Research Proposal: Evidence Based Practice for Labor Pain Management

This research proposal outlines a plan to enhance nursing education regarding epidural analgesia in labor and delivery services at the University of Sharjah, College of Medicine. The proposal addresses the significance of effective labor pain management, particularly through epidural analgesia, and identifies a gap in nursing workforce skills. A review of literature highlights the importance of proper epidural analgesia administration and the complications arising from inadequate knowledge. The proposal aims to improve nursing competence and patient outcomes by implementing educational training and performance monitoring, addressing issues such as unintentional intravascular cannulation and the benefits of techniques like programmed intermittent epidural bolus (PIEB). The research identifies limitations in previous studies, including small sample sizes and single-setting data collection, emphasizing the need for further investigation and improved training protocols.

Running head: RESEARCH PROPOSAL
Evidence Based Practice for Labor Pain Management Education for Nurses
Name of Student
Name of University
Author Note

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1Title
Evidence based practice for pain management education for nurses working in the delivery room
for patients with epidural analgesia using HSE change Model
1.1 Brief Description of the Organization
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.
2 The Nature of Change
2.1 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

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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
2.2 Available Knowledge
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:

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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

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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.

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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.

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2.3 Rationale
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,

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& 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.
2.4 Research gap:
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.
2.5 Aims and Objectives
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-

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 Specific: the specific goal of the paper is to involve the nursing workforce and educate
them about the epidural analgesic techniques during delivery.
 Measurable: the success rate of the research will be measured by interventional
monitoring of the workforce by supervisors for the maintenance of safe clinical practice
 Achievable: The research goal can be achieved by involving the by setting up
interventional supervision as well as set up training programs within the nursing
workforce. This can be evaluated by the senior practitioner and professors who aree part
of the university.
 Relevant: The importance of the research is to provide better patient outcome and avoid
prenatal birthing complications due to mishandling and suboptimal labor pain
management
 Timely: The success rate of the proposal and the implementation can be completed
within 37-40 weeks after the commencement of the nursing training.
3. Evaluation
3.1. 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

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take the responsibility to align with the mentioned initiatives of the evaluation program (Fan et
al., 2015).
3.2. 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

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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.
3.3. Evaluation approach
3.3.1. 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.

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Figure 1: Cycle of evaluation process
Source: (Easterby-Smith, Thorpe & Jackson, 2012)
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.

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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.
3.4. Measures
3.4.1. 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.
3.4.2. 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

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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.
3.5. Analysis
3.5.1. 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.

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3.6. Ethical Considerations
3.6.1. 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).
4. Change Management
4.1. HSE Change Model
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

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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.
Fig 2: HSE Change Management Model
Source: (Brookes et al., 2013)
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.

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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.
4.2. Identification of the key stakeholders, their relationship to the organisation and their
role in this project
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

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that will help to identify the most appropriate implementations on the patients while ensuring the
overall growth of the nursing stuffs.
4.3. Anticipation of the potential blocks and obstacles to the change being implemented
There are multiple potential blocks that can be faced during the execution process from
various stakeholders. The potential operational blocks and obstacles are:
 The trainee nurses can convey against this change implementation management and
training program.
 During the execution of the change management lack of equipment and medical materials
of supplier can cause additional distortion.
 The inappropriate scheduling can make unnecessary conflict with availability of trainers
and doctors.
 Sudden absence of supportive care givers and additional staffs can cause unexpected
suspension of the overall workflow (Doppelt, 2017).
 Any emergency condition can induce additional tension within the pre plan change
management framework.
 Any operational discrepancy can cause loss of times which can lead to managerial delay.
5 Limitation
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

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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.

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6 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

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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.
7 Gantt chart
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

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Fig 3: Gantt chart
Source: Author
Evaluation
Implement modification
Analysis of training needs
Data analysis
Data collection
Literature Review
Selection of methods
Identification of problem
0 4 8 12 16 20 24 28 32 36 40Starting time
(week)

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