Discuss about the Evidence based practice for pain management education for nurses working in the delivery room for patients with epidural analgesia using HSE change Model.
The University of Sharjah, College of Medicine and other allied healthcare, which provides excellence in basic medical sciences, clinical sciences and family and Community medicine as well as behavioral sciences. The University’s mission is to train medical professionals who are educated with the best academics inside an excellent academic environment. The university’s vision is to maintain its position as the leader in the healthcare industry in its care service and make the best out of it healthcare workforce. The university holds fourteen colleges and provides 94 variations of medical courses with wide range of degrees of bachelors, masters as well as higher educational degrees of Doctoral and Diploma. As a part of the healthcare community, the main objective of the University is to develop improved techniques in the labor and delivery care centre. A team of dedicated students, practitioners, professors and researchers work together in unity to attain best possible patient outcome by maintaining the practice of incorporating clinical research.
Nature and significance of the Change
Labor Pain is a very intense form of pain sensation that a woman undergoes while giving birth. This kind of pain occurs due to the muscle contraction in the uterus to push out the neonate. The process pain management, which is effective in labor pain, is called epidural analgesia, which effectively reduces the pain using different techniques like relaxation, distraction, breathing techniques as well as certain administering certain drugs. It is very important to maintain proper management of the labor pain to avoid delivery related complications that might possibly leads to neonate mortality. The pain management is important to prevent pain shock in mother is which is commonly observed. The technique of epidural analgesia in labor pain management is a complicated technique which the nurses do not have proper skills required to administer the analgesia. The complications regarding the proper administration of epidural analgesic is essential to be weighed before providing proper healthcare. The problem with the nursing workforce is that these techniques are not properly practiced. The research proposal aims to formulate a plan, which will include nursing education regarding the epidural analgesic in labor and delivery services. The outcome form the research will provide an insight into the evaluation of the nursing workforce in general. Educational training and performance monitoring is important to assess the efficacy of the care workforce. The general improvement of the care service will impact the
A review of literature provides the opportunity to the researcher to explore and analyses the literature published before and the research work that has already been attempted in the topic of the study. In this case the research proposal utilizes the review of literature as a means to evaluate the existing knowledge regarding the topic and the research gap that has been left behind.
Epidural analgesia:
Labor pain can be considered one of the most crucial sensation of the pain that the pain that the women during child birth suffer with, and hence the need for facultative and extensive pain management is imperative. However, among the different pain management methods those are generally employed in the delivery room is epidural analgesia. According to Liu, Chang and Chen (2010), the women that are in the process of labor are going through a variety of different kinds of pain, the severity of the pain depends on both physiological and psychological factors such as stress, anxiety, previous experience and the emotional support that the women receive. Hence, that is the reason why the nursing individuals need to have a clear understanding of the exact pain management technique to apply when handling the women with labor pain.
According to the article by Rashid, Tariq and Moeen (2012), one of the most frequently utilized pain management techniques that are used in the management of pain in the labor rooms is the opioids, however there are great complications associated with the use of this particular pain medication technique. Hence, instead of the fast and direct results, the concept of epidural analgesia is far more increasingly adapted in the labor pain management, according to the author of the articles, the use of epidural analgesia helps in better pain management effectively. However, the nurses lack extensive knowledge regarding the usability and relevance of epidural analgesia, how to utilize it and when to utilize it.
Another relevant article by Barakzai et al. (2010) directed at the fact that for the most of the women going through labor experience pain that is equivalent to the severe complex regional pain syndrome or the pain experienced by the amputation of a finger. Hence it is crucial that the nurses handling a particular woman with excruciating labor management to know how to manage the pain the pain immediately and optimally. Epidural analgesia comprises of a combination of two different analgesics, a local anesthetic agent (such as the lidocaine or bupivacaine) and an opioid analgesic agent (morphine or fentanyl) . The analgesic action involves the chemical acting on the spinal nerve routes, spinal cord and para-vertebral nerves. According to the Pitkänen et al. (2013), the epidural analgesia uses a very complex administration method involving direct injection into the lumbar epidural space. It is very crucial for the injection to be pushed in the right manner to the right place for the injection to diffuse across the dura and reach the subarachnoid space where it can reach the spinal nerve routes.
According to Leo et al. (2010), the successful injection of the epidural analgesia produces a segmental sympathetic and sensory nerve block and also acts on decreasing the endogenous catecholamine concentration. As explained by the authors, the culmination of these activities in exact order facilitates the onset of pain relief. Any mistake or error in the procedure that disrupts the cycle and can lead to severe complications in the patients.
As supported by the Rashid, Tariq and Moeen (2012), the complications associated with the epidural analgesia can lead to severe and in certain cases even fatal consequences in the delivery room. And according to the most of the research, it has been discovered that the lack of knowledge and expertise in the nursing professionals regarding how and where to inject the epidural analgesia leads to the most of the complications. According to the Szabo (2013), intrapartum analgesia, whether it is epidural or nueraxial, the lack of knowledge among the nurses or care professionals in general, leads to fatal consequences for the patients and prolonged and acute pain after labor. According to the Gambling et al. (2013), the lack of proper knowledge regarding the evidence based practice on how to implement the epidural analgesia as also results into post partum complications such as infection, bleeding or hemorrhage, spinal deformity, high block, postdural Puncture Headache, and even neuromuscular or central nervous system diseases. Hence according to the authors there is need for extensive knowledge and understanding of the nurses regarding this procedure and how to safely perform it.
As per the survey study by the Pitkänen et al. (2013), the nurses suffer from an acute low knowledge regarding the use of epidural analgesia, although, the clinical experience of the nursing professionals has provided them with positive attitudes and practices regarding the use of the analgesia, the lack of training has been unable to fill the gap. On a more elaborative note, the study discovered that only 54% of the respondents of the study had been given a proper training on the process of epidural analgesia and proper management of it. As a result, this data unravels key indicators of the low competence and low confidence in the nursing workforce in performing and managing epidural analgesia with safety and optimal effectiveness.
A new research has shown that “programmed intermittent epidural bolus” (PIEB) is a new technique, which will reduce the effect of risks associated with epidural labor anesthesia. The researchers showed that in comparison to the continuous epidural infusion (CEI), the PIEB has better advantage and provides better sensory blockage in the pain management during labor. The process requires proper education to the healthcare workforce about the complications that accompany techniques in the patient controlled epidural analgesia (Kanczuk et al., 2017). It has observed in many clinical research papers that the maternal satisfaction can be achieved with PIEB more quickly than CEI, by locally administering the anesthesia and preventing the complications associated with vaginal delivery of the neonate. The administration of the bolus and the generation of pressure during labor are important to be kept in mind in the delivery room.
Epidural analgesia is the most important form of pain management method requested by laboring women more than fifty percent of the time. It is a very effective method to reduce the labor pain, but there are certain complications that the nurses need to avoid (Fang Ding & Song, 2016). The process causes the elevation of blood pressures, which can create oxygen deficiency during delivery. It has been pointed out by the research group lead by An et al., showed that mishandling of the epidural anesthesia may cause spinal fluid leakage, which creates further complications in the delivery room (An et al., 2016). Epidural analgesia makes it difficult for mothers in labor to push the baby out from the uterus, which is an important point to consider when providing nurses the training and education. There have also been evidence-based instances where the mishandling of epidural analgesic has caused complication in the neonates as well. The complications include respiratory complications when mothers experience delayed delivery, wrong positioning of the fetus also is induced by mishandling by nurses in epidural analgesics (Cravero, 2017). The nurses need to be aware of these consequences to provide better health care. The research published in Elsevier Health Sciences, have shown that nursing staff must be trained to understand the effects of these techniques and reduce the complications. According to a recent research, the nursing interventions for education as effectively improved the quality of care in a healthcare setting (Butcher et al., 2018). The nursing education will improve the competence of the nurses while administering the injection more clearly. The phenomenon of unintentional intravascular cannulation, which needs to be taught to the nurses with constant supervision to maintain the technique. Many researchers have shown that for administering the anesthesia injection the knowledge for proper region of injection, or neural-axial anesthesia is important in terms of nursing competence and experience (Perlas, Chaparro, & Chin, 2016). A research showed that interventional administration of catheter-based techniques in epidural analgesia in labor pain management can provide improved patient outcome. The researchers conducted a randomized controlled trail to evaluated the efficacy of these wire mediated epidural analgesia catheters. The secondary outcomes of the research was to contemplate the number of supervisors required to perform the task individually (Philip et al., 2018). The researchers did not find any significant variation in their results when they compared the results odd multiport or uniport based catheters.
The research has been identified in the paper, that the extent of knowledge regarding the epidural analgesia among the nurses could not be determined in the research. The sample size was small which a drawback in the research is. The research was carried out in a single setting which is a drawback since there can be less or negligible transfer of data of the findings. The comparisons cannot be drawn regarding the standards of knowledge among nurses in other facilities of the region.
The aim of the research proposal provides the platform to achieve the goals set for the research. In this paper the aim is to formulate techniques that would provide patient care centered education in nursing staff regarding the pain management of labor or delivery patient using evidence based practice, which would ensure that the prenatal malpractice is reduced and the patient as well their family receives best possible health outcome.
The objectives of the proposal is as follows-
Context
Every change management system requires proper evaluation in order to assess the efficiency of the training program introduced. It also included evaluation of performance of the nursing professionals who are undertaking the training sessions. The evaluation initiatives should be such that it would help to compare the set of goals and objectives of the training procedures and how well the initiatives that had been implemented to align with the goals and objectives of the training program. Therefore, these three objectives should be developed for the evaluation programs. Accordingly, the evaluation committee will be established with members who would take the responsibility to align with the mentioned initiatives of the evaluation program (Fan et al., 2015).
Specifics of the proposed team involved in the work
The evaluation committee would incorporate two individuals from the administrative department who would be mainly helping to meet the first objective that is assessing the efficiency of the training program as a whole. The two individuals would be mainly evaluating the cost effectiveness of the training program to find out how well the training sessions ad taken place within the budgeted fixed for training and whether further flow of finance is required or not. The committee would also comprise of four to five healthcare experts who are stalwarts in the field of gynecologist nursing. They would be taking open-ended surveys of nursing professionals to understand their perception about the efficiency of trainers. Another important meeting would be taken of the trainers to understand how the nurses are fairing in the training sessions under the trainers (Oermann & Gaberson, 2016). These would help to develop the knowledge of the quality of both the stakeholders who are engaged in the training sessions. Also three other specialists will be allocated who would be undertaking observations about how the nurses are conducting the pain management sessions of the pregnant patients by watching them in the practical sessions in the wards. The reports will be prepared based on the information that is gathered from both the department. On the reports developed by the first department about the cost effectiveness of the training sessions as well as the quality of the training sessions, developed the third department will mainly help in finding out how much the training has successfully aligned with the mission and vision of the training sessions. The training committee would be conducting meeting sessions where the heads of the departments participating as committee members would be coming together on the particular day (Al-Kloub et al., 2015). All the data collected by the three important departments would be put together as a presentation so that all the members if the committee can develop an idea about how the project is moving. Such meetings are often required as effective communication of the results helps each other to develop an overall idea about the whether the training programs is bring any benefits in the performance of the nurses and helping them to develop their skills and knowledge (Kelly et al., 2016). This would be helping to develop an idea that all initiatives are resulting in the best outcomes or something needs to be changed for the betterment of the training sessions.
Proposed approach/model or framework of evaluation
In order to evaluate the organizational change and implement the modified plan within the current organizational practice the selection of proper evaluation plan is highly required. To evaluate the process of training and development plan and collect appropriate evidences to identify further potential modification the evaluation will follow the Cyclic Evaluation Process. The cycle of this evaluation process will include various activities involving the stakeholders, developing the change management program, execute the change management model, elimination of opposing barriers, gather credible evidence, and identify required changes and focusing the next evaluation process. All of these segments of evaluation plan should have their attainability or utility feasibility, propriety and accuracy. These are the major constrains to make a successful evaluation process. To identify the impact of this multiple parts of evaluation process analysis of each phase of evaluation are needed.
Engaging Stakeholder: All the trainee nurses, caregivers, equipment suppliers, teachers, senior doctors and patients are the major stakeholders of these operational changes of University of Sharjah, College of Medicine. To justify the role of each stakeholder multiple meeting will be arranged initializing the change management practice on pain management education for nurses of delivery room.
Developing the program: Development and planning of this program will require identification of different educational needs of the nurses. The planning will be executed with the help of responsible stakeholders.
Execution of the program: Scheduling and monitoring the efficiency of the plan are the basic criteria of the execution process. Implementation the plan as per the practical situation will be the major concerns.
Gather credible feedbacks: After the execution part a data collection process will be conducted in order to gather the feedbacks from educators, nurses and patients about their experience and further scope of learning and requirements (Gerbec, 2017).
Identify the requirements for changes: After collecting the feedbacks the report will be analyzed to identify further scope of the change management program.
Proposed tools chosen for studying the processes and outcome of the change
The method of implementing the change within this specific work process will need some effective tools. These tools will help to collect data and information about the executed changes and their outcomes. For this purpose both open ended and close ended questions are need for educators, trainees and patients. For open ended data collection the interviews will be conducted on educators and nurse (Antwi & Kale, 2014). On the other hand, the survey will be conducted on the stakeholder patients. The open ended questions will help to identify the situational obstacles faced by the doctors and nurses at the process of execution. On the other hand the close ended survey will help to monitor the success rate of the implementation process.
Proposed methods employed for assessing completeness and accuracy of data
For this research identification of effective research method is one of the most essential concerns. For this research the positivism philosophy will be followed. As per the realism philosophy the research will need practical implementation of the research process with valuable interpretation of outcomes. In this current case study the most effective research design will be the descriptive research design. With descriptive research design will allow the research to conduct both qualitative and quantitative data collection on a sample. This method is also called mixed method approach where both qualitative and quantitative data and information will be collected. This research will focus on the primary data collection. In primary data collection the outcomes of these operational changes can be measured from both numerical and informational perspective.
Proposed qualitative and quantitative methods to develop findings from the data
For this research both qualitative and quantitative data analysis will be applied. The total sample size will be 50, where 10 trainers and doctors, 20 patients and 20 nurses are participating. For qualitative analysis the collected information from interview sessions will be analyzed with suitable interpretation technique (Holloway & Galvin, 2016). On the other hand, the survey report collected as per the response of patients will be analyzed with various numerical and mathematical process. This mathematical analysis of collected numerical data is referred as quantitative analysis. Documentation after each data analysis is one of the major criteria for this research. This documentation will help to find future scope of development and potential alteration in existing change management program.
Perceived ethical aspects of implementing the change and how you propose they will be addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest
The ethical consideration is highly significant part for ensuring the substantiation and credibility of the conducted research. The proposed methods and researchers will perform all the ethical considerations that will help to eliminate any ethical issues during the conduction of the research methods. The research will be conducted according to the regulation and authentic approval collected from the ethical committee (Offredy & Vickers, 2013). By conserving Data protection act, this research will ensure that all collected personal and professional data will be kept confidential, instead of using those data and information in any other purposes. On the other hand, the individual consent forms will be collected from patients, nurses and doctors to ensure that no one will be forced to participate in the research work. The stakeholder team will also collect the authentication certificate that will ensure none of this research method has negative impact on patient’s physiological and psychological health (Abdelhak, Grostick, & Hanken, 2014).
The HSE change management model has been developed to implement the required changes within the healthcare organization with the help of heath care staffs, doctors and nurses. This change model can help to improve the overall treatment procedure of any healthcare organization. HSE is unique change management models where the components of changes are independently interact with each others. In this change management process group work is an important criterion (Hayes, 2014). To improve the team working this model follows preparation phase, early development phase and team development phase.
The starting section of this HSE change management plan is Initiation. In this stage all the trainee nurses, caregivers, equipment suppliers, teachers, senior doctors and patients will be informed about these operational changes of University of Sharjah, College of Medicine. This initiation section is connected with planning and mainstreaming (Verhulst, & Lambrechts, 2015). In planning stage Building commitment within the stakeholders, determining the ideal changes regarding pain management and development of the implementation plan are the main concerns. Development and planning of this program will require, identification of different educational needs of the nurses. The planning will be executed with the help of responsible stakeholders. Before the mainstreaming the most significant part is implementation. Scheduling and monitoring the efficiency of the plan are the basic criteria of the execution process. In this context, implementation of the plan as per the practical situation will be the major concerns. Mainstreaming is related with the learning and evaluation part and identification of future scopes. After collecting the feedbacks the report will be analyzed to identify further scope of the change management program.
The major stakeholders of these operational changes of University of Sharjah, College of Medicine are all the trainee nurses, caregivers, equipment suppliers, teachers, senior doctors and patients. The stakeholder committee would consist of two individuals from the administrative department who would be committed to help the operational stakeholders to meet the efficiency of the training program. Other two stakeholder groups would be committed to estimate and calculate the cost effectiveness of this training program concerning the fixed budgeted for training and development and evaluation process. The committee will consist of five financial and healthcare experts who have enough experience to estimate the financial model for this research.
On the other hand another group of healthcare experts would be responsible for taking open-ended surveys of nursing professionals to understand their perception about the efficiency of trainers. This committee would have the responsibility to identify and eliminate the potential and operational obstacles. All of these stakeholders will be requested to conduct several meetings that will help to identify the most appropriate implementations on the patients while ensuring the overall growth of the nursing stuffs.
There are multiple potential blocks that can be faced during the execution process from various stakeholders. The potential operational blocks and obstacles are:
Any research study is associated with number of key limitations or obstacles that provides a set of complication to derail the progress of the study. For this research study as well, there are a few key complications and limitations that can serve as potential roadblocks in the oath of achieving the key outcomes of the scenario. First and foremost, it has to be mentioned that this research study will require a considerable amount of time in order to able to complete the interview survey, incorporate the training and educational plan and then judge the impact of the training in the practice scenario, hence it can be mentioned that time constraint will be a significant limitation or constraint of the study. Along with that, it has to be mentioned that the financial constraint can also be considered as a significant limitation of the study.
Along with that, the study will focus on different survey interviews and hence the information or feedback generated as a considerable part of data can be self modified and depends highly on the perception of the different individuals involves with the procedure. Hence the possibility of the data being biased can be considered high, which can serve as a limitation to the reliability and authenticity of the research study. The level of education that the majority of the data will be based on interviewing the nursing individuals and the patient will be subjected to the issue of breaching the privacy and confidentiality of both the patents and the nursing individuals, hence the accessibility of data and level of participation and follow can serve to be limitations in this scenario.
Lastly, it has to be mentioned that the research is going to be a time taking [procedure and the percentage of initial participation and the percentage of participants agreeing to follow up can be an issue in the follow up scenario as well. Lastly the sample size of the study is small which can be a considerable limitation in enhancing the generalization and transferability of the study. Hence, these are a few key obstacles that can serve to be excruciating challenges with the threat to negatively impact the success or outcome of the research study.
Conclusions:
On a concluding note, it has to be mentioned that labor pain attests to be most excruciating pain experienced by the women during childbirth and hence the need for proper pain management techniques in the nursing workforce handling the mothers during childbirth is profound. There are various different complications associated with ineffective or unsafe administration of epidural analgesia which can affect even the duration of labor and can lead to fatal consequences for the mother and the child. It has been mentioned that most of the evidence focusing on non pharmacological intervention for labor pain management only indicated at one or two studies and hence the findings are not definitive for assisting the impact of the pain management procedure. Hence the only clinically reasonable and evidence supported measure for pain management in labor room are pharmacological techniques involving different analgesics. However the most common and frequently used analgesic method for labor room pain management is the administration of epidural analgesia which combines the benefits of a local anesthesia accompanied by opioid based analgesic to provide a nervous system block. This is a far more effective pain management technique than regular anesthetic procedures and hence it has developed as the most trusted anesthetic procedure used by the healthcare professionals. However as discussed by the research, epidural analgesia is a complex procedure and there is need for extensive knowledge and expertise while performing it to ensure avoiding any complications. As discussed by the literature review there is extensive lack of knowledge and training in the nursing workforce regarding the safe and effective method to perform epidural analgesia and its proper management. Hence this research has attempted to explore the existent knowledge regarding epidural analgesia in the selected target nursing population of the organization and implementation of HSE change model to enhance the knowledge and expertise in the nursing workforce by the help of a training procedure. The results of the research were based on the improvement facilitated in the performance of the participant nurses with regards to administering epidural analgesia and proper management of it. This research could identify that proper training and skill enhancement can improve the knowledge among the nursing workforce and can help in reducing the frequency of post operative and post anesthetic complications with regards to administration of epidural analgesia. And hence it can be concluded that the findings of the study will provide a fertile ground for further research to focus on how to implement different training procedures in the academic degree of the maternity nurses to enhance their knowledge and expertise of performing and managing epidural analgesia administration with optimal safety and effectiveness.
|
Activity |
Starting time (week) |
Duration (week) |
|
Identification of problem |
1 |
2 |
|
Selection of methods |
2 |
3 |
|
Literature Review |
6 |
3 |
|
Data collection |
8 |
5 |
|
Data analysis |
12 |
3 |
|
Analysis of training needs |
16 |
3 |
|
Implement modification |
20 |
6 |
|
Evaluation |
27 |
12 |
References
Abdelhak, M., Grostick, S., & Hanken, M. A. (2014). Health Information-E-Book: Management of a Strategic Resource. Elsevier Health Sciences.
Al-Kloub, M. I., Salameh, T. N., & Froelicher, E. S. (2014). Nursing students evaluation of problem based learning and the impact of culture on the learning process and outcomes: A pilot project. Nurse education in practice, 14(2), 142-147.
An, X., Wu, S., He, F., Li, C., & Fang, X. (2016). Spontaneous intracranial hypotension following epidural anesthesia: a case report. Acta Anaesthesiologica Scandinavica, 60(5), 677-681.
Antwi, M., & Kale, M. (2014). Change Management in Healthcare. Kingston, ON: The Monieson Centre for Business Research in Healthcare, Queen’s University School of Business.
Barakzai, A., Haider, G., Yousuf, F., Haider, A., & Muhammad, N. (2010). Awareness of women regarding analgesia during labour. Journal of Ayub Medical College, Abbottabad: JAMC, 22(1), 73-75.
Bos, E. M., Hollmann, M. W., & Lirk, P. (2017). Safety and efficacy of epidural analgesia. Current Opinion in Anesthesiology, 30(6), 736-742.
Brookes, K., Limbert, C., Deacy, C., O’Reilly, A., Scott, S., & Thirlaway, K. (2013). Systematic review: work-related stress and the HSE management standards. Occupational medicine, 63(7), 463-472.
Cravero, J. P. (2017). Fetal Surgery. In Pediatric Anesthesiology Review (pp. 169-176). Springer, Cham.
Doppelt, B. (2017). Leading change toward sustainability: A change-management guide for business, government and civil society. Routledge.
Easterby-Smith, M., Thorpe, R., & Jackson, P. R. (2012). Management research. Sage.
Fan, J. Y., Wang, Y. H., Chao, L. F., Jane, S. W., & Hsu, L. L. (2015). Performance evaluation of nursing students following competency-based education. Nurse education today, 35(1), 97-103.
Fang, G., Ding, Z., & Song, Z. (2016). Comparison of the effects of epidural anesthesia and local anesthesia in lumbar transforaminal endoscopic surgery. Pain physician, 19(7), E1001-4.
Gambling, D., Berkowitz, J., Farrell, T. R., Pue, A., & Shay, D. (2013). A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during first and second stages of labor and at delivery. Anesthesia & Analgesia, 116(3), 636-643.
Gerbec, M. (2017). Safety change management–A new method for integrated management of organizational and technical changes. Safety Science, 100, 225-234.
Hayes, J. (2014). The theory and practice of change management. Palgrave Macmillan.
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare. John Wiley & Sons.
Kanczuk, M. E., Barrett, N. M., Arzola, C., Downey, K., Xiang, Y. Y., & Carvalho, J. C. (2017). Programmed intermittent epidural bolus for labor analgesia during first stage of labor: a biased-coin up-and-down sequential allocation trial to determine the optimum interval time between boluses of a fixed volume of 10 ml of bupivacaine 0.0625% with fentanyl 2 μg/mL. Anesthesia & Analgesia, 124(2), 537-541.
Kelly, M. A., Berragan, E., Husebø, S. E., & Orr, F. (2016). Simulation in nursing education—International perspectives and contemporary scope of practice. Journal of Nursing Scholarship, 48(3), 312-321.
Leo, S., Ocampo, C. E., Lim, Y., & Sia, A. T. (2010). A randomized comparison of automated intermittent mandatory boluses with a basal infusion in combination with patient-controlled epidural analgesia for labor and delivery. International journal of obstetric anesthesia, 19(4), 357-364.
Liu, Y. H., Chang, M. Y., & Chen, C. H. (2010). Effects of music therapy on labour pain and anxiety in Taiwanese first?time mothers. Journal of clinical nursing, 19(7?8), 1065-1072.
Melnyk, B. M., Gallagher?Ford, L., Long, L. E., & Fineout?Overholt, E. (2014). The establishment of evidence?based practice competencies for practicing registered nurses and advanced practice nurses in real?world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence?Based Nursing, 11(1), 5-15.
Oermann, M. H., & Gaberson, K. B. (2016). Evaluation and testing in nursing education. Springer Publishing Company.
Offredy, M., & Vickers, P. (2013). Developing a healthcare research proposal: An interactive student guide. John Wiley & Sons.
Perlas, A., Chaparro, L. E., & Chin, K. J. (2016). Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Regional anesthesia and pain medicine, 41(2), 251-260.
Pitkänen, M. T., Aromaa, U., Cozanitis, D. A., & Förster, J. G. (2013). Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiologica Scandinavica, 57(5), 553-564.
Rashid, S., Tariq, S., & Moeen, G. (2012). Epidural Analgesia in Labour. Annals of King Edward Medical University, 18(1), 58-58.
Szabo, A. L. (2013). Intrapartum neuraxial analgesia and breastfeeding outcomes: limitations of current knowledge. Anesthesia & Analgesia, 116(2), 399-405.
Verhulst, E., & Lambrechts, W. (2015). Fostering the incorporation of sustainable development in higher education. Lessons learned from a change management perspective. Journal of Cleaner Production, 106, 189-204.
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