Clinical disagreements during labor and birth: how does real life compare to best practice?

To describe how nurses would respond in common clinical situations involving disagreement with physician colleagues during labor and birth.

An electronic survey, consisting of five clinical disagreement case scenarios along with two open-ended questions regarding how to promote effective interdisciplinary communication and collaboration, was administered via a secure Web site. Seven hundred four obstetric nurses in a mid-size metropolitan area were invited to participate via mail. One hundred thirty-three nurses responded. Data were analyzed using descriptive statistics and thematic analysis of open-ended text responses.

Respondents were primarily aged > or =40, experienced in labor nursing, and held a BSN; 35% were members of the Association of Women's Health, Obstetric and Neonatal Nurses, 35% were certified in electronic fetal monitoring, and 33% were certified in inpatient obstetrics. In all five scenarios, most nurses were aware of current evidence and published standards of care (range 52%-86%). However, there was a wide discrepancy between current evidence/standards and what nurses indicated would occur in actual clinical practice.

In this well-educated and knowledgeable sample of experienced labor nurses, reports of what would occur in clinical practice did not match current evidence or standards of care. Adequate nursing knowledge may not be an accurate predictor of appropriate clinical practice. Confidence in administrative support appears to be one of the key factors in empowering nurses to pursue resolution of disagreements in patients' best interests, whereas medical hierarchy, fear, and intimidation are significant barriers.