Amazing Things Happen When Student Nurses Are Given Birth Doula Training

Abstract

At the Duke University School of Nursing, accelerated BSN students participate in a free Doulas of North America birth doula training to learn support of prenatal, intrapartum, and postpartum women and their families. They learn to participate as team members providing continuous physical and emotional support to women in the perinatal period and to appreciate how hormones support physiologic labor and birth. This training complements classroom information and clinical experiences.

Introduction

The subject of nurses and doulas working well on a team has been explored in conference presentations and birth literature. Results from a survey sent to birth doulas and labor and delivery nurses found that the most important thing each wanted from the other was respect (Ballen & Fulcher, 2006). Some doulas felt that nurses didn’t understand the value of their training and their tools. Some nurses felt that doulas sometimes overstepped their boundaries and interfered with interventions that were deemed necessary. This need for team collaboration was one of the reasons for training nursing students as birth doulas.

Birth Doula Training at Duke University School of Nursing

At Duke University School of Nursing (DUSON), all accelerated BSN (ABSN) students were invited to participate in a free Doulas of North America (DONA) birth doula training to learn support of prenatal, intrapartum, and postpartum women and their families. As part of the training, they learn to participate as team members providing continuous physical and emotional support to women in the perinatal period and to appreciate how hormones support physiologic labor and birth. These techniques will serve them as they work with clients in any area of the maternity setting.

This started in August 2013, when Barbara Hotelling, coauthor of this article, became a clinical nurse educator at DUSON and new students entering that fall asked if she would train them as (DONA) birth doulas. DUSON provided the handouts, and faculty in the Center for Nursing Discovery (CND) provided classroom space that included hospital beds, manikins, and other niceties of a simulation lab. The basic cost to students was time (16 hours) and the purchase of a required book—The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions by Penny Simkin. The collaboration taking place to make Doula training a reality at DUSON has been an overall wonderful experience for the ABSN students.

With each new semester, the same request has been made and over the course of six semesters, 123 Duke nursing students have been trained in seven workshops. The number of participants has increased each semester and trainings have had to be split into two groups to accommodate all who were interested. Faculty and staff are invited to participate and three individuals attended the trainings thus far. Those who want to pursue DONA certification have the opportunity to take the two additional required trainings. As a Lamaze Certified Childbirth Educator and an International Board-Certified Lactation Consultant, Hotelling provided the 3-hour breastfeeding curriculum and the 7-hour childbirth education information they would need for certification.

To track how students are benefiting from doula training, each participant is sent a short evaluation survey via e-mail after completion of the training. The response has been overwhelmingly positive, and students truly feel this training is worthwhile. The survey results combined with the increasing number of students requesting to receive doula training each semester is a strong indication that individuals don’t have to be destined for the maternal–child health setting to utilize doula training. Doula training is a skill set that nursing students are eager to add to their toolbox as they go forth in their RN career.

Duke University is not the first school of nursing to provide birth doula training for nursing students. At Johns Hopkins, the Birth Companions Program was started in 1997 and developed by faculty member Marion Dolloff (Paterno, Van Zandt, Murphy, & Jordan, 2012). Nursing students wanted to provide free, continuous labor support to low-income women in East Baltimore (Paterno et al., 2012, p. 28). Faculty members offered training. “The initial birth companion program focused on labor support for young mothers—those with special language, cultural, or education needs—and poor, single women with uncertain plans for labor support” (Jordan, VanZandt, & Oseroff, 2001, p. 89).

At Duke University School of Nursing, all accelerated BSN students were invited to participate in a free Doulas of North America birth doula training to learn support of prenatal, intrapartum, and postpartum women and their families.

In 1998, the training at Johns Hopkins became a two-credit elective course taught by a certified DONA trainer and included theories of both maternal and community health nursing. This service-learning program provided birth doulas for 405 births by 379 students between 1998 and 2006. Students in the program learn about postpartum health, infant care, and breastfeeding. Students learn to use nursing skills of communication with providers and nurses about a mother’s birth plan and they help identify other community resources for women (Jordan, Van Zandt, & Wright, 2008).

Each year, 60–80 baccalaureate students and all midwifery students take this elective course. Credit for the course includes providing doula care to one client, making a prenatal and a postpartum visit to the mother, and attending her labor and birth at the hospital of the mother’s choosing in the Baltimore metropolitan area. Students who choose to take on additional clients are paid for their services through the School of Nursing Community Outreach Program. (Johns Hopkins School of Nursing, n.d.)

Combined Classroom Learning and Clinical Experiences in Evidence-Based Care

There is continuity at DUSON between classroom content and clinical experiences. Faculty teach evidence-based care that includes the hormones of labor and how nurses can improve the birth environment and facilitate optimal birth. Students are expected to labor sit with the mothers and their families as much as possible. Clinical instructors then reinforce classroom content, and when practice deviates from evidence, they use these experiences after conferences as teaching tools.

Evidence-based classroom instruction: What DUSON students hear:

• Evidence-based maternal–infant nursing coupled with harsh reality

• Women’s perceptions of their birth affect their self-esteem, parenting, breastfeeding skills, and immediate birth outcomes

• Benefits of continuous labor support—and labor sitting

• Women’s satisfaction with their birth stems from being in control, elevating self-esteem, feelings of accomplishment, and positive memories of their providers and nurses

• Shared decision-making

• Satisfaction is not dependent on length of labor and birth or on number of interventions

• Women laboring with an epidural still need a doula

• Women’s partners need doulas, too

• When student nurses graduate to hospital practice, they probably won’t have time to labor sit. They will need doulas, too

• Study of policies and procedures that are based on the evidence

• Professionalism in advocacy

• Nurses and doulas cooperating together produces better care and satisfaction

In DONA Birth Doula training, students have time to get more depth in areas covered in class and have hands-on practice of nonpharmacological pain relief techniques, therapeutic communication specific to labor and birth, and parenting information to share based on Klaus, Klaus, and Kennell’s Amazing Talents of the Newborn and Tedder’s HUG Your Baby: Help, Understanding, Guidance for Young Families. Topics include

• What a doula does and doesn’t do, research, code of ethics, and standards of practice

• Prenatal support including birth planning and roles of the doula, partner, and any other support people

• Communication including reflective listening and cultural humility

• Support in labor including hormones, stress, pain, catecholamines, guidance for partners and doulas by phase of labor, and best research evidence on management of second stage of labor

• Comfort measures practice and group role-play

• Difficult labors, how to help a woman with an epidural and intradermal water blocks

• The newborn, breastfeeding, and postpartum support

Faculty noticed that those students who take the birth doula training are more comfortable in their labor-sitting roles. They have techniques to use to provide emotional and physical support and are sometimes surprised how well these techniques work.

Ballen and Fulcher (2006), in their article on the complementary roles of nurses and doulas to provide optimal care, noted that nurses have a lack of awareness and understanding of the doula’s role. This is an exciting part of training student nurses to not only understand the doula’s role on the mother’s team but also be able to use doula skills in attending laboring and postpartum women. They note that student nurses who go on to practice in maternal–child areas will be able to implement short birth doula strategies to improve outcomes and satisfaction with birth. In reality, these student nurses, whether or not they practice in a maternal–child setting, will be able to use many components of doula training with all types of clients. Specifically, the depth of understanding the supreme importance of support and how it changes the hormones of healing will benefit all clients they serve. This is integral to the art of nursing that is as important as the technical skills they are learning.

DUSON students are counseled in increasing the oxytocin level in any room where they are working with simple techniques as authentic caring, singing, laughing, and building trust. To decrease the cortisol levels that interfere with blood flow to the organs and that are increased with stress, students and graduate nurses can authentically listen and hear their client’s concerns using knowledge and therapeutic communication to relieve worries and stress. Students will also have information about the hormonal influences on pain and healing and be able to use nonpharmacological pain management to replace or to complement pain medications and to speed recovery.

Noticed in Clinical Experiences

All DUSON ABSN students have clinical experience in maternal–child hospital units. Faculty noticed that those students who take the birth doula training are more comfortable in their labor-sitting roles. They have techniques to use to provide emotional and physical support and are sometimes surprised how well these techniques work. The more confident students are sometimes paired with those less confident and both become more secure in their roles as they see how important their care is.

Students write two reflections during the clinical experience and some mention the relationship between the care they gave and their doula training. One student described a situation when upon entering the patient’s room, she noticed the mother in bed on her back working with contractions while the father and her mother sat on the couch with their cell phones in use. The student felt it was important to model how to get family members involved. As she helped the mother out of bed (with the nurse’s permission), the father and grandmother rose to help her. They all remained working as a team with the nurse and student from then on. When the student asked the patient if she would like to get up and walk, the patient immediately asked, “I can?” The student found it interesting that the patient, who was an experienced birthing mother, was not aware that she was allowed to get up and be mobile until the student suggested it.

After conferences, students discuss how they will implement their doula training from the workshop or at the clinical site once they are graduate nurses with busy schedules. They read Penny Simkin’s “Supportive care during labor: A guide for busy nurses” (Simkin, 2002) and explore ways this information is useful for any patient. Another student reflected:

After the birth was finished, I left feeling overjoyed that we played such an important role in this woman and baby’s life. It was even better to feel recognition when the patient’s mother asked to take a picture of us because she was so happy with the care we gave her daughter. I am proud of my clinical group that we took the initiative to labor sit and act as doulas.

Clinical experiences with on-site or workshop training in labor support skills give students self-confidence and satisfaction in caring for patients beyond the acquisition of technical skills.

Another student commented:

What impacted me the most during this experience is that I got to see first-hand how small interventions can make a big impact on our patients. Talking about fears and worries can ease pain and getting patients up and moving contributes so much to their recovery. I was happy that this was my first experience in maternity, because it stuck in my mind from then on how important these interventions were and how easily we as nurses can implement them.

Clinical experiences with on site or workshop training in labor support skills give students self-confidence and satisfaction in caring for patients beyond the acquisition of technical skills.

Survey Results

A brief evaluation survey was sent to ABSN students who completed the doula training and graduated or were still in the program. The survey consisted of eight statements that they were asked to agree with, disagree with, or remain neutral. Participation was voluntary, and responses were anonymous.

1. I was able to apply the knowledge I learned in doula training to the maternity clinical setting (95% agree)

2. Doula training provided me with a skillset to apply in the clinical setting that I found beneficial (96% agree)

3. Now that I have doula training, I am more comfortable assisting laboring women during my maternity clinical rotation (90% agree)

4. Doula training has provided me with the tools to provide non-obstetrical patients with pain management (90% agree)

5. I would recommend doula training to other nursing students (95% agree)

6. I would recommend this training to nursing students who don’t want to go into obstetrics as a career (70% agree)

7. Doula training supplements what we are learning in the classroom (95% agree)

8. Doula training empowered me to support a laboring mom utilizing evidence-based practice as a student nurse (90% agree)

Overall, survey results show that doula training was found to be very useful by the nursing students. It is exciting that students realize this benefit and how it can enhance their practice as a nurse. Several students realized later on in nursing school and into the beginnings of their career how valuable this training is. Doula training is one of the only times during nursing school that students are brought into the simulation lab to specifically practice nonpharmacologic pain management techniques. During the training, they role-play, bounce ideas off of each other, and receive valuable instruction. It is a safe environment to practice and to learn. The high percentage of students who are willing to recommend the training is very encouraging; the word is spreading that this is a great educational opportunity for future nurses. Students will begin their careers knowing the positive impact a doula can make, thus making them leaders in creating a culture where doulas are supported, empowered, and welcomed. As time goes on, surveys will continue to be sent to the newly trained doulas, so we can continue to evaluate the success of this training.

Student Outreach Based on Doula Training

Not all participants plan to become DONA certified, provide birth doula services, or work in areas of women’s health. All who train have the opportunity to volunteer for student-initiated birth doula services at several locations. One recent ABSN graduate participated in birth doula training, and while on a tour of the Women’s Birth and Wellness Center in Chapel Hill, spoke with the director Maureen Darcey, CNM, and collaboratively established a volunteer birth service with Dukelas (Duke doulas) to support families at that site. The Dukelas experience evidence-based care by midwives and this is probably one of their best opportunities to participate in women-led birth.

Working with Community Health faculty at DUSON, students have the opportunity to provide birth doula services for the Church World Services Immigration and Refugee program in Durham, North Carolina (http://cwsrdu.org/). Students were paired with four women in 2015 and provided labor support for three of them. The fourth woman had a cesarean birth and no doulas were allowed to be with her in surgery. Students provided support before and after the birth.

University of North Carolina Women’s Hospital in Chapel Hill, North Carolina, has a volunteer birth companion service. Doulas there have been trained by several DONA trainers including Barbara who is also a volunteer there. Because they are knowledgeable in DONA trainings, Dukelas are welcome to join the UNC service. Women’s Hospital is baby-friendly, and their policies and procedures are evidence based. Students have the opportunity to see women upright and using nonpharmacological and/or medications such as nitrous oxide for pain management.

As nursing students graduate and enter their careers, doula training is something they will always have to take with them. Each one will use the training in a different way during the journey as a nurse to enhance patient care. Some students have enjoyed being doulas to bridge the gap between graduation and the beginning of their first jobs. One student was able to be a doula in London at St. Mary’s Hospital for the birth of her niece.

Whether it’s locally, nationally, or internationally, DUSON students trained as doulas are making a difference in patient care every place they go. As they trickle out into the nursing field, a positive light can be shed on what it is to be a doula. Doula training enables holistic care of the patient and does not just focus on the medical issue at hand. Amazing things do happen when you give student nurses birth doula training. DUSON encourages students to participate in this experience of training and labor support. Students are altruistic and caring and those they touch and care for will benefit. As Mayra Sagady-Leslie says: “We have an emerging generation of women and men who are thinking for themselves and seeing that the current maternity system has many serious issues. They have a passion to make it better. Hope” (Leslie, 2008).

Biographies

ERIN O’BRIEN is originally from Edgewood, New Mexico, and she moved to North Carolina to attend the Accelerated BSN program at the Duke School of Nursing. Erin received doula training during the summer semester of 2014. After graduation in May 2015, she worked as a nurse at the Duke Birthing Center before relocating to Clayton, North Carolina. In January of 2016, Erin started working on the surgical floor at UNC Johnston Health where she continues to utilize her doula training to promote patient comfort.

BARBARA A. HOTELLING is a Clinical Nurse Educator at the Duke University School of Nursing. She has spent past decades becoming certified as Lamaze childbirth educator, DONA birth doula, IBCLC, and training Lamaze educators, DONA birth doulas, and HUG Your Baby parents and professionals.