Understanding doula integration through nurses’ eyes: The triadic relationship in hospital-based maternity care

Abstract Background Hospital-based doula programs remain rare (7.4% of US birthing hospitals), yet evidence supports continuous labor support for improved maternal-neonatal outcomes. Implementation challenges persist nationally despite policy initiatives. Few studies systematically examine perinatal nurses’ perspectives, despite them being key stakeholders whose attitudes critically influence program success. The objective of this study was to conduct a pre-implementation needs assessment identifying specific barriers, facilitators and contextual factors influencing hospital-based doula integration from perinatal nurses’ perspectives. Methods Qualitative study with seven perinatal nurses at an urban academic medical center preparing to launch a doula program. Semi-structured interviews explored nurses’ experiences with and perceptions of doula integration. Inductive content analysis was conducted using Atlas.ti web version. Results Participants were predominantly bachelor’s-prepared (71.43%), White (57.1%), aged 23–41 (median 32.5), with labor and delivery experience ranging from < 5 to 20 years. Most participants (71.4%) rarely worked with doulas, with 28.6% sometimes working with them. Analysis revealed three themes: (1) The Triadic Nurse-Patient-Doula Relationship – nurses consistently conceptualized doula integration as an interconnected three-party system (nurse-patient-doula) rather than separate dyadic relationships, (2) Stabilizing Factors that Strengthen Triadic Collaboration – open communication and relationship-building strengthened collaboration; (3) Destabilizing Factors that Undermine Triadic Collaboration – role and scope confusion, advocacy rigidity, mistrust and a lack of institutional infrastructure undermined collaboration. Conclusions This needs assessment identified triadic relationship dynamics as the central factors affecting successful integration of doulas, representing a reframing of doula implementation as an organizational challenge inherent in implementation. Findings provide implementation recommendations including communication protocols, standardized training, role complementarity emphasis, and collaborative birth planning mechanisms. The triadic relationship offers practical guidance for healthcare leaders integrating doula support while addressing complex interpersonal dynamics influencing implementation outcomes. Future studies should include racially and ethnically diverse nursing perspectives related to implementation strategies.