Pros: Written tests about EFM content are relatively easy to develop and can be administered to many nurses in a short time frame. Knowledge about key principles of fetal heart rate (FHR)
pattern interpretation, physiology, and appropriate nursing interventions can be evaluated by the use of multiple choice, fill-in-the-blank, and matching items. Most of the basic concepts can be covered in 25 to 50 test questions. Examination scoring can be accomplished easily and quickly. A minimum score can be established, and those who achieve the minimum passing score can be designated as possessing the minimum knowledge about EFM required for clinical practice. Written examination appears, at least on the surface, to provide objective data about the nurses’ knowledge base. Regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accept this method as evidence that the institution has made an appropriate effort to validate competence (JCAHO, 2004).

Cons: Although writing test questions can seem to be easy, few nurses have been educated in the rigorous process of item writing and examination development. Production of a psychometrically sound examination requires that those writing items are familiar with the process and have significant practice and experience in analyzing individual items and the examination as a whole. Without reliability and validity data about items that are used on the written examination, few conclusions can be drawn from the examination results. Obtaining reliability and validity data through the use of psychometric techniques is costly, time consuming, and beyond the scope of expertise of most nurses who develop EFM examinations in the institutional setting. Use of a poorly developed written examination as a method to validate competence can provide a false sense of assurance to the institution that the nurses who have achieved a passing score are indeed competent to provide intrapartum nursing care. A common practice is to use the same 25- to 50-item EFM examination every year. Although this may be done to conserve resources and time, another possible explanation for using the same examination each year is the limited content area of EFM. Test developers are challenged with the issue of how many ways can the same content be incorporated into a meaningful question. Thus, many perinatal nurses find themselves taking the same poorly developed written examination each year, and administrators in many institutions are led to believe that the nurses who care for women in labor have participated in a meaningful process to validate competence in EFM.

Recommendations: If the institution chooses written examination as the preferred method for evaluation of requisite knowledge of EFM, the best approach is to use an examination that has been shown to be psychometrically sound and legally defensible. There should be reliability and validity data for individual items and the examination as a whole. The examination should be developed by nurses who are experts in both EFM content and item writing. Items should be pretested before inclusion on the examination and continually evaluated after each examination administration. A rigorous approach to examination development should provide assurance that the successful candidate does possess appropriate level and depth of knowledge in EFM content. At present, there is only one examination about EFM content that meets these criteria: The EFM examination developed by a team of content experts through the National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC). Candidates for this examination are required to demonstrate that they are currently working in a clinical practice setting where EFM is used, but no longer have to hold one of the core NCC certifications in a specialty area of practice. Use of the NCC examination can save considerable time for the person who has been traditionally responsible for EFM examination development and allow them to pursue more valuable educational objectives. One of the added benefits of choosing NCC is the requirement for continuing education that is part of the maintenance process. Fifteen contact hours in EFM content are required every 3 years to maintain the NCC credential. There is the implied commitment to maintaining a current knowledge of EFM principles by nurses who are credentialed through the NCC examination process. Thus, this examination both evaluates knowledge using a rigorous process and promotes participation in continuing education programs. The NCC exam also is being used by many hospitals throughout the United States to validate the competency of nurse midwives, residents, and attending physicians.

Be especially wary of individuals and companies offering “certification” programs that include requirements to take their course and use their
book before sitting for the examination. Not only are psychometric testing factors an issue, there also seems to be an inherent conflict that can affect quality of the process when the examination is geared to the course content. If the institution is committed to written examination, the best use of financial resources is to participate in an examination developed and supported by a national organization with expertise in the examination process.

Pros: Skills checklists are an excellent method of ensuring that all expected skills are covered during the orientation process and accuracy in implementing these skills has been observed. Refer to the AWHONN Clinical Competencies and Education Guide: Antepartum and Intrapartum Fetal Heart Monitoring (AWHONN, 2006) for a list of suggested clinical skills for nurses who use EFM. They can be adapted and revised based on unit practices. Comprehensive well-developed skills checklists serve as a reference to guide the preceptor during orientation and provide the orientee with a defined set of clinical expectations for the labor and birth unit. Direct observation of accurate implementation of the designated technical skills should be criteria for completion of orientation and assumption of primary responsibility for patient care. Regulatory agencies such as JCAHO accept skills checklists as evidence that the institution has attempted to verify clinical skills for professional nurses (JCAHO, 2006).

Cons: Technical skills associated with use of EFM are not complex. Once nurses have been observed performing all expected technical skills several times with accuracy during orientation, it can be assumed they maintain those skills if they are providing patient care on a routine basis unless there is evidence to suggest otherwise. Nurses who have difficulties with technical aspects of EFM are usually quickly identified by peers or through clinical situations where their deficiencies are apparent. These situations can be addressed with strategies designed for the individual nurse.

Verification of skills for experienced nurses should focus on consistency rather than a baseline evaluation. Use of skills checklists for annual clinical skills verification for experienced perinatal nurses are not helpful in truly assessing whether the nurse consistently applies technical expertise to every clinical interaction. Observer bias is a confounding issue. When an experienced nurse is observed during clinical skills implementation, more likely than not, the nurse will be on his or her “best behavior.” Adherence to unit policies, sterile technique, and appropriate nurse-patient interactions is likely to be at the highest level when another nurse is directly observing clinical behavior. This method does not provide information about routine nursing interventions when the observer/evaluator is not present. Use of skills checklists for experienced nurses provides a false sense of assurance that the nurse under observation gives technically competent care on a routine basis (Simpson, 1998).

Recommendations: Use skills checklists for orientation of new nurses only as a reference to ensure that expected technical skills have been covered and directly observed by the preceptor before assuming primary responsibility for patient care. Avoid use of skills checklists for experienced nurses.

Pros: EFM strip reviews are popular methods of competence validation because the questions are associated with a specific clinical case and a graphic display of the FHR pattern. In most cases, single items on written examinations provide little information about the clinical situation related to the topic being tested. Participants may assume more about the case than is contained in the question, which can lead to an incorrect response or frustration. Many nurses are visual learners and find it easier to relate to a picture of the FHR rather than narrative descriptions when attempting to answer questions about appropriate clinical interventions. Case studies with EFM strips are more interesting and closer to daily reality in the clinical setting than a series of single-topic examination items. Responses to case study questions are more likely to result from critical thinking and interpretation than single-topic examination items. Thus, information from a case study approach to competence validation is more valuable than scores on written examinations (Simpson, 1998). Regulatory agencies such as JCAHO accept this method as evidence that the institution has
made an appropriate effort to validate competence (JCAHO, 2004).

An additional benefit of using case studies with EFM strips is the knowledge gained by those who participate in the development process. A committee of staff nurse volunteers can be recruited to develop case studies from interesting strips of actual patients. A group process can be used to review the expected responses, appropriate interpretations, and related interventions. This discussion can lead to an increased knowledge of EFM principles for all involved. Not all participants need be nurse experts with many years of clinical experience. A willingness to volunteer can be the criterion for participation. This is an excellent opportunity to mentor nurses with less experience and develop collegial relationships between unit members.

The best approach, if at all possible, is to actively seek participation from physician colleagues in the case study development process. Any opportunity for collaboration between nurses and physicians who jointly are responsible for FHR pattern interpretation and clinical interventions should be seen as a positive step toward collaboration in everyday clinical interactions. Working with physicians on developing case studies is the ideal avenue for clarifying ongoing clinical issues where interpretation and expectations of both provider groups are not in sync. Physicians may expect a series of nursing interventions for a specific FHR pattern that are not the routine of many nurses on the unit. For example, there may be clinical disagreement about what to do when uterine hyperstimulation is the result of oxytocin administration but the FHR remains reassuring. Nurses may routinely decrease the oxytocin dosage or discontinue the infusion completely, whereas physician colleagues believe the nurses are overreacting. An open discussion of the rationale based on physiologic principles and standards of care may lead to less conflict in the clinical setting (Simpson, James, & Knox, 2006).

Another common area of disagreement is description of FHR patterns. Development of case studies and accurate responses can lead to a common understanding of FHR pattern nomenclature that is mutually agreed upon and routinely used by all providers. If not already in place, this is an opportunity to suggest adoption of a common set of definitions for FHR pattern interpretation and medical record documentation recommended by the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop (NICHD, 1997). These definitions are supported by the American College of Obstetricians and Gynecologists (ACOG; 2005) and AWHONN (2005)

Stay updated, free articles. Join our Telegram channel

Join