Using Institutional Ethnography to Explicate the Everyday Realities of Nurses’ Work in Labor and Delivery

Abstract

Fetal health surveillance is a significant everyday work responsibility for labor and delivery nurses. Here, nursing care is increasingly focused on technological interventions, particularly with the use of continuous electronic fetal monitoring. Using Institutional Ethnography, we explored how nurses conduct this work and uncovered the ruling relations coordinating how nurses “do” fetal health surveillance. Analysis revealed how these powerful ruling relations associated with the biomedical and medical-legal discourses coordinated nurses’ fetal monitoring work. Forms requiring documentation of biophysical data caused nurses to focus on technological interventions with much less attention given to holistic and supportive care measures. In doing so, nurses inadvertently activated and participated in these powerful ruling discourses. The practice of ensuring the safe birth of the baby through advances in technological surveillance and medical interventions took priority over well-established approaches to holistic nursing care.

Elucidating the Ruling Relations of Nurses’ Work in Labor and Delivery: An Institutional Ethnography

“…The number of informants in an IE investigation is not specified, instead the focus is to recruit enough informants in order expose the ruling relations across different times and places ( Devault & McCoy, 2006 ). In order to expose these ruling relations, Kelly paid very close attention to what documents the nurse informants referred to when they described how they conducted their work ( Kelly et al, 2022 ). The texts referred to by the nurse informants directed Kelly to recruit certain health care informants from both the regional health authority’s management and administrative teams ( n = 5) and one health care provider who represented a national multidisciplinary professional organization.…”

“…During our IE exploration it became evident that the biomedical model exerts influence as discourse in all aspects of intrapartum care ( Kelly et al, 2022 ). For decades, childbirth has been evolving into a bio -medical event.…”

“…Risk surveillance begins as soon as pregnancy is confirmed and continues throughout pregnancy, and the intrapartum period. For instance, Kelly et al (2022) discovered how the obstetrical health care team activated specific risk discourses to commence the use of the continuous electronic fetal monitor during women’s low-risk labors which subjects women and their babies to increased rates of instrumental vaginal and operative births.…”

“…Here, we report on findings specific to the ruling relations or extra-local forces that influence how nurses “do” fetal health surveillance and coordinate their work in labor and delivery. This investigation is part of a larger study which Kelly completed as part of her doctoral program which also included uncovering what actually happens when labor and delivery nurses conduct fetal health surveillance work ( Kelly et al, 2022 ). Our entry point into the study began at the local unit level; specifically, in an urban tertiary care labor and delivery unit within an Eastern Canadian province.…”

“…This qualitative methodology generates knowledge of how things happen as they do and makes apparent the social organization of people’s work ( D. E. Smith, 2005 , 2006 ). A more in-depth description of the methodology is available elsewhere ( Kelly et al, 2022 ). Through the use of two major analytical tools unique to IE, intertextual hierarchy and ideological circle, we uncovered how these two ruling discourses socially organize nurses’ work in labor and delivery.…”