CLINICAL COMPETENCE

Perinatal nursing education for single-room maternity care:

an evaluation of a competency-based model
Patricia A Janssen PhD
Departments of Family Practice and Health Care and Epidemiology, University of British Columbia, Vancouver, BC,
and BC Research Institute for Children’s and Women’s Health, Vancouver, BC, Canada

Lois Keen MED, RN

Children’s and Women’s Health Care Centre of British Columbia, Vancouver, BC, Canada

Jetty Soolsma MA, CNM

Children’s and Women’s Health Care Centre of British Columbia, Vancouver, BC, Canada

Laurie C Seymour BSN

Children’s and Women’s Health Care Centre of British Columbia, Vancouver, BC, Canada

Susan J Harris MD
Department of Family Practice, University of British Columbia, Vancouver, BC, and Children’s and Women’s Health Care
Centre of British Columbia, Vancouver, BC, Canada

Michael C Klein MD
Department of Family Practice, University of British Columbia, Vancouver, BC, and Children’s and Women’s Health Care
Centre of British Columbia, Vancouver, BC, Canada

Birgit Reime DScMPH

Children’s and Women’s Health Care Centre of British Columbia, Vancouver, BC, Canada

Submitted for publication: 18 December 2003

Accepted for publication: 11 May 2004

Correspondence: JANSSEN PA, KEEN L, SOOLSMA J, SEYMOUR LC, HARRIS SJ, KLEIN MC &
Patricia A Janssen R E I M E B ( 2 0 0 5 ) Journal of Clinical Nursing 14, 95–101
University of British Columbia Perinatal nursing education for single-room maternity care: an evaluation of a
Department of Health Care and
competency-based model
Epidemiology
Aims and objectives. To evaluate the success of a competency-based nursing
5804 Fairview Ave
Vancouver, BC V6T-1Z3 orientation programme for a single-room maternity care unit by measuring
Canada improvement in self-reported competency after six months.
Telephone: 1 604 806 9119 Background. Single-room maternity care has challenged obstetrical nurses to
E-mail: pjanssen@interchange.ubc.ca provide comprehensive nursing care during all phases of the in-hospital birth
experience. In this model, nurses provide intrapartum, postpartum and newborn
care in one room. To date, an evaluation of nursing education for single-room
maternity care has not been published.
Design. A prospective cohort design comparing self-reported competencies prior to
starting work in the single-room maternity care and six months after.
Methods. Nurses completed a competency-based education programme in which
they could select from a menu of learning methods and content areas according to
their individual needs. Learning methods included classroom lectures, self-paced

2005 Blackwell Publishing Ltd 95

PA Janssen et al.

learning packages, and preceptorships in the clinical area. Competencies were

measured by a standardized perinatal self-efficacy tool and a tool developed by the
authors for this study, the Single-Room Maternity Care Competency Tool. A paired
analysis was undertaken to take into account the paired (before and after) nature of
the design.
Results. Scores on the perinatal self-efficacy scale and the single-room maternity care
competency tool were improved. These differences were statistically significant.
Conclusions. Improvements in perinatal and single-room maternity care-specific
competencies suggest that our education programme was successful in preparing
nurses for their new role in the single-room maternity care setting. This conclusion is
supported by reported increases in nursing and patient satisfaction in the single-
room maternity care compared with the traditional labour/delivery and postpartum
settings.
Relevance to clinical practice. An education programme tailored to the learning
needs of experienced clinical nurses contributes to improvements in nursing com-
petencies and patient care.

Key words: competency-based education, nursing education, perinatal care, room-

ing-in care

Background The setting

Single-room maternity care (SRMC) provides intrapartum,
postpartum, and newborn care in one room. Nurses working
in an SRMC setting provide comprehensive and family-
centred perinatal care for the entire in-hospital birth experi-
ence. This model differs from traditional care whereby
women labour and give birth in the delivery suite, then
within two hours of birth are transferred to a postpartum
ward. The nurse in the new SRMC model of care must have a
greater depth of knowledge and a broader range of compe-
tencies than a nurse in the traditional model, where clinical
competency may exist in only one aspect of the childbirth
experience (Watson-MacDonell & Smith 1996).
Competency is defined as the ability to perform the
required skills in the designated environment in accordance
with the role and standards of the institution (Alspach 1992).
It is distinguished from competence which is merely the
possession of knowledge, skills and abilities required to
perform the job (Alspach 1992). A key responsibility of nurse
administrators is to ensure competency among nursing staff
(Cronin & Becherer 1999). Nurse competency plays an
important role in guaranteeing the quality of nursing
interventions and outcomes (Meretoja & Leino-Kilpi 2001).
The aim of this study was to evaluate the success of a
competency-based nursing education programme for an
SRMC setting by measuring improvement in self-reported
competency after six months. To date an evaluation of
nursing education for SRMC has not been published.
The SRMC was introduced as a seven-bed pilot project in
1997 at B.C. Women’s, a tertiary-level teaching maternity
hospital in Vancouver, British Columbia, Canada. The
introduction of this unit necessitated cross training of the
20 nurses hired to work in the SRMC, to ensure that they
were skilled in all areas of perinatal care. Consequently,
before the unit opened, nurses participated in a hospital-
funded perinatal training programme, developed specifically
to prepare them for work in the SRMC setting. The objectives
of the programme were: (i) to identify nurses’ individual
learning needs and to create individualized learning plans;
(ii) to develop learning objectives and nursing competencies
specific to the SRMC setting and (iii) to allow nurses
flexibility in choosing learning activities.
The education programme
The education model chosen for the education programme
was competency-based. A competency-based education pro-
gramme is learner focused (Alspach 1992) and is based on
the attainment of established competencies. Competency
has the following components: (i) assessment of previous
knowledge and skills; (ii) assessment of learning styles;
(iii) emphasis on outcome; (iv) use of self-directed learning
activities; (v) flexibility in time allowed for achievement of
outcome; and (vi) use of teacher as facilitator (Gurvis & Grey
1995).

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2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 95–101

Clinical competence Nursing education for Single-Room Maternity Care

To begin, nurses assessed their own learning needs related
to perinatal skills using an assessment tool already in use at
the hospital. This assessment was reviewed with a perinatal
nurse educator hired specifically for the SRMC programme.
Nurses then chose classroom lessons or self-paced learning
binders to meet their individualized learning objectives
(Fig. 1). Subject areas selected included foetal health assess-
ment, newborn care skills, infant nutrition, neonatal resus-
citation, cardio-pulmonary resuscitation, labour/delivery
skills and postpartum skills (Table 1). After completing these
learning activities, nurses then worked with a preceptor to
improve clinical skills related to the identified learning needs.
The preceptorship was complete when the preceptor signed a
checklist to indicate that new skills had been adequately
SRMC education plan
integrated into nursing practice. To facilitate their precep-
torship support of new staff, senior nursing staff in the
clinical areas were provided with a two-day workshop on
precepting.
A two-day orientation specific to competencies needed for
the new SRMC setting was also developed. The orientation
covered protocols for emergency transfer to the operating
room/high risk delivery suite on the floor below, and working
with new support roles developed for the unit, i.e. the
combined unit/admitting clerk role. Consolidation of clinical
competencies took place in the SRMC unit itself, which
opened as the nurses were finishing their preceptorships. The
nursing instructor was available to SRMC nurses on a daily
basis during this initial phase when newly acquired skills
were being practised.

Core group – 20 nurses Methods

Individualized learning needs assessment : Interview & needs assessment tool

Study sample
Classroom Self-directed activities
Six months prior to the opening of the new SRMC unit,
20 nursing positions were posted and nursing staff from the
Preceptorship for perinatal skills development delivery suite, antepartum, and postpartum units were invited
to apply. Nurses volunteered for the job, and those who met
SRMC orientation eligibility requirements were hired based on seniority in the
Perinatal Nursing Self-Efficacy Survey institution. All of the 20 nurses hired for the positions had
SRMC Competency Tool
previous experience in the delivery suite (mean 5.3 years) and
15 had experience in postpartum nursing as well (mean
Implementation of SRMC consolidation of
skills in the clinical area 3.7 years). Nine nurses were foreign-trained midwives and
three had Canadian advanced obstetrical nursing certificates.
Evaluation of competence at 6 months Nurses were all female and the mean age was 35.8 years.
Perinatal Nursing Self-Efficacy Survey
SRMC Competency Tool
Study design
Figure 1 Perinatal education programme
Just prior to starting work on the new unit, nurses completed
the Perinatal Nursing Self-Efficacy Survey (Murphy & Kraft
Table 1 Distribution of learning activities among nurses
1993). This tool was chosen because it measures nurses’
Self-directed perceptions of their own capability in areas of competency
learning relative to our study. Perceptions of self-efficacy have been
Topic Classroom package Preceptorship
shown to predict performance outcome (Rosenthal 1978). In
Foetal health assessment 9 addition, a new tool was designed, the SRMC Competency
(three days) Tool, to evaluate competencies specific to the SRMC setting.
Newborn skills (one day) 5 5 6 Surveys were handed to nurses by the Clinical Education
Infant nutrition (one day) 4 8 5
Coordinator. After completion, they were mailed anony-
Neonatal resuscitation 5
(self-paced modules) mously in sealed envelopes to the Education Office. The
Cardio-pulmonary 11 surveys were completed again six months after beginning
resuscitation (1.5 hours) work on the new unit to assess the development of
Labour delivery refresher 2 competencies over time. Six months was chosen as an
Postpartum refresher 8
adequate time period for consolidation of new skills and a
(two days)
reasonable time frame for evaluation after which decisions

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PA Janssen et al.
about potential programme changes would have to be made
(Hodges & Hansen 1999).
Measures
The Perinatal Nursing Self-Efficacy Survey
The Perinatal Nursing Self-Efficacy Survey (Murphy & Kraft
1993) is a standardized validated 27-item tool that measures
efficacy in three domains; labour-delivery skills, postpartum
teaching and support and postpartum technical skill. Validity
has been established using a known groups analysis that
demonstrated the ability of this tool to discriminate between
nurses working in different maternal/newborn practice areas.
In the original validation study by Murphy and Kraft, prin-
cipal factor analysis revealed a three-factor solution which
explained 75% of the observed variance. We conducted a
principal factor analysis (varimax rotation) with our data and
found one strong and several less powerful factors, suggesting
a one-dimensional construct. We eliminated three items with
double loadings. In view of the one-dimensional nature of the
scale in our setting and our small sample size, which restricts
the validity of a factor analysis, we did not create subscales
but calculated total scores for the 24 remaining items. The
maximum possible total score was 120. Cronbach’s alpha for
the 24-item scale was 0.95.
The SRMC Competency Tool
The content of this tool was developed after review of objec-
tives set by the Steering Committee for the SRMC, a literature
review, and site visits to other SRMC units. Face validity was
established by SRMC staff including nurses, patient service
aids and clerks. Construct validity of the 22 core items of the
SRMC Competency Tool was tested by principal factor ana-
lysis. Seven factors emerged, together explaining 93% of the
variance in scores. Factor 1 explained 54% of the variance.
This analysis suggests SRMC competency to represent a single
dimension without subdomains. Therefore, reliability was
assessed for the total scale only. Cronbach’s alpha was 0.97.
The maximum possible score was 110.
Statistical analysis
Responses at the time of the introduction of SRMC and
six months later were compared using the Wilcoxon matched
pairs signed rank sum test statistic. This test was chosen
because the two samples are not independent and the small
size of the sample makes a non-parametric distribution a
better choice than the t distribution (Altman 1991). A type I
(alpha) error of P £ 0.05, two sided, was chosen to denote
statistical significance.
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2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 95–101
Prior to starting the study, a Certificate of Ethical Approval
was obtained from the University of British Columbia
Behavioural Ethics Board and the BC Women’s Hospital
Research Review Committee.
Results
Baseline surveys were completed by 19 of 20 nurses. One
nurse was on sick leave at the first measurement period. A
total of 15 nurses completed the second set of surveys. Nurses
who did not complete the survey at six months did not differ
statistically significantly from the nurses who did in terms of
age (32.3 ± 2.7 vs. 36.5 ± 8.8, P ¼ 0.24), attainment of a
baccalaureate degree in nursing, (50% vs. 28.6%, P ¼ 0.42)
or advanced obstetrical preparation (73% vs. 60%, P ¼
0.68).
During the initial six months of SRMC implementation,
statistically significant improvements were noted on the
Perinatal Nursing Self-Efficacy Survey (Table 2). The mean
total score prior to working in the SRMC was 105.37 ±
10.46 compared with 110.9 ± 8.43 after working in SRMC,
P ¼ 0.007. Statistically significant improvements were noted
on the following individual items: (i) interpreting foetal
monitoring tracings; (ii) recognizing the signs/symptoms of
foetal distress; (iii) determining whether delivery is imminent;
(iv) recognizing when labour is not progressing normally;
(v) identifying a dysfunctional family; and (vi) instructing
mothers about breastfeeding. The direction of change in all
items was towards improvement in confidence with the
exception of three items: caring for an infant who has been
circumcised, which did not change, instructing mothers and
their significant others about formula feeding and caring for a
patient who has delivered by Caesarean section. These latter
two items were scored lower at six months although the
differences were not statistically significant.
On the SRMC Competency Tool, a statistically significant
improvement overall was achieved. The mean total score prior
to working in SRMC was 96.5six ± 9.83 compared with
102.18 ± 6.16 after six months, P ¼ 0.017 (Table 3). Statis-
tically significant improvements were noted in the following
items: identifying and transferring newborns requiring level II
(observation nursery) and level III (neonatal intensive care)
treatment; recognizing emergency situations or potential
problems in a timely manner; making appropriate decisions
about pain management; diagnosing active labour; doing
effective/appropriate discharge planning; and knowing how to
access the Patient Services Aide. Other non-statistically
significant changes were in a positive direction with the
exception of using a team approach which remained
unchanged, and four items which were scored lower at
Clinical competence Nursing education for Single-Room Maternity Care

Table 2 Perinatal nursing self-efficacy survey

Competence (ratings are mean values on a scale of 1–5, where 1 ¼ not at all confident and Before SRMC At 6 months
5 ¼ extremely confident) (n ¼ 19) (n ¼ 15)

I feel confident
Using assessment techniques to detect high-risk maternal condition 4.53 4.58
Interpreting foetal monitoring tracings* 4.16 4.31
Recognizing the signs/symptoms of foetal distress* 4.58 4.77
Intervening appropriately when there are indications of foetal distress 4.58 4.77
Supporting patients experiencing the pain and discomfort of labour and delivery 4.63 4.8
Monitoring a patient receiving epidural anaesthesia 4.63 4.77
Explaining the labour process to patients and their significant others 4.74 4.85
Assisting patients and their significant others through labour and delivery 4.74 4.84
Determining whether delivery is imminent* 4.63 4.85
Recognizing when labour is not progressing normally* 4.47 4.77
Assisting physicians during delivery 4.68 4.69
Identifying a dysfunctional family* 4.11 4.31
Problem-solving with mothers experiencing breastfeeding difficulties 4.10 4.46
Recognizing the signs and symptoms of postpartum complications 4.36 4.46
Determining whether or not an episiotomy is healing properly 4.47 4.53
Caring for a patient who has delivered by Caesarean section 4.37 4.31
Determining if a newborn is transitioning normally to extrauterine life 4.42 4.46
Instructing patients how to perform self-care activities, such as peri-care 4.73 4.84
Teaching parents how to care for their infants 4.63 4.69
Instructing mothers and their significant others about formula feeding 4.26 4.23
Instructing mothers about breastfeeding* 4.42 4.67
Instructing parents to care for an infant who has been circumcised 3.84 3.84
Preparing mothers and their partners for adjustments related to parenthood 4.17 4.46
Teaching families how to identify and intervene during emergencies 4.42 4.46

Among items marked with an ‘*’ differences were statistically significant, P < 0.05.

six months; acting as a patient advocate is staffing-related
matters, involving patient/family in decision-making, acces-
sing resources for day-to-day management, and using appro-
priate documentation related to emergencies.
Discussion
Our competency-based education model was successful in
improving self-reported nursing competencies. Our evalua-
tion supports the utility of an education programme designed
specifically for nurses beginning work in an SRMC setting.
Cross training of staff for work in the SRMC unit has not
been rigorously evaluated to our knowledge. One report from
St Mary’s Hospital in Minneapolis (Reed & Schmid 1986)
discussed a preceptor-based cross training programme. This
programme initially involved didactic and practice-based
teaching according to individual learning needs. It was later
expanded into a more complex and flexible competency-
based programme monitored by preceptors. Reed and Schmid
(1986) mentioned the importance of competency-based out-
comes, maintaining that completing a skill list did not neces-
sarily imply experience and confidence in decision-making.
Our study evaluated confidence before and after working in
the SRMC setting.
In this study, we were limited by the small sample size
constituted by our SRMC nursing staff. A larger study would
have greater opportunity to demonstrate statistically signifi-
cant improvements. We cannot exclude the possibility that
some of our statistically significant findings are due to a type I
error as a result of the multiple comparisons reported. In
addition, as nurses were not randomly assigned to SRMC, it
is likely that our cohort was particularly motivated to learn
and adapt to a new setting. However, in our study, we were
still able to demonstrate an improvement in competency over
time, even if our sample was biased towards particularly
enthusiastic nurses. Future studies should consider a rand-
omized design with a larger sample size and statistical
corrections for potential type I errors.
In a related study at our institution, SRMC nurses’
satisfaction with their work experience was compared with
that of nurses working in the traditional delivery suite/
postpartum rooms (Janssen et al. 2001). In that study, a
survey was completed six months before and three months
after the SRMC opened. Survey findings indicated that on

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PA Janssen et al.

Table 3 SRMC competency tool

Competency (mean values on a scale of 1–5, where 1 ¼ not at all confident and Prior After
5 ¼ extremely confident) (n ¼ 19) (n ¼ 15)

In clinical practice I feel confident

Acting as patient advocate in staffing-related matters 4.58 4.54
Involving patient/family in decision-making around care 4.74 4.69
In my ability to work with diversity in patient/family beliefs and values 4.58 4.69
Accessing resources for day-to-day management of clients 4.32 4.08
Expressing the SRMC philosophy in day-to-day care of patients and families 4.74 4.75
Recognizing staffing needs 4.48 4.50
Using a team approach to make appropriate decisions about staffing and 4.58 4.58
communicating and documenting the needs
Effectively using the clinical pathways 4.42 4.67
Proper use of focus charting and variance reporting 4.33 4.50
Using the appropriate documentation related to emergencies 3.90 3.83
In identifying and transferring newborns requiring Central Nursery and NCN care* 4.42 4.54
Making effective and safe decisions about patients needing urgent/emergency transfer 4.53 4.67
In recognizing emergent situations and/or potential problems in a timely manner* 4.58 4.75
Making appropriate decisions about pain management* 4.74 4.92
Diagnosing active labour* 4.72 4.92
Making appropriate decisions in triage/transport situations 4.31 4.46
In doing effective/appropriate discharge planning* 4.32 4.70
In providing patient education in a timely manner according to patient need 4.50 4.62
In conducing an effective learning needs assessment of a patient 4.50 4.62
Appropriately accessing residents/MSI 4.50 4.67
Accessing team leaders for emergency and day-to-day staffing issues 4.39 4.50
Knowing how to access Patient Services Aide* 4.56 4.77

Among items marked with an ‘*’ differences were statistically significant, P < 0.05.

average, nurses working in the SRMC felt competent in all
areas of perinatal nursing compared with nurses in the
traditional setting who were only similarly confident in their
specific area of expertise (delivery suite or postpartum/
newborn). These findings support the results of the current
study.
Another measure of the success of an education pro-
gramme is improved client outcomes. An additional study at
our institution reported higher patient ratings of quality of
nursing care and teaching in the SRMC compared with the
traditional delivery suite/postpartum setting (Janssen et al.
2000). Health outcomes in the SRMC unit compared with
those of mothers of comparable risk status in the traditional
setting were similar, but women cared for in the SRMC unit
were discharged on average seven hours earlier (Harris et al.
2004). Discharge took place when patient-centred learning
outcomes, assessed using clinical pathways, were achieved.
It is important to note that while scores on most items
improved, some did not. The ongoing lack of confidence
around emergencies may be due to the limited number dealt
with as well as the complexity of the process of having to
transfer a patient downstairs under emergency circumstances.
Confidence in instruction related to formula feeding might
not have improved because breastfeeding was specifically
emphasized and the programme did not enlarge upon
previous knowledge related to formula feeding. Confidence
scores for caring for a patient who had a Caesarean section
likely decreased because women requiring a Caesarean
section were transferred out of SRMC. Other items related
to patient advocacy and accessing resources for management
of clients which did not improve during the initial six months
might indicate the need for additional education and precep-
toring after the first six months on the SRMC unit. Inter-
mittent reassessments of self-reported clinical skills and
knowledge may be of ongoing value.
Conclusion
The nursing education programme for SRMC represents an
original approach. Unique features of this competency-based
curriculum included: nurses’ identification of their own
learning needs; opportunity to choose from a menu of
learning styles; self-evaluation of performance with input
from a preceptor; and consolidation of skills for six months.
Nurses working in the SRMC reported that their competency
improved after completing the education programme. As the

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2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 95–101
Clinical competence
complexity of nursing skills and knowledge continue to grow
in order to meet the ever-increasing acuity of both patients
and the therapeutic modalities employed in their treatment,
health care facilities will be challenged to develop and
evaluate education programmes targeted for specific clinical
areas. In the current study, we have demonstrated the utility
of an education programme designed specifically for perinatal
nurses working in the SRMC setting.
Contributions
Study design: PAJ, LK, JS, SJH, MCK; data analysis: PAJ, BR;
manuscript preparation: PAJ, LK, JS, LCS, SJH, MCK, BR.
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