Pros: Written tests (including both traditional paper and pencil and computerized) 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 nurse’s knowledge base. Regulatory agencies such as the Joint Commission accept this method as evidence that the institution has made an appropriate effort to validate competence.⁵

Cons: Although devising test questions may seem easy, few nurses have been educated in the rigorous process of test 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 test items and the examination as a whole. Without reliability and validity data about items that are used on the written examination, few sound conclusions can be drawn from the examination results. Obtaining such 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. Further degrading this method of competence validation is the unfortunate common practice of reusing the same examination. Although this may be done to conserve resources and time, another possible explanation for repeating the same examination each year is the limited content area of EFM. Test developers are challenged with the limits of incorporating the same, relatively small amount of content into new, meaningful questions. Thus, in many institutions, perinatal nurses find themselves taking the same poorly developed written examination each year, while administrators remain under the impression that these nurses have participated in a meaningful process to validate competence in EFM.

Recommendations: If an 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 clinicians who are experts in the areas of both EFM content and item writing. Items should be pretested before inclusion on the examination and continuously 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, the only EFM examination that meets these criteria is that developed by a team of content experts through the National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC). Eligibility for this examination requires candidates to demonstrate that they are currently working in a clinical practice setting where EFM is used. The test is applicable for multidisciplinary competence validation and may be taken by nurses, physicians, and midwives. Use of the NCC examination can save considerable time for the person in the institution who is responsible for EFM examination development, allowing 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 specific to EFM content are required every 3 years to maintain this NCC credential. There is the implied commitment to maintaining current knowledge of EFM principles by those who are credentialed through the NCC examination process. Thus, this examination evaluates knowledge using a rigorous process and promotes multidisciplinary participation in continuing education programs.

It is important to be circumspect in regard to ascribing to programs offered by individuals and companies who award a “certification” following completion of an examination they have prepared and that includes requirements to take their course and use their book. Not only are psychometric testing factors an issue, there also seems to be an inherent conflict that can affect the quality of the process when an examination is geared to course content. If an institution is committed to utilizing 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 that accuracy in implementing these skills has been observed. Refer to the AWHONN Clinical Competencies and Education Guide: Antepartum and Intrapartum Fetal Heart Monitoring¹ for a list of suggested clinical skills for nurses who use EFM. These can be adapted and revised based on institutional or 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. 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 will accept skills checklists as evidence that the institution has attempted to verify clinical skills for professional nurses.

Cons: Technical skills associated with use of EFM are not overly complex. Once nurses have been observed performing all expected technical skills several times with accuracy, it can be assumed those skills are maintained if the nurse is providing such patient care on a routine basis (unless some evidence arises to suggest otherwise). Nurses who have difficulties with the technical aspects of EFM are usually quickly identified by peers or through clinical situations where their deficiencies become apparent. These situations can be addressed with remediation 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 presents a confounding issue because adherence to unit policies and appropriate nurse-patient interactions are likely to be at the highest level when one is being knowingly observed. Therefore, this method does not provide information about routine nursing interventions when an 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.⁶

Recommendations: Skills checklists are useful for orientation of new nurses only, as a reference to ensure that expected technical skills have been demonstrated by the orientee before primary responsibility for patient care is assigned. Use of skills checklists for experienced nurses should be avoided.

Pros: EFM strip review is a popular method of competence validation because the questions posed are associated with a specific clinical case and a graphic display of the FHR pattern. In many cases, single test items on written examinations provide scarce detail of the clinical scenario related to the question posed. Participants may find this frustrating, and they often try to fill in the missing information on their own. Such assumptions can lead to incorrect responses. Many nurses are visual learners and find it easier to relate to a picture of the FHR pattern, rather than narrative descriptions, when attempting to answer questions regarding appropriate clinical interventions. A case study approach is inherently more interesting to the adult learner because it is closer to his or her daily experiences in the clinical setting. Responses to case study questions are more likely to germinate from critical thinking and interpretation than with single-topic examination items. Thus, information from a case study approach to competence validation is more valuable than scores on written examinations.⁶ Regulatory agencies such as the Joint Commission accept this method as evidence that the institution has made an appropriate effort to validate competence.⁵

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.

The most effective approach to case study is to actively seek participation from physician and nurse midwife colleagues. Any opportunity for collaboration between disciplines jointly responsible for FHR pattern interpretation and clinical interventions should be encouraged. The process of developing and reviewing case studies is an ideal avenue for clarifying ongoing clinical issues and coordinating the interpretation and expectations of provider groups. For example, a physician may expect a series of responses or interventions for specific FHR or uterine activity (UA) pattern that is not in tandem with current nursing practice at the institution. Disagreement about the course of clinical management in the presence of tachysystole as the result of oxytocin administration is a common issue. When the FHR remains reassuring, nurses may still routinely decrease the oxytocin dosage or discontinue the infusion completely, according to their knowledge base or even institutional policy. Physician colleagues may believe the nurses are overreacting by adjusting the oxytocin when the FHR is not yet showing signs of deterioration. An open discussion of the rationale based on physiologic principles, current research, and standards of care may lead to less conflict in the clinical setting.⁷

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 initially recommended by the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop in 1997 and then further defined and updated in 2008.⁸,⁹ These definitions are supported by the American College of Obstetricians and Gynecologists¹⁰ and AWHONN.¹ It is important to adopt a standard set of definitions so that all providers are speaking the same language in both oral communication and written documentation in the medical record.⁵ A clear definition of fetal well-being should guide the majority of unit operations and can be used to simplify communication between nurses and physicians.¹¹ The presence of fetal well-being is the criterion for maternal discharge, maternal medications, and use of oxytocin and epidural anesthesia in most clinical situations. Absence of fetal well-being necessitates direct physician evaluation, with written documentation of further clinical management.¹¹ Coming to agreement on definitions can be a significant outcome of joint development of and participation in EFM case study review. It is possible that interdisciplinary collaboration will have a positive spillover effect on daily clinical operations.⁷