Hinde_Honors_Project_FINAL.docx

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Reflections on Utilizing Doulas to Improve Nursing Student Preparation and Self-Confidence in Providing Labor and Birth Support

Tori A. Hinde

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Abstract

Undergraduate nursing students generally have very limited opportunities to provide care to patients and families during labor and birth. This article explores a strategy to prepare nursing students for their first hospital clinical in labor and delivery (L&D) by utilizing birth doulas to teach labor support through interactive learning techniques. Continuous labor support is an evidence-based practice and is recommended by professional organizations including the Association of Women’s Health, Obstetric and Neonatal Nurses and the American College of Obstetricians and Gynecologists. BSN students in their second semester of nursing school were asked to evaluate their level of comfort in the L&D setting and their confidence in providing labor support prior to their first clinical. Post-intervention survey responses (n= 102) indicated an increase in comfort with beginning clinical in the L&D setting. Prior to the labor support

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Reflections on Utilizing Doulas to Improve Nursing Student Preparation and Self-confidence in Providing Labor and Birth Support

This paper provides an overview of my honors project, which explored utilizing doulas to improve nursing student preparation and self-confidence in providing labor and birth support. After giving birth to my own children, supporting other families in the transition of birth became my calling. These experiences inspired me to become a nurse and informed my honors project. For my project, I planned and implemented a doula-led labor support workshop for second-semester undergraduate nursing students to prepare them for their clinical experience in labor and delivery. According to student surveys, working in small groups with experienced doulas as facilitators substantially improved students’ confidence and comfort in providing labor support prior to their first obstetric clinical. I described my project and results in a manuscript that I submitted for publication in Nurse Educator, a peer-reviewed journal. Through my honors project, I learned about the process of designing a study, completing an application to the Internal Review Board, designing survey tools, collecting and analyzing data, and writing and submitting a manuscript to a professional journal. Completing an honors project has inspired me to consider a future as a nurse researcher and educator.

Personal Background

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support was so helpful to me, and I became more interested in learning about roles of doulas and nurse midwives in childbirth.

In the years between becoming a mother and beginning nursing school, I sought jobs and volunteer positions that allowed me to support families in pregnancy, birth and postpartum while beginning to take prerequisite classes for nursing school. I trained as a birth doula, volunteering with Birth Partners, a volunteer doula program at UNC Medical Center, and also taking on my own private birth doula clients. I learned about the physical and emotional needs of birthing persons and their families during pregnancy, birth and postpartum. I wanted to take all I had learned as a birth doula and carry the knowledge and skills into nursing school, where I could learn more about physiologic birth and support and educate and care for families as a health care worker.

Honors Project Development

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students in the maternal-newborn nursing course. The timing was serendipitous because the new baccalaureate curriculum had 2-hour breakout classes that would allow for small groups of students and interactive work.

I had seen first-hand in my maternal-newborn clinical experience that students lacked confidence and knowledge about physiologic birth prior to their clinical. Students arrived in clinical with nervous excitement. They found themselves in a position where they wanted to help support families, but did not know what to do. For the students in the new BSN curriculum, maternal-newborn nursing would also be their first semester of a hospital-based clinical

environment. I recalled my own nerves the first time I walked into a patient’s room and learned to navigate therapeutic communication and building rapport with patients. A labor support workshop could also offer a chance for students to role play and prepare to walk in a patient’s room for the first time as a student nurse, in addition to preparing them to provide labor and birth support.

To begin the development of the project, I explored existing research on the benefits of labor support, barriers to nurses providing that support and student confidence in the labor and delivery setting. This research became the foundation of my Internal Review Board (IRB) proposal and later the background of my manuscript. From the manuscript background section

(Full manuscript found in appendix A):

Continuous labor support is an evidence-based practice1 and is recommended by

professional organizations including the American College of Obstetricians and

Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal

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advocacy, and offering of information.4 Labor support is associated with improved

maternal and neonatal outcomes including increased rate of spontaneous vaginal birth,

decreased rate of cesarean birth, higher 5-minute APGAR scores and fewer negative

feelings about childbirth.1 In a 2017 committee opinion, ACOG concluded that

continuous emotional support, such as doula care, is associated with improved outcomes

for women in labor.2 Additionally, ACOG suggested offering women a variety of

non-pharmacological techniques to help them cope with labor pain such as water therapy,

relaxation techniques and massage.2 ACOG also recommended frequent position

changes in labor to promote comfort and optimize fetal position.2 AWHONN also issued

a position statement that continuous labor support from a registered nurse is essential to

optimizing birth outcomes.3 AWHONN recommends that nurses partner with birthing

persons to develop a plan of care based on their needs and their desires and expectations

for labor and birth.3

Due to the increased acuity of patients, nurses today often have less time to

provide the crucial role of labor support.5 Nursing students are well positioned to

provide labor support during clinical rotations as they traditionally are paired with one

patient and are able to stay with the laboring person throughout their shift, whereas

registered nurses often care for multiple patients simultaneously. However,

undergraduate nursing students preparing for their first obstetric clinical lack knowledge

and confidence in providing labor support.6 Most nursing students have limited exposure

to childbirth prior to their first clinical and there is substantial need to give nursing

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Birth doulas are trained professionals who provide continuous physical,

emotional and informational support throughout the birthing process.7 As experts in

labor support, birth doulas are qualified to lead students in small group discussions,

demonstrations and role plays to prepare them to provide labor support.

After reviewing existing published literature, I began planning a workshop that would give students an opportunity to learn about specific aspects of labor and birth support and practice supporting families during labor and birth. Breakout groups previously used in Birth Partners doula training sessions became the foundation for our student workshop: introductions, engaging the senses, upright and active, and complications

Part of my project was devoted to finding existing research on student knowledge and confidence in labor support and maternity clinical. I also sought surveys that measured student confidence. After consulting with a librarian through the Health Sciences Library, I determined that a Likert survey would be the best way to evaluate confidence and measure change in

confidence before and after the workshop. My advisor shared another Likert survey she had used for evaluating an operating room doula training and I used that as a basis for the surveys for this project. The surveys were a mix of questions about demographic information such as age, gender, experience with birth and labor support as well as the Likert scale questions about comfort level in labor and delivery clinical and confidence in five areas of labor support:

introducing yourself to patient, discussing birth preferences, recommending safe and appropriate positions, using touch to support patient in labor and providing emotional support. (See

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Once the literature review was complete, the workshop was designed, and the surveys were drafted, I submitted a request for exemption to the IRB. This was my first experience with the IRB and I learned how to navigate the system and submit a proposal with my advisor’s support and with the assistance of my nursing research professor. The IRB analyst responded to the proposal with questions, and following edits, our proposal was granted an exemption.

In order to staff the workshop with volunteer doulas, I drafted an email to Birth Partners doulas introducing myself, explaining the purpose of the workshop and outlining the format of the four stations. With the help of my advisor, we recruited experienced doulas and assigned them to stations. In preparation for the workshop, we reserved four separate classrooms to host each of the stations and gathered necessary supplies including birth balls, hand lotion, bed sheets for demonstrating rebozo support, and sample birth plans.

Next, we needed to designate student groups. The larger maternal-newborn class was broken into 3 smaller group classes of 28-40 students that each lasted 2 hours. I assigned the students in each 2-hour class to smaller groups of 7-10 students. The doulas would stay at the same station and the students would rotate through each room. Students would spend 25 minutes at each station before moving on to the next. I drafted an email to students assigning them to groups and explaining the workshop. In preparation for the workshop, I printed, paired and numbered pre- and post-surveys so that each student’s pre-survey could me matched to their post-survey without using any identifiable characteristics. A script was included for the facilitators to read prior to distributing the surveys explaining that participation was voluntary and would not have any impact on students’ course grades.

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With the help of nine Birth Partners doulas, students in all three classes rotated through the four stations during their 2-hr class time, spending 25 min at each station. They responded to paper and pencil surveys at the beginning of the first session and again at the end of their final station. Here is a section of my manuscript (appendix A) outlining each of the five stations:

The introduction station discussed how to initiate conversation with a birthing

person and their companion(s) and how to build rapport. The doulas in this station also

shared sample birth plans and introduced topics that students might expect to see on a

birth plan. Students then practiced introducing themselves and asking about birth

preferences and patient wishes. In the engaging the senses station, doulas demonstrated

hand massage, shared sample words of affirmation, discussed creating a calm space and

water therapy in labor. Students practiced hand massage on one another. In the upright

and active station, doulas discussed the importance of position changes during labor and

led students through various positions including the use of an exercise ball and bed sheet

as tools to help provide comfort and assistance with supportive positioning. Students had

the opportunity to role play and practice utilizing these new skills. In the final station,

common labor and birth complications were discussed. Doulas used a stretcher to

demonstrate patient positioning during an epidural placement and how to support a

family during emergent situations, including cesarean birth.

Throughout the four stations, doulas shared personal stories of supporting

families in childbirth. Students were able to ask questions and practice the interventions

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prepare students for their upcoming clinical by demystifying birth and providing them

with concrete tools to use in their maternity clinical.

Outcomes

Following the workshop, I developed a spreadsheet with a codebook for data entry from the surveys. Each pre-survey was matched to a corresponding, numbered post-survey. The responses were entered into a spreadsheet with 102 completed pre and post surveys collected. Health Economist Dr. Jesse Hinde assisted with the data analysis using statistical data software, Stata v15.0. Outcomes were discussed in the manuscript (appendix A):

According to student surveys, 85% (n=102) of students had not attended a birth

prior to the training. Survey responses indicated an increased comfort level being in

labor and delivery setting as a nursing student after the workshop. Prior to the labor

support training, 21.5% of students reported feeling comfortable or extremely

comfortable. After the training, 82.4% of students reported feeling comfortable or

extremely comfortable. Students also reported increased confidence in all five areas of

labor support: 1) Confidence introducing themselves to patients increased from 80.6% of

students feeling confident or extremely confident to 95.1% after the training; 2)

Confidence in discussing birth preferences increased from 24.3% of students feeling

confident or extremely confident to 76.7%; 3) Confidence in recommending safe and

appropriate positions for labor increased from 5% of students feeling confident or

extremely confident to 84%; 4) Confidence in using touch to support a patient in labor

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Confidence in providing emotional support to a laboring patient increased from 38% of

students feeling confident or extremely confident to 87%.

Nearly all students (98%) were satisfied with the workshop. Among open-ended

comments, students reported that they appreciated learning different techniques and

having an opportunity for hands-on practice before beginning patient care experiences.

Students also appreciated hearing labor and birth stories and experiences from the

doulas. Additionally, students reported that it was helpful to see the demonstrations of

techniques before trying themselves through role-playing.

In addition to the student surveys collected immediately before and after the workshop, doula volunteers received an electronic survey about their experiences as facilitators. Four doulas responded to the survey. Overall, they requested more guidance and suggestions for each of the stations. “Having five key points to communicate for each station would be really helpful - for the doulas and even then having a print-out for the nursing students to look back and reference.” Other responses focused on finding ways to make the stations more interactive. One doula suggested incorporating a labor scenario and asking students how they would help or support in that situation as one way to make the workshop more interactive. Doulas also expressed gratitude in the opportunity to share the importance of labor support and their passion for birth with the nursing students.

The overwhelmingly positive survey responses led to the following conclusion (appendix A):

Working in small groups with experienced doulas as facilitators substantially

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obstetric clinical. Utilizing discussions, demonstrations and hands-on practice met the

needs of learners, and students responded favorably to the experience. The majority of

students had little prior exposure to birthing experiences and the birth doula strategy

improved self-efficacy and sense of preparedness among nursing students. The workshop

also served as an opportunity for interprofessional collaboration with birth workers

through which students learned to understand and appreciate the role of birth doulas.

Nursing education programs should consider adopting similar strategies to help prepare

their students.

Drafting a Manuscript

Once the outcomes of the workshop were determined, I sought to find an appropriate journal to target for publication of my project. I conducted a search through the Health Sciences Library database of journals to identify those in the women’s health and obstetrical nursing fields. Since our intervention was aimed at educating nursing students, I also sought appropriate journals for nurse educators. After discussing with my advisor, we determined that the journal

Nurse Educator would be the best fit. Specifically, Nurse Educator has a department on teaching strategies that appeared to be an ideal target for our article based on reviewing past issues.

Before beginning to write, I reviewed the author guidelines and submission instructions for Nurse Educator. The guidelines require manuscripts be prepared according to the American Medical Association Manual of Style, which was unfamiliar to me. The reference style was also novel to me. References are to be cited consecutively by number and listed by order of

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use of headers and tables to inform my own writing. I completed a draft of my manuscript and shared it with my advisor and co-author. The draft underwent multiple reviews. The feedback and edits from my advisor helped me grow and improve my scientific writing skills.

Reflection

Completing an honors project was both challenging and rewarding. It was a lesson in managing many small details and communicating with my advisor and other stakeholders. It was my first experience submitting an IRB application, which was intimidating, but much more manageable than I expected. I learned to utilize my resources including the Health Sciences Library, my advisor, and other nursing mentors. I loved working with other nursing students and found joy in seeing their confidence grow during the workshop. It was also rewarding to bring together doulas and nursing students as interprofessional colleagues. I was inspired by the opportunity teach and hope to find ways to grow as a nurse educator.

One area I strive to improve is in clarity of communication. In order to design the workshop, I relied on the assistance of my advisor and volunteer doulas. The survey feedback from the doulas illuminated the need for more specific directions and details. For example, some of the doulas struggled to find parking and others arrived unclear with what was expected of them in facilitating the workshop. I learned that frequent and highly-detailed communication is important when working with teams and delegating tasks. Since the project was self-directed, I also learned that it is my responsibility to stay focused on a project in order for it to be

successfully accomplished.

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Appendix A

Utilizing Doulas to Improve Nursing Student Preparation and Self-Confidence in Providing Labor and Birth Support

Introduction

Undergraduate nursing students generally have very limited opportunities to provide care to patients and families during labor and birth. For many students, the clinical rotation on a labor and delivery unit is their first exposure to childbirth. Providing opportunities for students to engage in labor and birth support practices before they begin patient and family care experiences in maternity clinical may increase their level of preparedness and self-confidence. This article explores a strategy to prepare nursing students for their first hospital clinical in labor and delivery by utilizing birth doulas to teach students labor support through interactive learning techniques.

Background

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variety of non-pharmacological techniques to help them cope with labor pain such as water therapy, relaxation techniques and massage.2 ACOG also recommended frequent position changes in labor to promote comfort and optimize fetal position.2 AWHONN also issued a position statement that continuous labor support from a registered nurse is essential to optimizing birth outcomes.3 AWHONN recommends that nurses partner with birthing persons to develop a plan of care based on their needs and their desires and expectations for labor and birth.3

Due to the increased acuity of patients, nurses today often have less time to provide the crucial role of labor support.5 Nursing students are well positioned to provide labor support during clinical rotations as they traditionally are paired with one patient and are able to stay with the laboring person throughout their shift, whereas registered nurses often care for multiple patients simultaneously. However, undergraduate nursing students preparing for their first obstetric clinical lack knowledge and confidence in providing labor support.6 Most nursing students have limited exposure to childbirth prior to their first clinical and there is substantial need to give nursing students hands-on training that can help prepare them for this role.

Birth doulas are trained professionals who provide continuous physical, emotional and informational support throughout the birthing process.7 As experts in labor support, birth doulas are qualified to lead students in small group discussions, demonstrations and role plays to prepare them to provide labor support.

Teaching Strategy

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and role playing. The doulas utilized four different stations: introductions, engaging the senses, upright and active, and complications. Each station lasted 25 minutes. The small-group design allowed students to ask questions, interact with one another and with the doulas, practice hands-on techniques and take turns role playing as the birthing pershands-on and student nurse.

The introduction station discussed how to initiate conversation with a birthing person and their companion(s) and how to build rapport. The doulas in this station also shared sample birth plans and introduced topics that students might expect to see on a birth plan. Students then practiced introducing themselves and asking about birth preferences and patient wishes. In the

engaging the senses station, doulas demonstrated hand massage, shared sample words of

affirmation, discussed creating a calm space and water therapy in labor. Students practiced hand massage on one another. In the upright and active station, doulas discussed the importance of position changes during labor and led students through various positions including the use of an exercise ball and bed sheet as tools to help provide comfort and assistance with supportive positioning. Students had the opportunity to role play and practice utilizing these new skills. In the final station, common labor and birth complications were discussed. Doulas used a stretcher to demonstrate patient positioning during an epidural placement and how to support a family during emergent situations, including cesarean birth.

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Paper and pencil surveys were collected before and after the 2-hour learning activity. Students were asked several demographic questions on the pre-survey. They were also asked to evaluate their level of comfort in the labor and delivery setting and their confidence in providing labor support prior to their first clinical. Six Likert type survey questions were included in the pre-survey and seven Likert type questions were in the post-survey. Both surveys were created by the authors. One hundred and two completed pre- and post-surveys were collected. This study was considered exempt by the University of North Carolina Institutional Review Board. All data were de-identified by the first author. Participation in the surveys was voluntary and students were given the opportunity to decline with no impact on their participation grade for the associated course.

Outcomes

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feeling confident or extremely confident to 85%, and; 5) Confidence in providing emotional support to a laboring patient increased from 38% of students feeling confident or extremely confident to 87%.

Nearly all students (98%) were satisfied with the workshop. Among open-ended comments, students reported that they appreciated learning different techniques and having an opportunity for hands-on practice before beginning patient care experiences. Students also appreciated hearing labor and birth stories and experiences from the doulas. Additionally, students reported that it was helpful to see the demonstrations of techniques before trying themselves through role-playing.

Based on student feedback, more hands-on practice and handouts to reference later may be incorporated into future trainings. Doulas also requested more instructions and tools in the future to help prepare for the training and to improve the fidelity of the instruction.

Conclusions

Working in small groups with experienced doulas as facilitators substantially improved students’ confidence and comfort in providing labor support prior to their first obstetric clinical. Utilizing discussions, demonstrations and hands-on practice met the needs of learners, and students responded favorably to the experience. The majority of students had little prior exposure to birthing experiences and the birth doula strategy improved self-efficacy and sense of

preparedness among nursing students. The workshop also served as an opportunity for

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References

1. Bohren, MA, Hofmeyr, GJ, Sakala, C, Fukuzawa, RK, Cuthbert, A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017 July 6; 7: CD003766. doi: 10.1002/14651858.CD003766.pub6.

2. American College of Obstetricians and Gynecologists. Approaches to limit interventions during labor and birth. Committee opinion No. 687. Obstet Gynecol. 2019 Feb; 133(2): 406-408. oi: 10.1097/AOG.0000000000003081.

3. Association of Women’s Health, Obstetric and Neonatal Nurses. Position statement on continuous labor support for every woman. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing. 2018 Jan; 47(1): 73-74.

4. Payant, L, Davies, B, Graham, ID, Peterson, WE, Clinich, J. Nurses’ intentions to

provide continuous labor support to women. J Obstet Gynecol Neonatal Nurs. 2008 July -Aug;37(4): 405-415. doi: 10.1111/j.1552-6909.2008.00257.x.

5. Cunningham, SD, Herrera, C, Udo, IE, Kozhimannil, KB, Barrette, E, Magriples, U, Ickovics, JR. Maternal medical complexity: Impact on prenatal health care spending among women at low risk for cesarean section. Women’s Health Issues. 2017 Sep - Oct; 27(5): 551-558. doi: 10.1016/j.whi.2017.03.003

6. Burgess, A, Morin, L, Shiffer, W. A labor support workshop to improve undergraduate nursing students’ understanding of the importance of high touch in a high-tech world.

Perinat Educ. 2019 July 1; 28(3): 142-150.

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Labor Support Workshop Pre-Survey 1. What is your age: ______

2. How do you describe yourself?

o

Female

o

Male

o

Non-binary

o

Prefer to self-describe: _______________

o

Prefer not to say

3. Have you previously attended a vaginal birth?

o

Yes

o

No

4. If you answered “Yes” to #1, in what context did you attend a birth?

o

As the laboring person.

o

As a doula.

o

As a partner of the laboring person.

o

As a family or friend of the laboring person.

o

Other: ______________________________ 5. Have you previously participated in a doula training?

o

Yes

o

No

6. Have you provided doula care prior to this workshop?

o

Yes

o

No

7. If you answered “Yes” to #6, how many clients have you cared for in birth? (If you have never provided doula care, skip this question.) _______

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For items 9 – 13, please rate your current confidence in your ability to perform the following items (please circle your selection):

9. Introduce yourself and describe your role as a student nurse to your patient: NOT AT ALL

CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 10. Discuss your patient’s preferences for their birth:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 11. Recommend safe and appropriate positions for your patient at various stages of labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 12. Use touch to support your patient in labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 13. Provide emotional support to your patient in labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

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Labor Support Workshop Post-Survey

1. Please rate your overall satisfaction with this workshop:

EXTREMELY DISSATISFIED

DISSATISFIED NEUTRAL SATISFIED EXTREMELY SATISFIED

2. What was most effective about this workshop?

3. What can we improve about the workshop?

4. Please rate your comfort level (or anticipated comfort level) being in the labor and delivery setting after attending this workshop.

EXTREMELY UNCOMFORTABLE

UNCOMFORTABLE NEUTRAL COMFORTABLE EXTREMELY COMFORTABLE

For items 5 – 9, please rate your confidence in your ability to perform the following items after attending this workshop (please circle your selection):

5. Introduce yourself and describe your role as a student nurse to your patient: NOT AT ALL

CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 6. Discuss your patient’s preferences for their birth:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 7. Recommend safe and appropriate positions for your patient at various stages of labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 8. Use touch to support your patient in labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT 9. Provide emotional support to your patient in labor:

NOT AT ALL CONFIDENT

MOSTLY NOT CONFIDENT

NEUTRAL CONFIDENT EXTREMELY

CONFIDENT

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References

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