Labor and Delivery Staffing Question

[alaboroflove]

I'm a fairly new grad, feeling somewhat overwhelmed by my position. I'm seeking some guidance/encouragement/honesty/anecdotal advice from other labor and delivery nurses out there who have experiences beyond my small corner of the obstetric world.

Some background on my facility: I work at a fairly large teaching hospital - we typically do ~10,000 deliveries/year. Our facility has a level 4 NICU as well as a dedicated high risk antepartum unit, making our hospital a magnet for higher risk deliveries in our geographical area. We are not an LDRP, only an LDR. Our antepartum unit has 45 beds (it typically runs around half capacity), labor and delivery has 30 beds (typically runs at full or near-full capacity), triage has 9 beds, and there are 6 women's ORs (one OR is usually designated to GYN surgeries, while the others run c-sections)

I started working at my facility as a new grad, about a year ago. I act sort of as a float pool nurse between the high risk antepartum unit, the labor unit, and the women's OR, but due to patient census and staffing needs, I spend most of my shifts on the labor unit. My orientation included 12 weeks on the antepartum unit, 11 weeks on the labor unit, and 1 week in the women's OR (from what I've heard from others, this was a pretty great orientation, but I might have liked some more training in the OR)

Our staffing ratios are 1:1 in the OR, 1:2 on labor, and usually 1:4 on high risk antepartum (many ask why the ratio is higher on antepartum, and the main reason for this is that we ONLY do intermittent fetal heart rate monitoring in antepartum (in increments of 2 hour periods) NOT continuous monitoring, whereas all patients on the labor and delivery unit are on CONTINUOUS fetal heart rate monitoring. As such, all antepartum magnesium patients are cared for on labor and delivery). We have aides on our antepartum unit, but we don't have aides on our labor unit.

Nurses on labor and delivery perform all basic tasks for their patients such as: foley catheter insertions, IV starts, checking vitals, blood glucose checks, blood draws etc. We are almost always 1:2 on labor, though occasionally we'll have slower days. At my facility, PACU is staffed by another team of nurses entirely, and only highly experienced nurses staff the OB emergency department/triage.

Being at a facility of this size definitely has some obvious perks. It's well organized, by necessity. The 30 Labor beds are split into 3 wings, and each wing has a "mini charge nurse." These mini charge nurses are meant to attend any deliveries that occur in their wing, in line with the recommendation that all deliveries be attended by two nurses - one for mom, and one for baby. When they don't have a delivery to attend, these mini charge nurses can serve as a decent resource nurse. We also always have plenty of NICU staff nearby, in the event we need immediate assistance. Additionally, we ALWAYS have one resource nurse (sometimes 2, or even 3 on a slow/overstaffed day) with no patient assignment to help around the unit where needed. That's particularly helpful during emergent admissions. The charge nurse NEVER takes part in direct patient care, but they do attend assisted lady partsl deliveries (forceps/vacuums) to facilitate communication with the OR team.

Situations where our staffing ratio is 1:1:

• For epidural placement and for a 15 minute recovery period thereafter
  
• For about 1 hour after delivery time (at the one hour mark, you are expected to reassume responsibility of your other patient)
  
• (Almost always) for spontaneous fetal demise/termination situations (very rarely we have to be 2:1)
  
• Pushing, regardless of parity
  

To give an idea about the patient population our labor unit serves, below are some patient assignments I've experienced recently:

Patient A - an induction for gestational diabetes, on pitocin, with insulin and Q1 blood sugar checks.

Patient B - another induction, for IUGR. Induction done with cervical ripening, then a foley bulb, followed by pitocin and an amnioinfusion.

Another: Patient A - a preterm labor patient on magnesium with elevated blood pressures, and

Patient B - an induction, on pitocin, with extremely elevated pressures requiring frequent IV hypertensive medications

Another: patient A- a TOLAC in active labor, and

Patient B - an active labor patient on pitocin without risk factors

Or: Patient A - recently delivered couplet, both mom and baby requiring Q30 minute blood sugars and

Patient B - an active labor patient on pitocin

About 90% of our patients receive pitocin during labor, and probably 1 in 3 of our lady partsl deliveries are inductions for some sort of high risk factors.

To be clear, I have never had more than 2 patients on the labor and delivery unit at one time (or a couplet in the recovery period, and a mom in labor) and I am very thankful for this. However, I sometimes feel like the two patients I DO have stretch me very thin, especially as a new grad with little experience.

I was looking over ACOG staffing recommendations recently and realized many of our practices are in direct opposition to these recommendations. Among the recommendations for 1:1 staffing were:

• complicated labors, such as moms with diabetes or other risk factors
  
• TOLACs
  
• 2 full hours of recovery after delivery
  
• Patients receiving pitocin, due to the diligence required with fetal heart rate monitoring
  
• Preterm labor patients on magnesium
  

In your experience, do places exist where these staffing recommendations are taken seriously? Am I reasonable for feeling slightly overwhelmed? I love the work that I do, but I frequently operate in fear that I will be stretched too thin. I often feel like I can confidently handle one higher risk patient, but two becomes very challenging for me. I'm wondering if I should advocate for/seek different ratios given patient circumstances, or if that's an unrealistic expectation? In many ways, I feel spoiled at my facility with resources. But in others, I feel overwhelmed by the acuity.

[ashleyisawesome, BSN, RN]

Where I work, we are 1:1 in labor most of the time, 1:2 is an exception only when we are slammed and there is no other option. We are usually 1:3-4 in antepartum and we do continuous monitoring in those assignments if needed. We do sometimes take more than one patient on Mag. I never have an antepartum and a labor patient together unless it's one of those SHTF situations. We are 1:1 in the OR, and if our labor patient goes to the OR, we go with them and circulate (charge and NICU take care of the baby).

We are a bit smaller than your unit, but we still do high risk deliveries and are moderately busy. We do about 300 deliveries a month with 10 labor rooms, 4 triage rooms, 4 PACU bays (can be overflow triage if need be), 2 OB ORs. We have a couple dedicated antepartum rooms, but can throw them in a postpartum room or a labor room if we need to. We have one charge nurse on with no assignment who attends deliveries as baby nurse. She is in charge of the whole unit including postpartum and nursery. A good chunk of the labor nurses and all of the nursery nurses are also trained to be baby nurse so we can call one of them if charge is in another delivery.

We do everything we can to avoid doubling on labor patients. The triage nurse will take out a labor patient and charge will become the triage nurse. We will make a postpartum nurse split up her couplets and come take out a labor patient (most of our nurses are trained to all areas). We keep cervical ripening and foley bulb inductions in triage overnight until they are ready for pit or they rupture/go into active labor. We will call nurses at home and offer them double bonus to come in.

In the rare cases we have to double up, we try to double up with the most uncomplicated patients. We definitely wouldn't be doubling very active labor patients, diabetics, twins, pre-eclamptics on mag/getting labetolol, demises, patients with intermittently bad strips, etc. The few times I've had to do it I've either had an early induction/PROM just starting pit, or an early labor patient with an easy antepartum who just needs NSTs or tones qshift.

I think you are valid in feeling overwhelmed. I would be and I have been a labor nurse for 3 years.

[Graceisland, BSN, RN]

Yes, I am a 2 year new grad hire and I feel that your acuities would also make me feel stretched super thin and I might feel overwhelmed or a bit cranky. Have you brought up the ACOG recommendations with your Director? What do some of the other nurses on your unit say?

[labordude, BSN, RN]

Those are also beyond AWHONN staffing guidelines for perinatal units. You can find a copy of those on Google pretty easily and they are available to all AWHONN member's free of charge on the website. You've probably gotten "well it's always been this way" or "you'll manage" or worse, "no one's died yet." None of those are acceptable answers and if you start using the words "patient safety" people might listen!

[klone, MSN, RN]

I am the manager of an LDRPN and yes we absolutely do follow AWHONN's staffing guidelines. The only time a labor nurse has more than one patient is for cervical ripening. As soon as she's ROM'ed, or Pit is started, or she needs pain management, she is 1:1.

[alaboroflove]

I really appreciate all of these responses and find the prospect of other facilities operating differently encouraging. I have not approached my director about this yet, mostly out of fear and due to my lack of seniority. The unit is very sink-or-swim - many new grads don't make it. Older nurses that have learned to swim in these conditions expect newcomers to do the same.

It sounds like it may be worth bringing up. The hospital's "staffing police" will call daily to encourage sending staff home to make ratios 1:2 (this is a budget initiative, less nurses to pay) its an overall culture issue, and I do think patient safety and satisfaction suffer because of it.

[labordude, BSN, RN]

I am the manager of an LDRPN and yes we absolutely do follow AWHONN's staffing guidelines. The only time a labor nurse has more than one patient is for cervical ripening. As soon as she's ROM'ed, or Pit is started, or she needs pain management, she is 1:1.

We often start out this way with a cytotec patient and a labor, usually in the hopes that the labor patient will deliver before the cervical ripening patient needs anything more...it doesn't always happen that way. On the upside, we are aiming for free charge. I think part of it is just ingrained historical behavior of "we've always done it this way" and part is an administrative push to control labor costs. Too many of those administrators have no context to their goals though, other than the bottom line.

I'd love to work for you, you're probably an amazing manager.

[klone, MSN, RN]

I'd love to work for you, you're probably an amazing manager.

Thank you. I try, and I think most of my staff respect me. I'm lucky that I have a very good boss (the CNO) who is able to see the big picture. Yes, our productivity index may not be as good as some of the other departments, but we also have the highest HCAHPS scores of any other unit in the hospital. A huge part of that is that happy nurses = happy patients, and reasonable ratios = happy nurses. Plus, it's just the right thing to do.

[klone, MSN, RN]

I will tell you that absolutely, decreasing staffing levels is the top priority of the bean counters. Labor is the 1st, 2nd, and 3rd biggest expense to any facility. By a mile. They have blinders, and just see the numbers, without fully understanding the complex dynamics between staffing ratios and patient safety and satisfaction.

However, meeting budget goals means nothing if you have a 1-star rating from CMS. So you need to have the "middle people" who can walk that balance between fiscal responsibility and staff/patient satisfaction.

[mtnviews]

I work for two L&D units, both level III LDR who also house antepartum, care for many high-risk patients, but aren't as busy as yours - both probably average around 3500-4000 deliveries a year. Both are pretty excellent at staffing appropriately (one probably a little too generously, but they get backlash every time they try to tighten up a bit).

One unit is 1:2 cervical ripening, but otherwise 1:1 labor (pit, etc), antepartum ratio depends on stability but often 1-3 (usually 1 or 2).

The other unit often staffs 1:1 even for cervical ripening unless staffing is strapped. They likewise do 1-3 for antes, usually 1-2. In two and a half years, I can easily count on one hand how many times I've had more than one "labor" patient including early labor/cervical ripening, and one time the charge kept asking if I needed a patient unloaded once she had a nurse free up. Uh no, they're both pain free with gorgeous strips, it's really fine.

Both places have charges who do not take assignments, and at least one open/resource nurse. Those resources you feel spoiled by are out there at other places too that follow AWHONN guidelines. I don't blame you for being overwhelmed! I'm not sure if it's just your facility, or if places that do that sort of volume just have a hard time keeping up with the turnover. One of my facility's sister hospitals is similar to your volume, and I've spoken to nurses on labor and postpartum who transferred from there, who had much more strained and potentially unsafe assignments.

[labordude, BSN, RN]

I will tell you that absolutely, decreasing staffing levels is the top priority of the bean counters. Labor is the 1st, 2nd, and 3rd biggest expense to any facility. By a mile. They have blinders, and just see the numbers, without fully understanding the complex dynamics between staffing ratios and patient safety and satisfaction.

However, meeting budget goals means nothing if you have a 1-star rating from CMS. So you need to have the "middle people" who can walk that balance between fiscal responsibility and staff/patient satisfaction.

This is part of the reason that nurse managers and directors really need training in the financial aspect of the job. It's always easier to add business knowledge on top of clinical knowledge than it is to add clinical knowledge to business people. My organization has several CEOs who are nurses at the location level and our system CEO/president is also a nurse. It brings a different thought process than someone who is an MD, a lawyer, or administrator only at the top.