Level I nursery doing a level II job?

[AriRN33]

Hi all. Just needed to vent and wanted to get some opinions on my current work situation. I currently work as a nursery nurse on a busy LDRPN. We recently had a new pediatrician take over newborn care and is wanting to bring about several changes. I’ve worked on this unit for 5.5 years and we have always been a Level 1 nursery. We would keep infants 35 weeks or greater, ones that require O2 for less than 48 hrs, require IV fluids/abx as long as they were stable. Any baby that was unstable, not improving, or preemies would be transferred to NICU. The new pediatrician is now wanting us to keep 33/34 weekers, babies requiring CPAP for 3-5 days (or more in some cases), feeder/growers (even some requiring tube feedings), as well as our well babies. We do not have a NICU at our hospital and the nearest one is 45 minutes away. Several nurses have voiced concerns about this. We are generally staffed with 2 nursery nurses for each shift, but we also attend deliveries, transition babies and care for our babies from birth to discharge. We take up to 6 babies each and at times that can include a “sick” baby. We are now going to be taking care of readmitted bili babies as well (on top of everything else that we do). Not all of our nurses have been trained to properly take care of babies like this. Our manager and CNO seem to think that this is perfectly ok and don’t see where there could be a huge safety issue with this. There are times where we are drowning in the nursery (especially lately) and it feels almost impossible to give proper care to everyone. From going to delivery after delivery, trying to help new moms, and take care of sick babies all at the same time. Our L&D nurses don’t catch babies and it is an act of Congress to get them to do couplet care or just come in the nursery while you see your well babies if they are not busy. Our manager says she is thinking of hiring an additional nurse for each shift, but it will be a couple of months before she is able to do that. I’m seriously thinking about looking for a new job if things continue like they are. Thoughts? (Thanks for letting me vent)

[klone, MSN, RN]

First, don't be mistaken - you already have a level 2 special care nursery, NOT a level 1 newborn nursery. Typically, a level 1 does not take infants <36 weeks, or infants that require O2 or IV. I certainly hope your hospital is billing for these level 2 infants.

Second, I would look to the AWHONN staffing guidelines for guidance as to what is appropriate nurse staffing ratios for these special care infants. I would also look at the book Guidelines for Perinatal Care, which hopefully your manager has a copy of.

You're right, that this is a HUGE practice change that can't just happen without serious planning and forethought, and additional training and staffing. At the last facility I managed, we were a small community hospital but had a level 2 SCN, and nurses who were "NICU competent" had to go through a lot of training, as well as a couple weeks of shadowing/precepting/training at our sister facility where we transferred our sick infants to. Then they worked alongside an already trained and competent NICU nurse at our facility for several weeks/months before they were deemed competent to take care of these special care infants.

I think I would start by setting up a meeting with your manager and your pediatric chief with data on what the national standards are for safe staffing for these NICU infants, and propose that they come up with a comprehensive training/orientation program to get these nurses competent, BEFORE they start admitting these special care infants to your facility.

Are you union? If so, utilize them. You and your colleagues should be filing an ADO EVERY SINGLE TIME you are given an assignment for which you are not adequately trained or competent, or that exceeds safe staffing of these high acuity patients.

[klone, MSN, RN]

And just for your reference, the AWHONN staffing guideline is as follows:

Normal term newborns 1:5-6

Late preterm, feeder growers, stable infants that require more care (I would also put bili babies or babies on IVs in that category) 1:3-4

Intermediate care infants (less than 35 weeks, requiring O2 support, or multiple issues such as IV AND phototherapy AND feeding issues, for example) 1:2-3

[LibraSunCNM, BSN, MSN, CNM]

It sounds like one of two things needs to happen to maintain safety: 1.) they need to properly train and staff you to care for these sicker neonates, which may include training the LDRP nurses to do actual couplet care (which should not take an act of Congress, that's ridiculous) so that you don't have to care for well babies, or 2.) stop accepting such sick babies. Anything other than those scenarios sounds very unsafe. How many deliveries do you do in a month?