FACTORS RELATED TO PROFESSIONAL LABOR SUPPORT BEHAVIORS AMONG INTRAPARTUM NURSES IN THE NORTHEAST OF VIET NAM

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1 FACTORS RELATED TO PROFESSIONAL LABOR SUPPORT BEHAVIORS AMONG INTRAPARTUM NURSES IN THE NORTHEAST OF VIET NAM LUONG THI HOA A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE MASTER DEGREE IN NURSING SCIENCE (INTERNATIONAL PROGRAM) FACULTY OF NURSING BURAPHA UNIVERSITY AUGUST 2015 COPYRIGHT OF BURAPHA UNIVERSITY

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3 ACKNOWLEDGEMENT I would like to first and foremost, thank my major-advisor, Assistant Professor Dr.Siriwan Sangin and my co-advisor, Associate Professor Dr.Wannee Deiosres for their warm support, for sharing their knowledge and time, as well as for providing a helpful insight and guiding me through this process. I have learned much about research and writing from them. I am ever so grateful for their ability to keep me laughing despite whatever situation arose. Thank you for sharing your wisdom and expertise. A special acknowledgement goes to the Project Program Health Human Resource Development under Ministry of Health of Viet Nam for their financial support. I send my sincere thankfulness to the Dean and all the lecturers and staffs of Faculty of Nursing, Burapaha University. I truly appreciate everything you did for me. I would like to extend special thanks to principal of Thai Nguyen University of medicine and Pharmacy, particularly to the Dean of Nursing Faculty and my colleagues for their supporting and encouragement every step of my way. I want to acknowledge the respondents for consenting to participate in the research study. They provided important information that was crucial for the completion of chapter four and five of my research project report. I also express a special thank you to my classmates and my friends. They are a great source of smile and strength. It has been a joy to experience this educational journey with them. I will always treasure the memories of our time together. Finally, I am deeply grateful to my all family members, particularly, my husband and my daughter. Their love and support made it possible for me to complete this venture. Thank you for giving me the time and freedom to pursue this goal. Thank you all. Luong Thi Hoa

4 iv : MAJOR: NURSING SCIENCE; M.N.S. KEYWORD: PROFESSIONAL LABOR SUPPORT/ SELF-EFFICACY FOR LABOR SUPPORT/ ATTITUDES TOWARD LABOR SUPPORT/ INTRAPARTUM NURSES/ VIETNAM LUONG THI HOA: FACTORS RELATED TO PROFESSIONAL LABOR SUPPORT BEHAVIORS AMONG INTRAPARTUM NURSES IN THE NORTHEAST OF VIETNAM. ADVISORY COMMITTEE: SIRIWAN SANGIN, Ph.D., WANNEE DEOISRES, Ph.D. 88 P This correlational study aimed to describe professional labor support behaviors (PLSBs) and to determine the factors related to PLSBs among intrapartum nurses in the Northeast of Vietnam. The Social Cognitive Theory was applied as a conceptual framework for this study. Eighty four intrapartum nurses who have worked at Obstetrics and Gynecology Department in three of level 1 hospitals in the Northeast of Vietnam were randomly selected o participate in the study during February-March, Demographic questionnaire, Self-efficacy for Labor Support Scale, Attitudes toward Labor Support Scale, and Labor Support Questionnaire were used to collect data. Data were analyzed by using percentage, mean, standard deviation, and Pearson product-moment correlation coefficients. The result showed that the PLSBs of intrapartum nurses were at a moderate level (M = 3.04, SD =.33). Self-efficacy for labor support (r =.63, p <.001), attitudes towards labor support (r =.49, p <.001), and work experience in intrapartum care (r =.28, p <.01) were significantly related to PLSBs. This finding suggested that strategies need to be developed for intrapartum nurses to improve their self-efficacy for labor support and attitudes toward labor support. Moreover, intrapartum nurses who had more experiences in labor support should serve as a role model to help the novice ones in providing labor support for laboring women.

5 v CONTENTS Page ABSTRACT... iv CONTENT... v LIST OF TABLES... vii LIST OF FIGURES... viii CHAPTER 1 INTRODUCTION... 1 Background and significance... 1 Research objectives... 5 Research hypothesis... 5 Scope of the study... 5 Conceptual framework... 6 Operational definition of terms LITERATURE REVIEW... 9 Concept of labor support and professional labor support... 9 Social cognitive theory Factors related to professional labor support Summary the gap of knowledge RESEARCH METHODOLOGY Study design Study setting Target population and sample Research instruments Protection of human subjects Data collection procedures Data analysis RESULTS Part 1 Demographic characteristic of subjects... 34

6 vi CONTENTS (Cont.) CHAPTER Page Part 2 Description of studied variables which includes PLSBs, self-efficacy for labor support, attitudes toward labor support, and work experience in intrapartum care Part 3 The relationship between self-efficacy for labor support, attitudes toward labor support, work experience in intrapartum care and PLSBs DISCUSSION Summary Discussion Limitation of the study Implication for nursing practice Implication for nursing education Recommendation for future nursing research Conclusion REFERENCES APPENDICES APPENDIXE APPENDIXE APPENDIXE APPENDIXE APPENDIXE APPENDIXE APPENDIXE BIOGRAPHY... 88

7 vii LIST OF TABLES Tables Page 1 Population and sample size in each hospital and in total Range, mean, standard deviation, and level of PLSBs in each dimension and total Mean, standard deviation of PLSBs among groups of education level of intrapartum nurses Difference in score of PLSBs among groups of education level of intrapartum nurses Mean, standard deviation, and range of self-efficacy for labor support, attitudes toward labor support, and work experience in intrapartum care Relationships between self-efficacy for labor support, attitudes towards labor support, work experience in intrapartum care and PLSBs Test of normality of work experience variable Test of normality of self-efficacy for labor support Test of normality of attitudes toward labor support Test of normality of professional labor support behavior Test the randomness of studied variables Linearity by F-test... 82

8 viii LIST OF FIGURES Figures Page 1 Conceptual framework... 7

9 CHAPTER I INTRODUCTION Background and significance Childbirth is one of the most vulnerable events in a woman's life. Prior to 20 th century, most of births were given at home as a normal process. A midwife or doula and other people such as mother, mother-in law, husband or partner, or female relative gathered and provided supports to the laboring women. However, the subsequent shift to hospital due to the promise of safety and un-infections environment usually isolated women from family (Brodsky, 2006; Odent, 2009; Zwelling, 2008). Women in labor usually feel anxious and painful. They have expected that their physical and emotional needs will be met. Another expectation was that they would have the continuous presence of an intrapartum nurse who provided the labor support and other cultural appropriate cares to help them control and manage pain (Bowers, 2002). Labor support refers to supportive cares to laboring women during her labor and delivery process. Sauls (2000) defined labor support provided by intrapartum nurses as the intentional human interaction between the intrapartum nurse and the laboring woman that assists the client to cope in a positive manner during the process of giving birth (p. 125). Nurse researchers have categorized labor support in four main dimensions as emotional support, physical or tangible support, informational or instructional support and advocacy (Adam & Bianchi, 2008; Hodnett, Gates, Hofmeyr, & Sakala, 2013). Effects of labor support on maternal and fetal outcomes have been emphasized in a bunch of researches. It is proposed to be the reduction of maternal anxiety and stress responses that a woman may experience in labor (Corbett & Callister, 2000). In addition, the providing labor support may encourage activities and positions in labor that are known to be beneficial to the progress of labor (Hodnett et al., 2013). Positive outcomes for mother such as shorter labors, decreased analgesia including epidurals, fewer cesarean or forceps deliveries, less oxytocin using, and improved satisfaction with the labor experience (Hodnett & Osborn, 1989; Hodnett et al., 2008;

10 2 Kashanian, Javadi, & Haghighi, 2010; Morhason-Bello et al., 2009; Radin, Harmon, & Hanson, 1993; Yuenyong, O Brien, & Jirapeet, 2012). Besides, the adolescent mothers also perceived that intrapartum nurses support on pain relief, nonjudgmental nursing care, and emotional support as being helpful and play an important role during their positive childbirth experiences (Sauls, 2004 a). Supportive care also promoted the benefit for fetal health such as earlier breastfeeding and higher APGAR scores (Halldorsdottir & Karlottir, 2011; Hodnett et al., 2013; Langer, Campero, Garcia, & Reynoso, 1998; Morhason-Bello et al., 2009; Mottl-Santiago et al., 2008). Provision of support in labor is one of the evidence-based practice standards known to reduce morbidity and mortality (Ith, Dawson, & Homer, 2013). In contrast, a poor support during labor and birth delivery process is associated with the increasing number of medicated births, epidurals, and cesarean section (Trueba, Contreras, Velazco, & Lara, 2000), a higher rate of negative childbirth experiences and postnatal mental health problems including postnatal depression and post-traumatic stress disorder (Creedy, Shochet, & Horsfall, 2000; Czarnocka & Slade, 2000; Lemola, Stadlmayr, & Grob, 2007). Thus, the potential for the consequent dehumanization of women's birth experiences led to calls for a return to continuous support for women during labor in hospital birth settings (Oboro, Oyeniran, Akinola, & Isawumi, 2011). In several documents, the World Health Organization emphasized that a woman in labor should never be abandoned; the midwife should be continuously present to provide the best possible support (World Health Organization [WHO], 1996). A comprehensive approach to the nursing management requires the intraparum nurse to incorporate the use of labor support behavior into practice (Adams & Bianchi, 2008). The supportive cares could be provided by either hospital staffs such as intrapatum nurses or by the women s companions of her social network such as her female relative or her husband (Rosen, 2004). However, in many low-income countries including Viet Nam, women are not permitted to have relatives with them in the delivery room (Nyman, Downe, & Berg, 2011). Thus, intrapartum nurses have a unique opportunity and great potential to positively impact the physiological and psychosocial outcomes of the women s childbirth process (Davies & Hodnett, 2002; Payant, Davies, Graham, Peterson, & Clinch, 2008).

11 3 In reality, observational studies from over the world showed that intrapartum nurses spent only 6% to 29.7% of their time actually providing intrapartum support (Falko, 2001; Gagnon & Waghorn, 1996; Gale, Fothergill-Bourbonnais, & Chamberlain, 2001; McNiven, Hodnett, & O Brien-Pallas, 1992). The supportive cares of intrapartum nurses still cannot meet women expectations (Dunne, Fraser, & Gardner, 2014; Ith et al., 2013) and even did not related to reduction on the rate of cesarean delivery (Hodnett et al., 2002). Overall, labor support by intrapartum nurses was reported to be lacking or insufficient (Larkin, Begley, & Devane, 2012). In Viet Nam, intrapartum nurses have been incorporated into the medical system and they are the primary caretakers of laboring women (Ministry of Health [MOH], 2014). According to World Health Organization (WHO, 2013), 92% of birth in Viet Nam was attended by intrapartum nurse. Nevertheless, it is currently unknown how many Vietnamese women have accessed to supportive cares provided by an intrapartum nurse. In Vietnamese public hospitals, the laboring women were arranged in the waiting room from their admission until they get a full cervical dilation. During this time, intrapartum nurses routine care mainly focuses on checking women s vital signs, monitoring of uterine contractions and progress of labor, and evaluating the health status of mother and fetus. The comforting touch to relief labor pain and encouragement along with direction for stress coping or promote the fetal descent were rarely used by intrapartum nurses (Luong, 2007). In the delivery rooms, they were harsher in their communication with the women although the hospital policy states that all women should be treated with respect. When women complain about pain, intrapartum nurses often downplay the pain or the women have to repeat that they are in pain a few times before the intrapartum nurses attend to their complaints. Intrapartum nurses and other staffs work deliberately, however, showing little support and empathy for laboring women (Målqvist, Lincetto, Nguyen, Burgessc, & Dinh, 2013). To enhance maternal and neonatal outcomes as well as improving the quality of maternity health service, thus, it is important to explore the factors related to labor supportive care of Vietnamese intrapartum nurses. From Bandura's Social Cognitive Theory (1986), human function is viewed as the product of a dynamic interplay of environmental, personal, and behavioral influences. It means that individual s specific

12 4 behavior has been associated with personal factors (such as self-efficacy for behavior practice, attitudes toward that behavior) and environmental factors. Among personal factors, individuals possess cognitive belief that enables them to exercise a measure of control over their thoughts, feelings, actions, and affective belief that means "what people think, believe, and feel affects how they behave" (Bandura, 1997, p. 25). Thus, it can be postulated that self-efficacy for labor support and attitudes toward labor support relate to labor support behaviors of intrapartum nurses. According to Davies and Hodnett (2002), the nurses self-efficacy for labor support is a central concept to address concerning the adoption of this evidence-based clinical technique in maternity health service. Their study s result also revealed that labor and delivery nurses reported higher scores of self-efficacy for labor support than postpartum nurses. This result may due to an opportunity to frequently practice specific role behavior statistically increase the one s belief in his or her ability to perform that behavior (Hupcey, 1990). Moreover, with a rapidly transforming socio-economic situation, more attention should be paid to health care service providers attitude toward evidence based practice (Ministry of Health [MOH], 2003). Nurses attitudes toward care practice and its relationship with their behavior have been investigated (McKinlay, Couston, & Cowan, 2001; Tabak & Ozon, 2004). In maternity care, previous studies suggested that attitude toward labor support was the predictor of intention to practice this care (Aschenbrenner, 2013; Payant et al., 2008; Sauls, 2007). Since attitude has related to behavior (Fishbein & Ajzen, 2010; Graham, Logan, Davies, & Nimrod, 2004), understanding nurses attitudes toward labor support could promote their provision of supportive cares. Besides, previous studies revealed that intrapartum nurses work experience was important factor affecting professional labor support behaviors (Barrett & Stark, 2010; Sleutel, Schultz, & Wyble, 2007). These studies result revealed a relationship between nurses work experience in intrapartum care and nurses labor support behavior. Therefore, there would be an expected significant relationship between work experience in intrapartum care and professional labor support behaviors among Vietnamese intrapartum nurses.

13 5 From the literature review, there was no research in Viet Nam that examines the factors related to professional labor support behaviors. Therefore, this study intended to describe the professional labor support behaviors and examine the relationship between self-efficacy for labor support; attitudes toward labor support; work experience in intrapartum care and professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. This research would provide a better understanding on professional labor support to intraprtum nurses and may assist with development of interventions to improve intrapartum care as well as maternal and neonatal outcomes. Research objectives 1. To describe professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. 2. To determine the relationships between self-efficacy for labor support, attitudes toward labor support, work experience in intrapartum care, and professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. Research hypothesis 1. There is a positive relationship between self-efficacy for labor support and professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. 2. There is a positive relationship between attitudes toward labor support and professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. 3. There is a positive relationship between work experience in inrapartum care and professional labor support behaviors among intrapartum nurses in the Northeast of Viet Nam. Scope of the study This study focused on professional labor support behaviors and relationship between self-efficacy for labor support, attitude toward labor support, work experience

14 6 in intrapartum care and professional labor support behaviors among Vietnamese intrapartum nurses in the Northeast of Viet Nam. The target population in the study was 106 intrapartum nurses who have worked in Obstetrics and Gynecology Department at three level-i hospitals in the Northeast of Viet Nam. Data were collected from February to March, Conceptual framework The Social Cognitive Theory (Bandura, 1986) and evidences from literature review were applied as a conceptual framework for this study. Bandura s theory addresses the dynamic relationship between individuals, the environment, and their behavior. The theory conception of reciprocal determinism view (a) personal factors in the form of cognitive, affective, and biological events, (b) behavior, and (c) environmental influences create interactions that result in a triadic reciprocity. This study investigated behavior and also paid attention to the relationship between personal factor and behavior. The researcher applied professional labor support behaviors to refer to behavior, self-efficacy for labor support, attitudes toward labor support, to refer to personal factor. The concept of work experience in intrapartum care was included in this study as suggested by literature. Self-efficacy refers to beliefs about one s ability to perform a particular task or action (Bandura, 1986). If intrapartum nurses believe in their ability to practice supportive cares, they would take content and theory knowledge concerning labor support supportive technical hand skills as well as critical thinking and decision making skills. But perhaps most importantly, intrapartum nurses with a high sense of self-efficacy believe that these competencies can make a difference in women s health outcomes, and that they can persist through stressful situational circumstances to perform these care by themselves (Jordan & Farley, 2008). This confidence or belief in one s own abilities is the best conceptualized self-efficacy, as a component of Social Cognitive Theory. According to Bandura (1986), the individuals behavior was also affected by what they think or believe, and how they feel. In order to facilitate supportive cares for laboring women it is necessary to understand the nurses attitudes toward labor support because a persistent challenge to changing health practices is the entrenched

15 7 behavior of health service providers (MOH, 2003). Falko (2001) explained that nurses may not spend more time with their women during labor because they may not realize that providing supportive care is the essential element in their nursing role. Although research which study nurses attitudes toward labor support is limited, researchers proposed that intrapartum nurses intention to provide supportive cares to laboring women was influenced by their attitudes toward this evidence-based practice (Aschenbrenner, 2013; Payant et al., 2008; Sauls, 2007). The concepts of nurses work experience in intrapartum care were included in the conceptual framework of this study as suggested by the literature review (Barrett & Stark, 2010; Sleutel et al., 2007). According to Benner (2001), it takes time, most likely more than 5 years, in a consistent setting to develop expertise. Thus, intrapartum nurses need time to develop into expert caregivers, also. Experience allows nurses to recognize what is going on (make judgments) and know how to react (make decisions). The intrapartum nurses years of experience and consequent intuitive knowledge and decision-making skills were acknowledged by physician and nurse colleagues (Jame, Simpson, & Knox, 2003). The conceptual framework of this study was illustrated in Figure 1. Self-efficacy for labor support Attitudes toward labor support Professional labor support behaviors behavior Work experience in intrapartum care Figure 1 Conceptual framework Operational definition of terms Intrapartum nurse refers to a person who has successfully completed on one of the prescribed course of studies in midwifery in Viet Nam which includes midwifery certificate from secondary nursing school (2 years of training after high

16 8 school); diploma midwifery education (3 years of training after high school); and bachelor of nursing in maternity pathway (4 years of training after high school). They have legally practiced midwifery at least six months as a labor and delivery nurse at the time that this study was conducted. Professional labor support behaviors (PLSBs) refers to the supportive cares that intrapartum nurse provides to women from their admission into hospital until the delivery. PLSBs include four dimensions as emotional support, tangible support, informational support, and advocacy. PLSBs were measured by part 2 of the labor support questionnaire (Sauls, 2000). Self- efficacy for labor support refers to how confident an intrapartum nurse is in her ability to use techniques for providing effective professional labor support to laboring women. It was measured by self-efficacy for labor support scale (Davies & Hodnett, 2002). Attitudes toward labor support refer to intrapartum nurses opinions and positive or negative feelings about the importance and benefits of providing labor support to laboring women. It was measured by subscale Attitude of the nurses view on continuous labor support questionnaire (Payant et al., 2008). Work experience in intrapartum care refers to number of months each intrapartum nurse has been working in labor and delivery room. It was measured by the Demographic Questionnaire which was developed by the researcher.

17 CHAPTER II LITERATURE REVIEW In this chapter, the literature on labor support was reviewed. The following sections were presented: 1. Concept of labor support and professional labor support 1.1 Definitions of labor support 1.2 Labor support provider 1.3 Professional labor support 1.4 Significance of professional labor support 1.5 Measurement of professional labor support 1.6 Intrapartum nurse and current practice of labor support in Viet Nam 2. Social Cognitive Theory 3. Factors related to professional labor support 3.1 Self- efficacy for labor support 3.2 Attitudes toward labor support 3.3 Work experience in intrapartum care. 4. Summary of gaps of knowledge Concept of labor support and professional labor support Definitions of labor support Researchers have defined labor support and its components in various ways. Hodnett et al. (2002) stated that labor support is a term used to describe the presence of an empathic person who offers advice, information, comfort measures, and other forms of tangible assistance to help a woman cope with the stress of labor and birth (p. 1374). Close continuous support is defined as the attendance of a caregiver to a woman during labour and the presence is timely and covers 80%-90% of the time when a woman is in active labour (Davies et al., 2002). Presence and being with woman have been said to be virtually the same concept as social support in labor. To be a labor support provider is to be available to the woman, to listen, to see her situation mirrored in her body and to share the responsibility of childbirth (Hunter,

18 ). Labor support provider One of the variants in describing labor support lies in who should provide it in labor. From the literature, the labor support people whose task was to provide continuous support for the laboring woman were categorized as hospital staff such as (intrapartum nurses or midwives), women who were not hospital employees and had no personal relationship to the laboring woman (such as doulas), and companions of the woman s choice from her social network (such as her mother, her husband/ partner or her friend) (Hodnett et al., 2013; Rosen, 2004). There have no doula in Viet Nam, thus, the researcher categorizes labor support provider as non-professional provider and professional provider, in this chapter. Nonprofessional provider is a person without formal training to provide support (e.g., a mother, a female relative, a husband/ partner, or a friend) who have in companied with laboring women since her admission into the hospital for childbirth. Professional provider could be an intrapartum nurse or a midwife who has been trained in midwifery and has experience in intrapartum care for laboring women. Professional labor support Professional labor support refers to the intentional human interaction between the intrapartum nurse and the laboring woman that assists the client to cope in a positive manner during the process of giving birth (Sauls, 2000, p. 125). Intentional human interactions on the part of the intrapartum nurse are theorized to include dimensions of emotional support, tangible support, informational support, and advocacy. Other research teams also suggested that supportive care during labor may involve emotional support, tangible comfort measures, informational or instructional and advocacy (Adams & Bianchi, 2008; Hodnett e al., 2013). The dimensions of professional labor support are described as following. Emotional support is the behaviors that promote comfort and reassurance, demonstrate competency, and are helpful and respectful of woman. Intrapartum nurse should appear calm and confident in her interaction with the woman; demonstrate understanding and caring; provide praise such as telling the woman she is doing well or that labor is progressing normally. The emotional support is separated by three

19 11 aspects as emotional support- reassurance; emotional support-creating control, security, and comfort; and emotional support-nurse caring behaviors (Sauls, 2006). Tangible support is the performance of tasks to meet physical need of woman in labor: provide distraction techniques, such as light social conversation, having her watch TV or listen to music, during the earl phage of labor if appropriate; provide companionship by staying with the woman if she requests; provide physical comfort through the use of hot/ cold therapy such as compresses, warm blanket, sips of water, wet washcloth, and oral hygiene; provide massages between contractions to help the woman relax, such as back rubs, leg rubs; assist with the movement and position changes, etc. (Sauls, 2006). Instructional/ informational support is the process of exchanging information to meet the learning and knowledge needs of parturient parents concerning aspects of breathing, relaxation, and pushing techniques; intrapartum nurse also reinforces previous instruction; assists with breathing and relaxation techniques prior to an epidural or during natural childbirth (Sauls, 2006). Advocacy usually is the facilitation of communication between the woman and hospital staff to assist her in making informed decisions, such as listen to and respects the women s opinion and wishes concerning her birth plan; interprets the couple s wishes to the other hospital staff; discussing alternatives with the women concerning her birth plan; acts on women s behalf to ensure her birth plan is followed (Sauls, 2006). In summary, professional labor support refers to presence of an intrapartum nurse or midwife who offers the physical or tangible, instruction or informational, emotional supporting behaviors and advocacy to assist the laboring woman to cope in positive manner during the process of giving birth. Professional labor support has been conceptualized as complementary to but distinct from the support the woman receives from her companies such as from family member, or from the husband or partner (Hodnett, 1996). Significance of labor support Studies of labor support are heterogeneous in terms of the populations studied, baseline characteristics of the participants and the hospital environment, training of the labor support providers, and type, timing, and consistency of labor

20 12 support. However, two following systematic reviews of the better designed studies yielded consistent results. A meta-analysis of Scott, Berkowitz, and Klaus (1999) compared outcomes of intermittent and continuous labor support by lay person or doula to healthy woman. Eleven clinical trials with 4,391 women revealed an aggregated data. Mother in the continuous doula support group experienced shorter labors (weighted mean difference was-1.64, CI to -.96); used less analgesia (OR.64, 95 % CI ), oxytocin (OR.29, 95% CI ), forceps (OR.43, 95% CI ), and cesarean delivery methods (OR.49, 95% CI ) than the intermittent doula support group. There were no significant differences on any outcomes between intermittent doula support group and no doula support group. The Cochrane meta-analysis of 22 randomized clinical trials involving over 15,000 women found that continuous one-to-one support during labor provided by trained or untrained individuals had beneficial effects across a variety of health care settings and socioeconomic and ethnic groups, including: Reduction in cesarean delivery (RR 0.78, 95% CI ); Reduction in need of medication for pain relief (RR.0.90, 95% CI ); Reduction in use of regional analgesia (RR 0.93, 95%CI ); Reduction in length of labor (weighted mean difference hours, 95% CI to -0.31); Increase in spontaneous vaginal births (RR 1.08, 95% CI ). These findings provided validation for the important of continuous labor support for the greatest impact on improving outcomes (Hodnett et al., 2013). These meta-analyses and the comprehensive review revealed positive relationship between labor support and improved mother and newborn outcomes. A review of individual studies, including pertinent studies from the most recent systematic review by Hodnett et al. (2013) and from the comprehensive literature search, was completed to further describe support during labor, its relationship to improved outcomes, and differences based on provider of support. The following review focuses on labor support from professional provider. Outcomes of labor support provided by intrapartum nurses The impact of professional labor support on maternal and neonatal outcomes have been evaluated in many studies (Gagnon, Waghorn, & Covell, 1997; Hodnett & Osborn, 1989; Hodnett et al., 2002; Hodnett et al., 2008; Kashanian et al., 2010; Radin

21 13 et al., 1993). These studies are heterogeneous in terms of the populations studied, baseline characteristics of the participants and the hospital environment, type, timing, and consistency of labor support. Therefore, the impacts of labor support from professional provider seemed to vary through studies. Labor support provided by intrapartum nurses during labor may reduce the duration of labor and the number of cesarean deliveries. A randomized trial of 100 eligible nulliparous women who had not received education classes on childbirth was conducted by Kashanian et al. (2010). In the intervention group (n = 50), continuous support during labor was provided; the control group (n = 50) did not receive continuous support. Mean duration of the active phase of labor, second stage of labor, and the number of cesarean deliveries were significantly lower in the intervention group compared with the control group. Nursing care, more than any other variable including type of physician s resistance, or subject characteristics, was associated with cesarean rate (Radin et al., 1993). Hodnett and Osborn (1989) determined the physical and psychological effects of midwives or lay midwives in training on childbirth outcomes. There were a less used of analgesia, oxytocin, and fewer deliveries requiring forceps or episiotomy in the supported group. A direct educational intervention utilized nurse experts to educate nurses in a formalized approach to labor support in a two-day workshop (Hodnett et al., 2008). The formalized or structured approach included (a) attention to environment, (b) palpation of fetal position, (c) positioning to promote labor, (d) pain assessment and interventions to manage discomfort, (e) assessment of mother s emotional status, and (f) techniques to reduce distress. These interventions were consistent with findings of a Delphi study to identify important intrapartum support interventions (Miltner, 2000) and a single case study (Sleutel, 2000). Participating nurses provided structured care to women in a labor assessment unit in accordance with the formalized approach over 1-4 hours and did not continue into the labor unit for the remainder of the labor. Mothers in the experimental group reported more satisfaction with nurses helpfulness and the amount of attention received during intrapartum care. There was a positive trend toward vaginal birth for the structured care group (OR 1.12, 95% CI , p >.05) but it did not reach statistical significance.

22 14 In contrast, some authors concluded continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth (Gagnon et al., 1997; Hodnett et al., 1996; Hodnett et al., 2002). A two-day training program in labor support focused on developing strategic plans to increase the amount of labor support provided to patients (Hodnett et al., 1996). Designed nurse volunteers led the implementation of the strategic plan at 20 hospitals in Canada. No significant impact on labor outcomes was identified. In addition, effectiveness of nurses as a provider of labor support was evaluated with 6915 woman in thirteen United States and Canadian hospitals where annual cesarean delivery rates of at least 15% evaluated. Result showed that the rates of cesarean delivery were almost identical in the 2 groups (12.5% in the continuous labor support group and 12.6% in the usual care group; p =.44). Moreover, there were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women's perceived control during childbirth or in depression, measured at 6 to 8 postpartum weeks (Hodnett et al., 2002). Gagnon et al. (1997) examined an educational intervention involved a 30-hour training workshop and quarterly refreshers on use of one-to-one care which consisted the presence of a nurse during labor and birth providing physical comfort measures, relaxation and coping techniques, and stress and pain management in an effort to promote positive labor outcomes. A beneficial trend due to one-to-one nurse support was found with a 17 percent reduction in risk of oxytocin stimulation (relative risk of experimental vs. control = 0.83; 95% CI ). However, no significant differences were found in overall labor durations and overall rates of total cesarean section, cesarean section for cephalopelvic disproportion, epidural analgesia, admission to the neonatal intensive care unit, instrumental vaginal delivery, and perineal trauma (Gagnon et al., 1997). In summary, the professional labor support apparently did not revealed many significant impacts on childbirth outcomes. Result of a systematic review by Hodnett et al. (2013) revealed that labor support appeared to have a stronger impact on anesthesia or analgesia, spontaneous birth, and instrumental birth when the caregiver was not a hospital employee. Furthermore, women still described the experience of midwives as uncaring during labor (Eliasson, Kainz, & von Post, 2008), they also experienced lack support from the midwife during labor, which sometimes results in

23 15 intense fear of childbirth in a subsequent pregnancy (Nilsson, Bondas, & Lundgren, 2010). It was unclear why the outcomes were not as great when intrapartum nurses provided labor support. Measurement of professional labor support Questionnaires developed to evaluate professional labor support include the labor support scale (Sleutel, 2002) and the labor support questionnaire (Sauls, 2000). These were both self-report instruments but had different conceptual frameworks, purposes and factors. The labor support scale (Sleutel, 2002) was based on a social support framework, with the assumption that social support would lead to improved outcomes. The purpose was to evaluate frequency with which nurses performed labor support interventions and to describe perceptions of the utility of the actions. The scale was developed in two phases, with revisions occurring between them. A six-factor solution emerged during factor analysis, and the instrument had adequate reliability (.90 for frequency and.92 for helpfulness). The six factors were (a) instrumental or physical support, (b) emotional support, (c) partner support information/ advice, (d) advocacy, (e) mother-directed pushing, and (f) sustenance. Sleutel (2002) described three limitations of the instrument including (a) the inability to evaluate the use of labor support practices that may be used infrequently, such as a whirlpool; (b) many emotional items were deleted due to inadequate variance that may limit the ability of the instrument to discriminate in the emotional realm; and (c) it is a self-report instrument, which may be a limitation, as nurses may not accurately recall care they provided. The labor support questionnaire has two parts (Sauls, 2000). Part 1 measures intrapartum nurse s attitudes or degree of importance placed on professional labor support and part 2 measures behavioral usage of the supportive behavior. A six-point Likert-type scale was used, ranging from 0-5, with 0 representing not important or not used and 5 representing extremely important or always used. Participants indicate the value placed on behavior and frequency of behavior use, with potential scores ranging from 0 to 135. Total mean scores were ranged from 0 to 5. Higher scores indicate higher importance placed on the supportive behavior and higher use the behavior in practice. The Cronbach s alpha coefficient of part 1 and part 2 of labor support

24 16 questionnaire were.90 and.88, respectively. Content validity index was.94, indicating that 94% of the items were judged to be valid. Convergent validity was.57 (p =.00). While the Sauls s questionnaire (2000) and Sleutel s scale (2002) share similarities with focus on emotional support, tangible support, informational support and advocacy, the labor support questionnaire provided additional detail regarding the dimensions of emotional support (reassurance; creating control, security, and comfort; nurse caring behaviors). This addition increased content validity and made it a better measure of the wide range of support measures provided to women in labor. The labor support questionnaire has been demonstrated to be a reliable and valid tool. Therefore, the part 2 of labor support questionnaire was chosen to measure the PLSBs variable in this study. Intrapartum nurse in Viet Nam At present, there are 3 kinds of educational curriculum prepared for intrapartum nurses in Viet Nam including 1) midwifery certificate from secondary nursing school, 2) diploma midwifery education, 3) bachelor of nursing in maternity pathway. To become an intrapartum nurse who works in Obstetrics and Gynecology Department of a certain public hospital in Viet Nam, a person has to successfully complete the prescribed courses of studies in requisite education program, practice midwifery as a probationer at least 6 months and pass the specific practice exam which is approved by that hospital. 1. Midwifery certificate from secondary nursing school The students have to finish high schools and of course have granted certificates. They will have to take the exams to enter the secondary nursing schools. After complete studying in two years they will be certified from the secondary nursing school with the certain standard of knowledge and some other criteria. The Ministry of Health approved only a 2 years program. The curriculum consists of general subjects including foreign languages, information technology, politics, sports, military; the basic subjects such as anatomy-physiology, microbiology-parasites, pharmacology, nutrition, hygiene and disease prevention, communication skills and health education, management and health organizations; the specialized subjects such as fundamental of nursing, medical nursing, surgical nursing, pediatric nursing, obstetric nursing, infectious disease nursing, production gynecology nursing, disease specialist nursing, traditional

25 17 medicine, primary emergency, rehabilitation-physiotherapy, community nursing (MOH, 2014). At the present, most of intrapartum nurse graduated from this level. 2. Diploma midwifery education Total time of this educational program is 3 years; there are two ways to enroll in this program. The students who have graduated from high school must pass an entrance exam, and they will have to study full-time with this program. Second way students can enroll is to study part-time with this educational program. They also must pass an entrance exam. The students are intrapartum nurses who have at least two years of experience after they graduated from secondary nursing schools, total time is for 1 year of the study (MOH, 2014). Subjects including in the curriculum are as same as those in the midwifery certificate program from secondary nursing school. 3. Bachelor of nursing In 1985, the Ministry of Health along with the Ministry of Educational Training have allowed to open educational program of bachelor nursing. Bachelor's degree nursing class was first opened at the Hanoi Medical University. Total time of study is 4 years. There are four main pathways in this program, include: medical nursing, surgical nursing, pediatric nursing, and obstetric nursing. If students want to enroll this program, they must graduate from high school and they must pass the national entrance exam. They have to study full-time with this program during 4 years. Alternatively, this educational program will recruit intrapartum nurses who have at least two years of experience after they have diploma degree, or at least three years of experience after they have certificate of the secondary nursing school. They can study part-time during 4 years with this kind of enrollment (MOH, 2014). Current practice of labor support in Viet Nam In Vietnamese health care system, all public hospital were ranged in four level based on the national standard that was developed by the Ministry of Health [MOH] (2005). This national standard contains 5 main groups of evaluation criteria which are scored as followings: Groups of evaluation criteria Range of score 1. Group I (3 criteria): Function and responsibility Group II (4 criteria): Hospital s operation capacity Group III (8 criteria): Health workforce and personnel 1-30

26 18 4. Group IV (7 criteria): Quality of health care services Group V (10 criteria): Infrastructure and medical devices 1-20 The public hospital are scored and ranged in four levels as followings (MOH, 2005): Level of the hospital Range of score Level I Greater than 90 Level II From 70 to lesser than 90 Level III From 40 to lesser than 70 Level IV Lesser than 40 Generally, in Vietnamese public hospital, the poor infrastructure in addition to the nursing shortage is still the primary challenge that inhibits the improving the quality of maternity cares. Normally, each hospital s Obstetrics and Gynecology Department has some waiting rooms in which women stay with their one family member from their admission to hospital until the second stage of labor. When the laboring women are properly dilated at approximately 10cm they get in the solely delivery room, in which, three to four delivering tables along with several baby warmers, and a weighing machine are set. The rest of rooms in Obstetrics and Gynecology Department are used for postpartum women. Moreover, with a ratio of 10.1 midwives and nurses per 10,000 people in the period of (WHO, 2013) and an abundance of laboring women every day, one intrapartum nurse have assume responsibility for care offer to three or four laboring women. It is difficult to increasing staffing to meet unexpected increase in women demand. Achieving the best practice for women in labor such as the provision of labor support, thus, require much more effort from organization as well as intrapartum nurses. However, providing the continuous presence and support that is documented to aid in improved maternal and neonatal outcomes seem to be costly to intapartum nurses, and can be difficult. Onset and duration of labor is unknown, and constant availability to laboring women is disrupting to the family and personal life of intrapartum nurses. Supportive presence has a large element of giving of oneself that can be emotionally draining and physically exhausting (Nguyen, 2007). Although the National Standard Guideline for safety mother hood and newborn care was developed, many recommendations of evidence-based practice do not tend to be followed (MOH, 2003).

27 19 Social cognitive theory Social Cognitive Theory represents a triadic reciprocal causation model in which the behavior of a person, the characteristics of that person, and the environment within which the behavior is performed are constantly interacting. A change in one component has implications for the others (Bandura, 1986). Among other personal factors, individuals possess self- efficacy beliefs that enable them to exercise a measure of control over their thoughts, feelings, and actions. Self-efficacy is influenced by the expectation that behaving in a particular way will lead to a given outcome, and by the desirability of that outcome (Bandura, 1997). When intrapartum nurses have the opportunity to practice labor support for women they will develop higher efficacy beliefs in their abilities to perform behaviors associated with midwifery hallmark. Providing care behaviors requires the midwife to be a consistent presence at the side of the laboring woman, which may be difficult due to institutional and other work related factors. If they believe that labor support behaviors bring out positive benefits to laboring women they will more likely have a higher self-efficacy to those behaviors. Besides, individual s attitudes toward a certain behavior can be conceptualized as an affective event which belongs to concept of personal factors in Bandura s theory. Unless people believe that their actions will have the desired consequences, they have little incentive to engage in those actions (Bandura, 1986). In fact there are many factors influence a nurses care during labor, these include; staff patterns and attitudes, expectations of those providing care (Ghani & Berggren, 2011). Moreover, people do things that give them self-satisfaction and a sense of pride and self-worth (Bandura, 1997). Many intrapartum nurses derive their professional identity in large part by providing care that they believe makes a difference for childbearing women. This is why many intrapartum nurses choose the midwifery profession instead of pursuing a career in obstetrics (Ernst, 1996). By providing professional labor support, intrapartum nurses are not only contributing to positive health outcomes for women, but they are developing a positive sense of themselves as intrapartum nurses. Studies that have been guided by Social Cognitive Theory have found it useful to explain nursing behavior and factors relate to provision of care (Damschroder et al., 2009; Melnyk, Fineout-Overholt, Giggleman, & Cruz, 2010). The Social

28 20 Cognitive Theory is chosen to guide this study because of its efficacy in describing factors related to individuals behavior. It also provided the conceptual basis for the self-efficacy for labor support scale that is used to measure the self-efficacy for labor support variable in this study (Davies & Hodnett, 2002). Factors related to professional labor support Self-efficacy for labor support 1. Definition of self-efficacy According to Social Cognitive Theory, self-efficacy refers to "people's judgments of their capabilities to organize and execute courses of action required attaining designated types of performances" (Bandura, 1986, p. 391). Self-efficacy can influence people s choice of activities, and increase or hamper their motivation. Selfefficacy beliefs provide the foundation for human motivation, well being, and personal accomplishment. This is because unless people believe that their actions can produce the outcomes they desire, they have little incentive to act or to persevere in the face of difficulties. Much empirical evidence now supports Bandura's contention that self-efficacy beliefs touch virtually every aspect of people's lives-whether they think productively, self-debilitating, pessimistically or optimistically; how well they motivate themselves and persevere in the face of adversities; their vulnerability to stress and depression, and the life choices they make. Self-efficacy is also a critical determinant of self-regulation (Pajares 2002; Zulkosky, 2009). 2. Relationship between self-efficacy and PLSBs Based on Bandura s Social Cognitive Theory, researchers have established that self-efficacy beliefs and behavior changes and outcomes are highly correlated (Lenz & Shortridge-Baggett, 2002; Zhu, Norman, & While, 2013; Ziegler, 2005). A key factor in successful implementation of evidence-based practice (EBP) is a clinician s self-efficacy (Damschroder et al., 2009; Melnyk et al., 2010). One study tested the idea that a perception of self-efficacy, as defined by social cognitive theory, would positively influence the behavioral components necessary (i.e., generation of new knowledge and justifying of that knowledge) to maintain EBP implementation efforts within an organization. Results indicated that self-efficacy positively influenced evidence acquisition and application. Authors proposed that to acquire and apply the