“Delivering” Culture Change: A Quality Improvement Approach to Nurse-Resident Relations on Labor & Delivery

Background: Strained nurse-resident relations on Labor and Delivery are a widely recognized but inadequately addressed threat linked to adverse outcomes, trainee and nursing distress, hostile clinical learning environments, and patient safety issues. In our institution, a 2024 Program Evaluation Committee meeting SWOT analysis (Strength-Weakness-Opportunity-Threat) identified nurse-resident relations at a busy academic Labor and Delivery unit as an opportunity for improvement within our residency program. Issues included persistent unprofessional behaviors, inadequate and mistrusted reporting mechanisms, and a culture of silence with a fear of retaliation. Objective: To implement and evaluate a quality improvement model for improving nurse-resident relations on Labor & Delivery. Study Design: Using Kotter’s 8-Step Change Model as a framework, a multidisciplinary quality improvement initiative was launched in May 2024 as a joint effort by resident and nursing leadership. Interventions included creation of an anonymous QR code-based feedback survey, recognition of outstanding nurses and residents, monthly interdisciplinary leadership meetings to review concerns, structured social events, clarification and education regarding resident and nursing escalation pathways, and the establishment of a joint Nurse-Resident Workgroup. Results: In two years, a total of 74 nursing and resident-related incidents were submitted and addressed through the creation of an anonymous QR code-based feedback survey. In the first 7 months there were 26 submissions, in the second 7 months there were 41 submissions, and in the final 7 months there were 7 submissions. QR code submissions declined over time, which served as an indicator of culture improvement. A total of 100 kudos were submitted by both nurses and residents recognizing exemplary interprofessional behavior. Monthly nursing-initiated socials were established at the beginning of each resident rotation to intentionally strengthen camaraderie, promote teamwork, and help nurses and incoming interns build familiarity early in the rotation. As a second phase to the improvement efforts, a Nurse-Resident Workgroup was launched in November 2025, completing six structured meetings by June 2026. This workgroup consisted of a core team of 7 front-line nurses and rotating residents with a total of approximately 10 to 12 participants at each session. This in-person discussion was mediated by combined nursing and residency leadership and focused on conflict resolution and improved situational awareness between both nurses and residents without intensive investment outside of this structured time. Participants were anonymously polled at the fourth and fifth workgroup with 12/12 (100%) positive responses at the fourth workgroup and 9/10 (90%) positive responses at the fifth workgroup, with 0 negative responses in both workgroups. In addition, participants suggested 5 topics for future discussion. Conclusions: A structured and leadership-supported quality improvement initiative can meaningfully improve nurse-resident relationships on Labor and Delivery. The Nurse-Resident Workgroup is a replicable intervention that provides a structured venue for conflict resolution and improved situational awareness between nurses and residents. Discussion allows for understanding of diverse perspectives and roles, which ultimately led to system changes across nursing, residency, and faculty teams. This model provides a framework for other residency programs facing similar challenges and can be adapted to different unique Labor & Delivery environments.