labor and delivery nurse-patient ratio - page 4

by magz53 21,094 Views | 39 Comments

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... Read More


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    I think it's a bit scary to have med surg pts mixed with antepartums. These folks have so much wrong with them and are potential infectious agents when nurses have to go back and forth between their rooms to provide care. I haven't taken care of a M/S pt is so long that I probably would have no clue where to start and frankly I like it that way. I do L & D for a reason and it's not to take care of med surg. Wish I could be more empathatic but there it is. We used to have an antepartum unit but have long ago disbanded it. I work in a teaching facility and we Mag PTL only long enough to get Celestone on board then ship them to the floor (OB/PP/GYN). The attendings tell us that there is no advantage to keeping PTL pts on Mag for extended periods of time as it has no advantagous effects for the baby. Been in this business so long now that what was old is now new!
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    Yeah, I forget a lot of my med surg too, plus it has changed completely since I used to do it in the early 80's, however they don't give us a choice. If the "house" is full they just keep bringing them in, also they insist they have to "decompress" the ER so they don't have to close to trauma which is a big moneymaker for them. They don't really care if we know what to do with the pts or not. In fact, even though we are often called upon to do FHTS or fundal checks on pts who require telemetry or something on another floor ( I understand if they had a fetal monitor but that stuff you should have learned in school anyway). The point is that I think we should get help from med surg when we need it but we don't--its a one way street. Obviously if we are getting the pts that means that the other units are full (unless they're closed for holidays and the like) but then the supervisor should help out. The other day I had a transfer to a SNF, I had no idea what to do at all...but no one wanted to help, until my relief came in and she was new to OB so she remembered. Its really scary.
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    Good luck getting help from another floor. Wehn our unit was not closed we had to go help out PP,NBN, etc and although we could do their jobs not a one of themknew how to labor a pt. It seemeed as if we were just a glorified resource pull pool. glad there was enough staff involvement that we soon got that changed. Now they still don't come to help us but we are not tasked with staffing their unit. Although PP does have a unique way of getting back... They refuse to take PP pts because of short staff. While we on the other hand cannot tell ER to hold our pts in the ER until we can handle them, we just do it. I suppose that every unit has gripes unique to them about staffing and caring for pts that they know nothing about. In that I am sure we are not alone.
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    i googled the subject and y'all came up. On my unit currently 2 labors, has become standard, and now due to shortage, we are being given 3, and told to "do the best you can." yes THREE, and this is without regard to pre-eclamptics on mag and pit, multiple gestations, pre-termers actively laboring, VBACers on pit, or "regular" patients with medical comorbidities. I have personally had 2 sets of twins laboring simultaneously!! (Couldn't make this up if i tried) Recent scenario, co-worker of mine got a "talking to " because she spoke up when she, with THREE LABORING PATIENTS, was told to increase the pitocin, get the patients delivered because we had a full board . How about this, 13 laboring patients on the board, 4 nurses on the floor...Do the math. Every other week, someone resigns, sometimes in couplets. New hires have left before completion of orientation.
    Know what i need to do, was just hoping it would get better, thanks for the opportunity to vent!!
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    I only wish the "public" knew what really happens behind the scenes. They are the only ones who can make a difference. Nurses are powerless. Therein lies our frustration. We know how to give good care, rare is the shift when we are not spread dangerously thin. $$$$$$$$ is what it is all about from the hospital's perspective, but a good lawsuit can erase the profit quickly !!! One of the first things looked at in a deposition is the staffing but I guess that they are willing to take the risk.
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    Quote from SmilingBluEyes
    Ratios are defined very well in AWHONN. Check AWHONN Homepage

    I do know 1:2 in active labor (not very high risk) is the standard they currently recommend.
    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
  7. 0
    Quote from OBNurseInFL
    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...)
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    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.
  9. 0
    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????
  10. 1
    Quote from 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????
    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!!
    11RN likes this.


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