The Meaning of the Nurse s Presence During Childbirth Karen MacKinnon, Marjorie McIntyre, and Margaret Quance

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1 CLINICAL RESEARCH The Meaning of the Nurse s Presence During Childbirth Karen MacKinnon, Marjorie McIntyre, and Margaret Quance Objective: The purpose of this exploratory study was to develop new understandings of what it means to women in labor for a nurse to be present during childbirth. Design: Hermeneutic inquiry was used to explore the phenomenon of nursing presence during childbirth. The purpose of questioning in hermeneutic phenomenology is to stimulate thoughtful reflection and deeper exploration of the subject s experiences. Participants/Setting: Six women from an urban center in Canada volunteered to share their experiences of childbirth through conversations with the research team. Data Analysis: Audio-taped, transcribed interviews were analyzed along with the reflections of the research team. Results: Women attribute multiple meanings to the care provided by intrapartum nurses. However, what stood out in these women s accounts was that a nurse s presence was the way in which a nurse was there for them and was a very important part of their childbirth experience. Conclusions: Women s experiences of a nurse s presence cannot be understood apart from the institutional structures and work processes that shape their experiences. Further research is needed to explicate how hospital procedures, administrative structures, and medical practices enable or constrain the presence of the intrapartum nurse. JOGNN, 34, 28-36; DOI: / Keywords: Childbirth Hermeneutic inquiry Intrapartum nursing Meaning Presence Support Women s experiences Accepted: November 2003 Recent research has called into question the ability of intrapartum nurses to provide labor support during childbirth (Hodnett et al., 2002). Given the current economic pressures on our health care systems in Canada and in the United States, we are concerned that the results of this randomized controlled trial could be interpreted to mean that fewer registered nurses are needed to care for women in labor. There is a danger that the generalizing effects of these trials can silence the voices of individual women. This qualitative study of women s experiences of nursing presence during childbirth allows other voices to be heard by perinatal nurses and decision makers. Background Most births in Canada and the United States occur in hospital labor and delivery units. Despite significant differences between hospital labor and delivery units, what they hold in common is that women and their families labor in an unfamiliar environment and in the company of strangers. Although women may have established a relationship with a physician or midwife, labor and delivery nurses not previously known to the woman and her family are her initial contacts in the hospital and provide much of her care during labor. The woman s family members are usually the only support people who are previously known to her. The North American environment differs from many European settings where midwives provide most labor and birth care for women and families. Although physicians in North America are ultimately responsible for management decisions during 28 JOGNN Volume 34, Number 1

2 childbirth, they spend little time with women in labor, often arriving just in time for the birth. Intrapartum nurses spend more time with women and families during labor and are more likely to be physically present in the room with the woman in labor. The social environment for birth is complex partly because the nurse needs to work with physicians, within institutions, and in partnership with women and families. Tension occurs when nurses and physicians provide care not congruent with the needs and goals of the childbearing woman. Tension also occurs when the needs and priorities of the labor and delivery unit conflict with those of the woman and family members. Labor and delivery nursing practice is structured by its institutional context and by professional discourses about what constitutes good intrapartum nursing care. These discourses include family-centered and woman-centered care (Association of Women s Health, Obstetric and Neonatal Nurses, 2002), labor support (Hodnett, 1996), patient advocacy (Alberta Association of Registered Nurses, 1999; Canadian Nurses Association, 2002), and the concept of nursing presence (Doona, Haggerty & Chase, 1997; Smith, 2001). Although there is considerable overlap between these discourses, current midwifery and nursing literature conceptualizes presence as being supported and guided through childbirth on one s own terms (Berg, Lundgren, Hermansson, & Wahlberg, 1996). Most nurses would agree that it is reasonable for women to expect intrapartum nurses to be present during active labor and childbirth. However, significant disparities have been found to exist between what particular women plan to occur at their child s birth, what experienced nurses expect will happen, and in many cases what does happen (Beaton, 1990; Gale, Fothergill-Bourbonnais, & Chamberlain, 2001; Sleutel, 2000). Dissonance exists between the philosophic and theoretic claims of the profession in relation to nursing care, nursing practice, and the day-to-day lived realities of nurses and the women who labor with them. Purpose and Significance The overall purpose of this exploratory study was to develop new understandings of what it means for a nurse to be present during childbirth. Exploring what the presence of an intrapartum nurse means to a woman in labor is important because of the significance of birth in women s lives and the documented influence of labor support on birth outcomes (Hodnett, 1996, 2002; Sauls, 2002). Although supportive care during labor has been shown to decrease the likelihood of medication for pain relief, operative delivery, and low 5-minute Apgar scores in the newborn (Enkin et al., 2000; Miltner, 2000), other research indicates that supportive nursing care is not consistently provided for women in labor (Gagnon & Waghorn, 1996; Gale et al., 2001; McNiven, Hodnett, & O Brien-Pallas, 1992). A large, multicenter, randomized controlled trial of intrapartum nurses as providers of continuous support for women in labor was recently conducted in North America. Despite attempts to ensure the continuous presence of the intrapartum nurse for the intervention group, no significant differences in birth outcomes were found between the experimental and the control group. The investigators hypothesized that the effects of nursing support during labor and birth may be overpowered by the effects of birth environments characterized by high rates of routine interventions (Hodnett et al., 2002, p. 1380). The complexity of institutional settings in Canada and the United States could also have influenced the findings. Literature Review Women s Childbirth Experiences Lothian (1993) suggested there is no one right way to give birth. For each woman, the right way is the one that is consistent with her personal values, beliefs, and goals. Beaton (1990) suggested that birthing experiences in Canada are more likely to be structured by the nurse s definitions and understandings than by those of the woman or others who might be present for birth. She concluded that presuming to know the woman in labor s experience can negatively affect the individualization of care. There is a tension between Beaton s conclusions and labor and delivery nurses stated beliefs in the importance of knowing the woman and in individualizing care (Quance, 1997). Labor Support Psychosocial dimensions of the childbirth environment have been shown to have a greater impact on birth outcomes than atmosphere and decor, for example, homelike environments and relaxing color schemes (Hodnett, 2002; MacKinnon & MacKenzie, 1993). Camacho Carr (1994), in her study of the environmental factors influencing childbirth, identified two very different childbirth environments: supportive and nonsupportive. The supportive childbirth environment was defined as one in which support persons provided intense physical and psychological support and were close by women in labor. The nonsupportive childbirth environment was characterized by little or no physical or psychological support and support persons who were physically removed from the woman. Labor support has been defined in the literature as the presence of an empathetic person who offers advice, information, comfort measures, and other forms of tangi- January/February 2005 JOGNN 29

3 ble assistance to help a woman cope with the stress of labor and birth (Hodnett et al., 2002, p. 1374). Professional labor support has been conceptualized as complementary to but distinct from the support the woman receives from her partner (Hodnett, 1996). Since 1980, 14 randomized controlled trials of labor support have been reported (Hodnett, 2002). Meta-analyses of the results of these trials have produced strong evidence that labor support positively affects birth outcomes. Women who had continuous labor support had shorter labors and were less likely to have analgesia or anesthesia during labor than women who received intermittent care from intrapartum nurses. They were less likely to have operative deliveries, and their infants were less likely to have 5-minute Apgar scores of less than 7. The women who received labor support were also less likely to rate their childbirth experiences negatively and had lower rates of postpartum depression (Scot, Klaus, & Klaus, 1999). Bowers (2002) reviewed 17 qualitative studies of women s perceptions of support. She noted that women s perceptions were influenced by the interpersonal communication style of the caregiver and that the woman s cultural background affected those caregiver actions considered to be supportive. Bowers recommended further qualitative studies to enrich our understanding of the uniquely supportive role of the professional caregiver during childbirth (p. 752). Women s Satisfaction With Care Provided by Professional Nurses Other researchers have studied women s satisfaction with intrapartum nursing care. The following contributing factors have been identified: providing warm, friendly, personalized care that involves careful listening and mutual respect; providing emotional support; providing information and acting as a patient advocate; and providing a physical and emotional presence through comfort measures (Brown & Lumley, 1998; Field, 1987; Mackey & Stephans, 1994). Although professional competence was found to be important for a sense of security, the provision of supportive care and the acceptance of each woman as a unique human being were seen by women as the most important attributes of professional nursing care (Rubin, 1984; Sleutel, 2003). In summary, a woman s satisfaction with nursing care during childbirth depends on the woman s perception of support received and the intrapartum nurse s ability to establish rapport, communicate effectively, and provide competent care. The nurse s interpersonal skills are perceived as more important than technical skills (Copeland & Douglas, 1999). Miltner (2000, 2002) identified the complexity of nursing support during childbirth that requires integration of supportive care with other, more technical nursing interventions. Gale et al. (2001) noted that technology and intervention shape intrapartum nursing practice and affect the childbearing experiences of women and family members. Nursing Presence Nursing presence has been described as the essence of the professional nurse s caring relationship (Doona et al., 1997; Smith, 2001). A tension exists between the routine nature of birth on the labor and delivery unit and women s desire to be seen and supported as unique individuals. In Sweden, Berg et al. (1996) showed that the essence of women s encounters with the midwife during childbirth is presence. These researchers also identified three themes characterizing presence during childbirth: being seen as an individual, having a trusting relationship, and being supported and guided on one s own terms. Discourses of nursing presence and labor support shape the practice of professional nursing and the care that intrapartum nurses provide. However, we wanted to find out from women how they experienced the presence of the nurse during childbirth without these organizing conceptual frames. We wanted to open up the phenomena of women s experiences of the nurse s presence during childbirth through hermeneutic conversations. Research Question The primary research question addressed in this study was, What meanings do women in labor attribute to the intrapartum nurse s presence during their childbirth experience? Method/Design A hermeneutic phenomenological inquiry involves the generation of meanings through the interpretation of texts. In this research, the primary texts were those generated through conversational, audio-taped interviews with study participants. This type of questioning considers the way in which meanings are created in and through language and asks how it is possible for us to speak, think, and act in the ways that we do. Hermeneutics is not so much concerned with getting things right, but rather with asking what is at work in particular situations (Smith, 1999). Drawing on hermeneutic philosophy (Caputo, 1987; Gadamer, 1999), part of the intention of this research is to create a clearing or a space around the woman s experience of the nurse s presence so that a conversation about what is going on may occur. (In this research, the term conversation is used to distinguish this approach from interviews as a method. To conduct a conversation means to allow oneself to be conducted by the subject matter to which the partners in the dialogue 30 JOGNN Volume 34, Number 1

4 are oriented [Gadamer, 1999, p. 367].) Secondary texts included the notes generated individually and collectively by the research team and our reflections on the existing literature found to be relevant to the questions of this inquiry. (In this research, thoughtful reflections refer to heeding or paying attention to the past experiences of others and ourselves [Gadamer, 1996; van Manen, 1997].) Specifically, this method of study is important for understanding everyday experiences that may be invisible or unseen. For intrapartum nurses, birth is such a common experience that it is easy to take its meanings for granted. For the woman, giving birth is unique and emotional. These conversations explored the tension between the intrapartum nurse s experiences of birth as a routine occurrence and the woman s desire for a special birth experience. What happens when nurses provide care without questioning the meanings they take for granted and their assumptions? There is the possibility of assuming power over women and families who are vulnerable during childbirth. The interpretive or hermeneutic approach allows for consideration of unacknowledged or unexamined assumptions and beliefs. It allows for the phenomenon to be studied in context with all its inherent richness. In research conversations, participants were invited to explore their experiences of childbirth before focusing on their experiences with the presence of an intrapartum nurse. Although questions are an integral part of this process, other than a few opening questions to guide the conversation, the questions for the most part arise within the conversation itself. After encouraging women to describe their recent childbirth experience, women in this study were asked, What was it like for you to have a nurse present during your labor and birth? The purpose of questioning in hermeneutic phenomenology is to stimulate thoughtful reflection and deeper exploration of the experience. It is this in-depth exploration that produces the meanings and understandings of a particular experience. Participants/Setting A purposive sample was recruited from an urban center in Canada. Participants were volunteers who wanted to share their stories about nursing presence during their recent, particular birth experiences. Participants were selected by virtue of their status as expert witnesses to their experiences during childbirth, were at least 18 years old, were able to speak English fluently, and were interviewed during the first 6 months after childbirth. Interpretive research approaches tend to continue the selection process until the accounts generated yield a sufficiently rich description of the experience being studied (Field & Morse, 1985). Given the time involved in indepth conversations and analyses, the number of participants usually varies between 6 and 10. Six women (4 primiparous and 2 multiparous) volunteered to participate in this exploratory study. Each woman was given a pseudonym for identification purposes. Data Analysis Our interviews were conducted by two members of our research team who also reflected on the nonverbal cues that were part of our research conversations. We then carefully reviewed the audiotapes, listening for hesitant talk as clues to the not-quite-articulated experience (DeVault, 1990). Analysis by the research team involved the review of audiotapes and verbatim transcripts of the tape-recorded interviews to get a general sense of the experience for each participant, to identify particular ideas within each account, and then to make connections among all of the participants accounts. Final accounts or narratives are the interpretations made by members of the research team. Interpretation in hermeneutic inquiry is the process of coming to new understandings of the subjects experiences. Discussion of our findings with colleagues at professional conferences (MacKinnon, McIntyre, & Quance, 2002; MacKinnon, Quance, & McIntyre, 2001) has enriched our understandings and pointed the way to further work that needs to be done in this area. Results Analysis of the in-depth interviews suggests that women attribute multiple meanings to the care provided by labor and delivery nurses. Further analysis by the research team of the many and different meanings women attributed to their experiences with nurses allowed new understandings to emerge of what it was like for these women to have a nurse present for their birth. Our goal was not so much to suggest that there is one way for nurses to be with women through childbirth but rather to open the conversation up so that women have a say about what they value and would like from the nurses who share this intimate experience with them. These understandings will be used to present the women s accounts and our thoughtful reflections of our conversations with them. What stood out in each of these women s accounts, albeit expressed in different ways, was that a nurse s presence was the way in which a nurse was there for them and was a very important part of their experience. One woman said: I went in knowing that we would see the doctor somewhat but knowing that the doctor wouldn t be around all the time, but I don t think you realize how much January/February 2005 JOGNN 31

5 dependency you have on the nurses.... The role the nurse plays is, in a lot of ways, more important than the doctor s role. (Nancy, first baby) When asked about the importance of the nurse s presence during her labor, another woman said, It meant everything to me! (Janet, first baby). Women also described the kind of nursing presence they needed during childbirth. Women wanted the nurse to be available, to be emotionally involved, to help create a special moment, to hear and respond to their concerns, to share the responsibility for keeping them safe, and to act as a go-between for their family and the medical institution. Janet hired a doula as a helper so her husband could focus on being a father. She described the nurse as someone who has seen the whole process and knows the experience, who can anticipate your needs and be a little bit more emotionally involved, and who is not so clinical as a doctor but who also has knowledge of the biomedical aspects of birth. Another woman described how her first childbirth experience created trust in nurses as women who know how to help during childbirth: Like, I think with my first child, the nurses I remember quite vividly because I was concentrating on everything they said. It was so much more pertinent and important to me than what the partner was saying at that time.... Because they ve done it a million times and you know if they re saying hold on or breathe, that that s really what you need to do. (Joyce, second baby) The women s experience was greatly enhanced by having the opportunity to get to know the nurse and by feeling that the nurse knew them and the particulars of their situation. This feeling of being known and understood was enhanced when nurses provided information about what was happening and kept the woman informed and involved as her labor progressed. Sarah (first baby) said, I was quite concerned about that and, you know, about the possibility of decisions being made on my behalf and it being explained to me afterwards. Sarah got to know her nurses as women she could trust to keep her informed about what was happening and as women who also respected her ability to make competent decisions. Little is known about how nurses get to know the childbearing woman and family or how the woman and her family come to know the nurses. The women in our study had a lot to say about getting to know and being known by their nurses. Knowing the woman was understood as recognizing the uniqueness of her situation. One woman (Joyce) dismissed the telephone advice that she received before coming to the hospital because she understood that advice to be of a general nature and not tailored to her unique situation. Another important finding from our study was that women wanted the opportunity to get to know the nurses who cared for them. Needing to know and trust their nurse became a more pressing concern for these women as labor advanced and women drew inward to do the work of labor. Some women who came to the hospital in advanced labor and were held in triage until shortly before their baby s birth said they missed the opportunity to get to know and trust the intrapartum nurse during their labor. They experienced frustration and anger at not being heard, resented the intrusiveness of questioning in advanced labor, and felt that they had to prove to the institution that they were worthy of a room and a nurse. Some women identified the negative impact of the absence of the nurse s presence during their labor and birth. Women highlighted points where they thought the nurse s presence was not only important but imperative in the way things happened: I m not really aware that changing nurses to a more sympathetic character makes you deliver faster, so that s all total hearsay, but I think that is the impression people are left with in the end. (Helen, first baby) In other instances, the women were very critical about what did or did not happen or of the way it happened: Nobody came over and stroked my hair or just held my hand and said, you know, we re coming right with you. So I was desperately hanging on to Ron [my partner]. At one point, after [the nurse] had said, You can push, like, she literally then went back to whatever she was doing. (Joyce, second baby) Another woman (Teresa, second baby) described needing to let go of some of her responsibility as her labor progressed and needing to share this responsibility with a known and trusted nurse. Teresa said that with her first child she had four hours to get to know the nurses. This time, the only person who knew [what was going on] was me. Teresa wondered if her more difficult experience the second time was because the support wasn t there, and quite a bit was left with me. She wanted a nurse to kind of keep track of things as her labor advanced. In some ways, women arrive on the labor and delivery unit assuming that others will be there to support and guide them through the process. For the most part, when the team provides seamless care, it is not apparent nor are the women concerned about who does what as long as the care they need is there for them when they need it. As labor progressed, however, the role of the nurse became clearer to the women; when care was absent, the women attributed this gap in their care to the nurses, if only by default. Despite locating the responsibility for what happened with the nurses, the women could also see and were 32 JOGNN Volume 34, Number 1

6 quick to point out that the work of nurses was influenced by the institutional setting. Our analysis of these women s accounts suggested that women s experiences of a nurse s presence and the meanings attributed to them cannot be understood apart from the institutional structures and processes that shape them. For example, the practice of obstetric triage, an institutional protocol for managing women s access to hospital beds, influenced how the women understood the practices of the nurses caring for them. Women in our study Women s experiences of the nurse s presence cannot be understood apart from the institutional structures and work processes that shape their experiences. described triage as a holding tank where routine procedures were carried out and the forms completed. Women felt powerless as they waited for the doctor, felt they were not heard, and felt their experiences of labor were invalidated. For example, two women described a rule that prohibited the nurse from checking their dilation on admission because these women were under the care of a medical specialist. These women observed other women being examined by the nursing staff while they waited to be checked by the medical resident. One woman said she had every confidence in the nurses abilities to perform this assessment, felt that the rule didn t make sense to her, and further, that this rule was not in her best interests (Joyce, second baby). This rule seemed designed to ensure the participation of medical residents in the care of specialists patients. In this example, medical practices, rather than the nurses expertise, were structuring the nurses work in the triage setting. About needing her bodily experiences validated by vaginal examination, Joyce said: I just wanted somebody to check me to tell me, You re staying here. I would have known (I was progressing) if somebody had said to me, You re not walking around not because you re failing but because you re just that far along into labor. Our second major finding was that obstetric triage could be understood as an institutional structure for establishing medical/administrative control over women and nurses. Managerial, administrative, and medical structures and practices influence how nurses are able to carry out their support work with women in labor. Our research clearly demonstrated that women value the support work of labor and delivery nurses. Another finding from this exploratory study was that the labor and delivery nurse s role is very complex; relationships must be established and trust built under difficult circumstances. Intrapartum nurses use many ways of knowing to understand the particular situation and assess the woman in labor s needs. The notion of presence is actualized as nurses use various ways of knowing (cognitive, intuitive, experiential, and personal) to apprehend situations and institute support, care, and reassurance (Pierson, 1999, p. 300). The practice of skilled labor and delivery nurses is highly individualized, contextual, and reflective. Intrapartum nursing practice, then, is a complex art that can be experienced as a call for nursing presence. Limitations and Future Research Future research is needed to explicate the institutional processes affecting the support work of intrapartum nurses. Although previous research has identified the benefits of supportive care in labor (Hodnett, 2002; Scot et al., 1999), other research suggests that nurses do not consistently provide supportive care (Gagnon & Waghorn, 1996; Gale et al., 2001; McNiven et al., 1992). Despite these findings, there has been little attempt to study those elements of the work place setting that affect the support work of labor and delivery nurses. Women in this study identified institutional structures (such as obstetric triage) and work processes (such as rules that structured the provision of nursing care) negatively affecting their childbearing experiences. Analysis of the data from our study suggests that women s experiences of a nurse s presence cannot be understood apart from the institutional structures and work processes that influence what the nurse can and cannot do. Institutional ethnography could be used as methodology to explicate the social and institutional determinants of intrapartum nursing practice (Campbell & Gregor, 2002; DeVault & McCoy, 2002; Smith, 1987). Implications for Nursing Practice Women in our study highly valued the presence of the intrapartum nurse and recognized the competing demands on the nurse s time. However, women expected more of their nurses than they did of their physician. Janet described feeling abandoned by the nurse she had gotten to know and trust over the night shift. Her story speaks to a lack of connection with the nurses who came on shift next and of being abandoned by the system when she had to wait until a physician was available: January/February 2005 JOGNN 33

7 They kept checking his heart rate and he,... of course,... no, the baby s not in distress, the baby s not in distress, so,... but meanwhile, hey, I m having some trouble here, hello?... But that was sort of seen as,... well, as long as the baby s okay, to hell with you kind of thing. (Janet, first baby) How does a biomedical gaze that focuses on the fetus to the exclusion of the woman affect childbearing women s experiences? Goldberg suggests that the very foundations of perinatal nursing are endangered by the technological culture of hospitalization, and the influence of the medical paradigm, derived from Cartesian metaphysics (2002, p. 446). Are we complicit as nurses in creating invisible women, women who are not seen or heard within our health care institutions? Does the biomedical hegemony that focuses only on a safe delivery and a healthy baby create women as objects of our caring? The meaning of the nurse s presence for these women was based on a relationship and getting to know and trust their nurse. Rubin (1984) also found that women s trust in intrapartum nurses increased when women perceived nurses as well qualified and as understanding their unique situation and needs. There is a tension between these women s needs and institutional structures that partition women s childbearing experiences. Obstetric triage could be seen as another barrier to building relationships between women and nurses. Knowing the woman and providing the opportunity for her to get to know and trust her nurse is very difficult to accomplish within existing institutional structures. How could nursing care be structured to enable the support work of the intrapartum nurse? Women in this study challenged our ideas about knowing the woman as a unidirectional concept (Swanson, 1991). Women and nurses needed an opportunity to get to know each other before the woman drew inward in advanced labor. Women described questions and history taking as an intrusion during this vulnerable time. Sending women home in early labor or keeping them in triage did sometimes decrease the opportunity for the woman-nurse relationship to be established before childbirth. These women described this absence as feeling alone, isolated, and abandoned by the system and the nurse. Women in this study articulated that as labor advanced, so did their need to be able to trust their nurse(s) so that they could let go of some of the responsibility for the safety of their baby. Drawing on Rubin s work, Sleutel proposed that intrapartum nurses also need to be skilled at facilitating a woman s ability to totally surrender her body to a uniquely feminine task: that of giving birth (2003, p. 77). The presence of a known and trusted nurse might provide women with the opportunity to let go of some of the responsibility and do their primary job of labor. Skillful intrapartum nursing practice, then, requires both knowing what to do (knowing in general) and knowing about the particular concerns of this woman (contextual and situated knowing). What these women needed from their nurse was not a Super Nurse but a skilled practitioner who can move back and forth between what is already known about supportive care in labor and what is needed in this particular situation. Liaschenko suggests that knowing the person comes through an attentive gaze and heartfelt listening (1997, p. 37) and that knowing the person becomes critically important when the moral work of nursing practice includes acting for individuals (p. 30). These women also described having to prove that they were worthy of our care and waiting to be assigned to a room and a nurse. Is this a uniquely Canadian concern? Teresa, who knew that the woman in the next bed had more pressing medical concerns, spoke in a whispered Skillful intrapartum nursing practice requires both knowing what to do and knowing about a specific woman s particular concerns. voice about how her needs were invisible, unseen, and unmet. As nurses, we also need to think about how obstetric triage structures our thinking. Of course, the sickest patients need care first. Of course, the healthy woman in active labor isn t a priority unless she is precipitating. Of course, triage is a good place for medical students to learn. But how else could intrapartum nursing care be provided without resorting to the triage model? How could we learn to truly hear what women in labor are telling us and respond to their call for nursing care? Women in our study highly valued the presence and support work of the nurse. Nursing presence involves being there (physical presence), being with (emotional support), and being for (advocacy). These women are challenging the assumption that the support role of the labor and delivery nurse is less important than biomedical, legal, and administrative priorities. Nurses need to ask themselves whether and how biomedical surveillance can be accomplished in partnership with woman and families. Nurses need to be aware that technical functions and nursing the chart to reduce legal liability may conflict with their support work, leaving women feeling alone and abandoned. Health care providers and decision makers need to appreciate that one nurse may not be able to accomplish these institutional tasks and provide the support women need: 34 JOGNN Volume 34, Number 1

8 Birth is not only about making babies. Birth also is about making mothers strong, competent, capable mothers, who trust themselves and know their inner strength. (Katz Rothman, 1996, p. 254) Conclusion Our findings are positioned as an account that is a work in progress, and we invite others who may be positioned differently to reflect on these understandings and participate in an ongoing conversation about nursing presence during childbirth. We found that women s experiences of the nurse s presence cannot be understood apart from the institutional structures and work processes that Nursing presence involves being there, being with, and being for women. Women in this study highly valued the presence and support work of the intrapartum nurse. shape their experiences and that triage could be understood as an institutional structure for establishing medical/administrative control over women and nurses. Further research is needed to explicate how hospital procedures, administrative structures, and medical practices shape the support work of labor and delivery nurses. We do not know how institutional structures and work processes enable or constrain the presence of the intrapartum nurse. Acknowledgments A project of the Women s Health Initiatives Group, Faculty of Nursing, University of Calgary. Supported by the Nursing Research Endowment Award. REFERENCES Alberta Association of Registered Nurses. (1999). Nursing practice standards: Standards for a new millennium. Edmonton, AB: Author. Association of Women s Health, Obstetric and Neonatal Nurses. (2002). Standards for professional perinatal nursing practice and certification in Canada. Washington, DC: Author. Beaton, J. (1990). Dimensions of nurse and patient roles in labor. Health Care for Women International, 11, Berg, M., Lundgren, I., Hermansson, E., & Wahlberg, V. (1996). Women s experiences of the encounter with the midwife during childbirth. Midwifery, 12, Bowers, B. (2002). Mothers experiences of support: Exploration of qualitative research. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(6), Brown, S., & Lumley, J. (1998). Changing childbirth: Lessons from an Australian survey of 1336 women. British Journal of Obstetrics and Gynecology, 105(2), Camacho Carr, K. (1994). Characteristics of the supportive and non-supportive childbirth environment. International Journal of Childbirth Education, 9(3), Campbell, M., & Gregor, F. (2002). Mapping social relations: A primer in doing institutional ethnography. Aurora, Ontario: Garamond. Canadian Nurses Association. (2002). Code of ethics for registered nurses. Ottawa: Author. Caputo, J. (1987). Radical hermeneutics: Repetition, deconstruction and the hermeneutic project. Bloomington: Indiana University Press. Copeland, D., & Douglas, D. (1999). Communication strategies for the intrapartum nurse. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 28(6), DeVault, M. L. (1990). Talking and listening from women s standpoint: Feminist strategies for interviewing and analysis. Social Problems, 37(1), DeVault, M. L., & McCoy, L. (2002). Institutional ethnography: Using interviews to investigate ruling relations. In J. G. Gubrium & J. A. Holstein (Eds.), Handbook of interview research: Context and method (pp ). Thousand Oaks, CA: Sage. Doona, M. E., Haggerty, L. A., & Chase, S. K. (1997). Nursing presence: An existential exploration of the concept. Scholarly Inquiry for Nursing Practice: An International Journal, 11(1), Enkin, M., Skiers, M., Nelson, J., Crowder, C., Duly, L., Hodnett, E., et al. (2000). A guide to effective care during pregnancy and childbirth. Oxford, UK: Oxford University Press. Field, P. A. (1987). Maternity nurses: How parents see us. International Journal of Nursing Studies, 24(1), Field, P. A., & Morse, J. (1985). Nursing research: The application of qualitative approaches. Rockville, MD: Aspen Systems. Gadamer, H. G. (1996). The enigma of health. Stanford, CA: Stanford University Press. Gadamer, H. G. (1999). Truth and method (2nd ed.). New York: Continuum. Gagnon, A., & Waghorn, K. (1996). Supportive care by maternity nurses: A work sampling study in an intrapartum unit. Birth, 17(1), 1-6. Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Measuring nursing support during childbirth. MCN, The American Journal of Maternal/Child Nursing, 26(5), Goldberg, L. (2002). Rethinking the birthing body: Cartesian dualism and perinatal nursing. Journal of Advanced Nursing, 37(5), January/February 2005 JOGNN 35

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