labor and delivery nurse-patient ratio

[magz53]

Can anyone give me guidelines and/or references regarding nurse to patient ratio on labor and delivery?? I work in a small hospital with no ancillary staff such as aides, techs, runners or even a secretary on 3-11. I am not comfortable taking care of 2 active labor patients with pitocin running, epidurals, internal leads, IUPCs etc. We also get many "labor checks" which 9 times out of 10 are not in labor but require monitoring, assessments, UA's ( which we must enter in the computer and run to the lab which means we leave our labor patients unattended ) Granted, being small means this does not happen every shift but I think my license is on the line many an evening. Of course if it is more than one care provider, they think they are the only one who matters. A primip pushing is a one on one in my opinion but I am often treated as "old fashioned" as I am the oldest nurse on the floor. I think I hold my own and am capable of working to the max......but I am not inflating my ego by taking on more than I think I should. I just don't feel right about it. Help.

[tammy777]

Hi, SBE -

I've searched & searched the AWHONN homepage but cannot find the position statements that CLEARLY define what they consider to be appropriate staffing levels for L&D. I work in a small military facility, and our new CNS thought that it was just fine & within AWHONN/AACOG standards for me to labor an AMA grand multip with hx of multiple DVTS & PE's who had been off lovenox for less than 24 hours (being induced) AND a preterm induction for mild pre-eclampsia on pit & MGSO4. I can't believe that's considered SAFE! I just can't find anything to back up my opinion. Do you have any links to the actual pages or PDF's from AWHONN that are very clear-cut on this sort of thing? THANKS! I've been an L&D nurse since 1985 and I have loads of common sense, which apparently doesn't always match up with what the higher-echelon dictates... ahhh, well!

Thanks for your time!

KC

I'm looking for the same thing in California... Seems like the ratio laws are fairly vague and don't specify care/ratios for the higher risk patients... I'm hoping there are more specific posted somewhere... if not, they certainly should be because the scenario you mentioned above doesn't seem safe (in the text books it says a Mag pt should be 1:1, but I don't think that is what happens in the real world...)

[ldcmw1]

I'm a labor and delivery nurse myself and find that we are constantly out of the AWHONN guidelines!! I feel sorry for the nursing community!! It is sad to hear it doesn't seem better anywhere else.

[laborrntx]

I think that 1:2 is amazing even getting that! I work at a small hosptial and our unit is set up in a big rectangle where we have 6 labor room, 2 OR's, and 12 PP rooms. Our core for all areas is 3 nurses for ALL THOSE ROOMS! I am a new nurse a little less than 2 years and was charge for my 3rd time. I had 1 labor nurse w me, 1 baby nurse (we don't have a staffed nursery), and 1 floating nurse who'd never done moms by herself taking the moms on PP. At one point during a section which took my baby nurse and my 1 labor nurse I had 7 labors/triages ALONE. I was even pushing hydralazine and couldn't get help. It was the single worst night of my career. It makes me want to quit labor and delivery because I'm sick of feeling overwhelmed and I felt like my license was at risk although under the circumstances all the docs that came through the night and all the morning nurses said I did everything right and did a great job. I was at work for 19.5 hour between not being able to chart on anyones strip all night, do any charting other than real quick when I gave a med etc., I didn't eat, drink, or pee for all those hours. The last 3 of those hours I spent back charting on strips etc. I had some serious scares and some babies going bad, 2 STAT true life and death emergency sections at shift change, luckily dayshift had arrived and nights hadn't left so the outcomes were good but when I got home I was tearful, anxious, shaky. I couldn't sleep for hours and almost felt like I was suffering from post traumatic stress. Any older wiser more seasoned nurses have any advice for what we can do? PS I did a nurse residency program and am contracted to them for another 10 months. ADVICE????

[Fyreflie]

I think that 1:2 is amazing even getting that! I work at a small hosptial and our unit is set up in a big rectangle where we have 6 labor room, 2 OR's, and 12 PP rooms. Our core for all areas is 3 nurses for ALL THOSE ROOMS! I am a new nurse a little less than 2 years and was charge for my 3rd time. I had 1 labor nurse w me, 1 baby nurse (we don't have a staffed nursery), and 1 floating nurse who'd never done moms by herself taking the moms on PP. At one point during a section which took my baby nurse and my 1 labor nurse I had 7 labors/triages ALONE. I was even pushing hydralazine and couldn't get help. It was the single worst night of my career. It makes me want to quit labor and delivery because I'm sick of feeling overwhelmed and I felt like my license was at risk although under the circumstances all the docs that came through the night and all the morning nurses said I did everything right and did a great job. I was at work for 19.5 hour between not being able to chart on anyones strip all night, do any charting other than real quick when I gave a med etc., I didn't eat, drink, or pee for all those hours. The last 3 of those hours I spent back charting on strips etc. I had some serious scares and some babies going bad, 2 STAT true life and death emergency sections at shift change, luckily dayshift had arrived and nights hadn't left so the outcomes were good but when I got home I was tearful, anxious, shaky. I couldn't sleep for hours and almost felt like I was suffering from post traumatic stress. Any older wiser more seasoned nurses have any advice for what we can do? PS I did a nurse residency program and am contracted to them for another 10 months. ADVICE????

First thing I would advise--inform your manager in writing of your concerns every time you have an unsafe situation. This covers your butt if something does go wrong--you can point to your paper trail and say "I told them over and over that this situation/unit was unsafe and didn't get any help." Make sure it's by email and that you blind carbon copy to an email outside of work or print a copy immediately that shows the headers (to/from and date etc) to keep for your own records.

Second, if your facility has unsafe workload reporting forms, fill one out for every single situation. Get your colleagues to sign them too if they were involved. Photocopy and keep a copy for yourself.

If you have any meetings with your managers/supervisors where you feel threatened or uncomfortable, ask for the meeting to stop until you can invite a witness to the meeting (I've called my union rep here in Canada, if you are not with a union I think it's within your rights to ask for another person of your choosing to be present).

When workload is unsafe, make sure your patients ARE safe. I've resorted to things like:

--turning off oxytocin in all of my labouring rooms and documenting in their charts that it was discontinued due to staffing shortages/inability to safely monitor mom & baby

--if you don't have central monitoring and have someone continuously monitored, ask the mom/dad to call you "if XYZ" happens--FHR below 110 for more than a minute, not picking up on the monitor at all for more than a minute or two etc. Document your rationale ("patents asked to call RN for XYZ; RN unable to stay in room due to increased workload/lack of staff"). If you have someone on IA you can ask them to use their call bell at the 15 minute or 1/2 hour mark to "remind" you to come in if you are busy elsewhere.

--apologizing to patients for the delay (in starting an induction process etc) a d explaining that there are safe standards for monitoring during XYZ process and that you are unable to safely meet those standards and will attend to them as soon as it is safe to do so. I actually have had patients thank me for being honest with them instead of just saying "not quite yet" and leaving them to wait. You do run the risk of someone complaining to management, which I've had happen as well, but we had filled out our unsafe workload forms that day and were able to defend it--we were told not to discuss staffing problems with patients but maintained that they had the right to know!!!

--sticking up to your docs if you can't safely manage the workload and asking them to reschedule non-urgent inductions, exams, and other medical procedures. It's amazing how fast things change when you say "sorry, MD, we can't do your booked cs because we don't have enough staff--try again in a few hours/next shift!". At my first job it was amazing how we were able to get what we needed by making docs rebook procedures--they went a few steps higher than we could and complained and voila! Magically, extra money and staff appeared *sigh.*

Above all, document your ass off.

Good luck--I'm sorry you're going through this. Hopefully you can finish out your contract and get into a better position without anything bad happening. I've been where you are and it's not fun or pretty--mitigating risk constantly can be very stressful, and you always bring your work home with you that way which makes time off feel non-restful.

Do you have a hospital ethicist you could talk to, or even a counsellor? That might also help (maintaining confidentiality of course!).

PS on a more practical note--get/keep dried snacks in a Baggie close to where ever you sit/stand to chart and make sure it's a good protein/carb mix. Ditto a spill proof water bottle. If you don't get a chance to eat, drink, or take a bathroom break, document that in your workload safety form as well--that in and of itself is unsafe!!