan is for us to publish our research and continue our study. This will add to the science and to the knowledge of research in nursing. Thank you. And now we open for questions and discussions and thank you. Thank you. Questions, anybody? Katie Moriarty has, you know, written a great comment about following up with the women who've received extra support. Here's your next study. But, you know, how wonderfully you have taken the student from being a wall hanger in a process. Birth is so private. So many individuals say, I don't want any students in my room. I want quiet and I don't want people to see me. You've taken that student from being an observer into being an essential part of support and that's priceless. And in addition to that too, what we, okay, so now I'm down at an inner city hospital that does have two groups of midwives and they are wonderful. The midwives are excited when we come on because the students are using acupressure points. Thank you, Katie Moriarty, that they have not the nurses don't know about. So the nurses are saying to the students, how did you do that? Because we have, we had three patients go to complete and deliver the short time that we were there. And that was very rewarding for them. I'm like, just sit there and do those pressure points. And the patient was relaxed and she said, oh, they're not doing anything, but lo and behold, she went complete. And even if those nursing students don't choose labor and birth as their work area, they have skills that they are going to use with their family members, maybe with their own children with their neighbors. That's knowledge that gets spread out into the community. It isn't just held on the labor and delivery unit. I can I can attest to that because I had left labor and delivery for a little while and I've gone into recovery room. And in the recovery room, we've had patients coming out in a lot of pain. And before I can get them pain medication, I'm telling them to breathe, I'm asking them to take a nice deep breath in and out very nice. So I use some of those non pharmacological techniques in different areas. And so that's I mean, I've actually used them to help a patient with pain that was before until I can get them pain medication. Pamela, you bring up a good point. Quite often we care for individuals who say, oh, I don't need those techniques. I'm going to get an epidural. I would bet most of you have been on units that are so busy. You request the epidural. It may be 30 minutes. You're lucky if it's not two hours before the anesthesiologist can come. And we often say to women, you're going to need some techniques before you're ready to come into the hospital for birth. Or if it's a home birth, you're going to need some techniques while the midwife is on the way. So I've used that. Yeah. Yeah. Great to spread those techniques. And I think one of the outcome for their research is that students need to know theory is important. In applying that is important. In transitioning is important. So the title of our research was how to bridge the gap between theory and practice. And I think that students at senior one level were able to see this, how theory feeds into the clinical practice. But just noting like the use of acupressure points, though in some parts of the world, it's a very old practice. But here in the States, it's not practiced that frequently. And I know Katie is certified in Chinese medicine. And she taught me how to do the pressure points. And I have taken that knowledge to the clinical settings. And I've taught my students and my students state how they work. And we're teaching other people them. So it's just not applying pressure. You have to transfer your energy to the patient. And the patients recognize that. And ultimately, the patients are satisfied. And that's our other goal. So many methods for assisting individuals with coping. Here in British Columbia, midwives can get an extra certificate in acupuncture without doing a whole course in Chinese medicine. So most groups that have at least four or five midwives have someone who can come in with the little needles and do acupuncture when needed. I think it's fascinating. It is. Yeah. Well, okay. I'm not sure. Are there any more questions? We're excited to continue this. You know, and I think the students are too. We hope to interview them next semester and find out whether or not they are able to, they've taken this information and applied it to another clinical setting. So that's like a whole nother gamut of research that we can, you know, talk about. But it all started with the birthday mom. Mm hmm. Well, thank you all so much. I can't wait to see this publication. Thank you. Thank you. I'm sure many of us will put it to use around the world now. Right. You know, and just be open to those nursing students. They can be, they can actually be doing a lot to support their patient. Yeah. Yeah. Thank you for everyone who attended our presentation. Thank you. Thank you.