taz5869, RNC-OB

Oh, I am currently working at a Level III hospital. Prefer Level II or III with hospitalists.

Hi, I am looking to compile a list of hospitals/systems that follow AWHONN's Perinatal Staffing Guidelines. I recently had an interview with a manager who reported they had "good staffing", but as I was asking about their core staffing numbers it didn't add up with the number of deliveries they have, annually. I understand that it's not very realistic to be 1:1 for patients on pitocin, but am searching for hospital (ideally in Southern California) that staffs adequately to be 1:1 in the active stage of labor and when caring for high risk patients who are on magnesium, experiencing hypertensive crisis, etc. It doesn't make sense to me for hospitals to incorporate best practices from CMQCC and AWHONN and then not staff accordingly. I am looking to make a change from my current position that routinely doubles up magnesium/high risk patients and often will have RN's doubled up until one of their patients is complete. I've had deliveries while I still had two patients - the charge RN was watching my other patient because there were no staff members available to assume care. I am ready to make a change, but want to make sure that I am not jumping into a similar situation.

Hi, I am looking to compile a list of hospitals/systems that follow AWHONN's Perinatal Staffing Guidelines. I recently had an interview with a manager who reported they had "good staffing", but as I was asking about their core staffing numbers it didn't add up with the number of deliveries they have, annually. I understand that it's not very realistic to be 1:1 for patients on pitocin, but am searching for hospital (ideally in Southern California) that staffs adequately to be 1:1 in the active stage of labor and when caring for high risk patients who are on magnesium, experiencing hypertensive crisis, etc. It doesn't make sense to me for hospitals to incorporate best practices from CMQCC and AWHONN and then not staff accordingly. I am looking to make a change from my current position that routinely doubles up magnesium/high risk patients and often will have RN's doubled up until one of their patients is complete. I've had deliveries while I still had two patients - the charge RN was watching my other patient because there were no staff members available to assume care. I am ready to make a change, but want to make sure that I am not jumping into a similar situation.

This is a course I attended in person, prior to getting my RNC. I thought it was fantastic. It's available as a webinar, now. https://rnnces.com/product/iob-webinar-series-2021/

7 couplets +.... (((Shudders))). Totally unsafe... that's why AWHONN came out with their guidelines! Dont you you have any other options? Working at a hospital like that is putting your license on the line... not to mention putting the patients at risk. How can you possibly do all that you are supposed to do?

From my experience, the vast majority of women have some support people in the room… especially when they're still on a PCA. But, yes, the AWHONN guidelines and Baby Friendly initiative do not always gel… the beginning of that same paragraph states, IMHO, we have to use our best professional judgment for the situation. I personally would want to make sure that my pt. has a support person in the room if they're on a PCA or have an epidural, and I can site AWHONN guidelines for a reason if I bring baby out. But, if they're on percocet I'm going to use my professional judgment and if I feel like they're safe then I'll just make sure I'm rounding on them regularly and watching out for problems.

I just took it in October. There aren't a ton of strips, but there are other questions that pertain to fetal monitoring, too, so you will need to brush up on your strips and fetal monitoring as well as general L&D stuff. I am certified in EFM and have taken lots of classes in it, so I didn't worry about brushing up on that, but there were still a couple of questions on that subject that I really had to think about. Don't forget postpartum/newborn, too... a significant portion of the exam that covers those topics.

I wouldn't work for a hospital that had that kind of response to the AWHONN Staffing Guidelines and obviously doesn't care about pt. safety. AWHONN's staffing guidelines are evidenced-based... there's a huge bibliography at the end to support the updated 2010 guidelines.

AWHONN Guidelines for Professional Registered Nurse Staffing for Perinatal Units (2010 - current) states, (Section Mother-Baby Care, p.31)

Dear Bronze, I have been an OB nurse for a couple of years now and there is a huge learning curve - especially for new grads. It's really a tough transition for new grads when you're really just getting the basics down and I can't imagine starting right in the thick of it on a high-risk maternity floor! (I work with lower-risk patients). I'm sorry to hear that you feel so unsupported at work, though.... that makes it particularly tough. Here are a few things I recommend: 1. Utilize a good "nursing brain" for shift reports with all of the essential data.... there are several good ones here which I used as a template when I customized my own. As a new grad it will help you feel less scattered when you have to give report. 2. When you need to communicate with your docs, try to make sure you have all of the info. that might be pertinent to the pt. situation. Unfortunately, knowing what you need to know/report per pt. situation often comes with experience and knowledge about potential complications or disease processes. Part of it is going to be learned through experience, but try to anticipate what they might need to know: VS, significant assessment findings, pertinent maternal hx., meds given, lab results, I&O, interventions, etc. 3. Keep reading/studying/practicing when you're at home! The more you learn the more you will be prepared to deal with various situations. Practice "measuring" all kinds of round objects with your fingers... a bottle top, tupperware lid, etc. and then check your guesses to see how you did. I know it's hard when you have just graduated and have student loans and stuff, but invest in your field: go to conferences, watch videos or take online CE modules, make sure you understand the physiological concepts re: EFM, utilize free resources from places like https://www.cmqcc.org (preeclampsia & OB hemorrhage toolkits & more), Preterm labor assessment toolkit | March of Dimes (preterm labor assessment toolkit), and become an AWHONN member if you're not already one. 4. New grads are very task oriented because EVERYTHING is new to us. We have to think about every little thing - like remembering to position pt. on her side and turning on the record button on the fetal monitor whereas these things are just intuitive for experienced nurses. Get as organized as you can.... make notes regarding all of the tasks and things which you need to do and create a "checklist" to use as a template to help you keep your thoughts organized... I think it helped them become "habit" for me a lot faster. But.... be flexible!!!! Understand that you're not going to be able to always do it all at once or in order!!! You have to use nursing judgment a lot when you're prioritizing. (i.e. if your G1P0 34w pt. just arrived, has no contractions, has BP 172/108, is c/o vision changes, N/V and epigastric pain, what pertinent assessment data will the doctor need and what are your priorities? You'll need to hone in on preeclampsia assessment items and let the rest of the stuff wait until the pt. is stabilized. Is a SVE important? Do you really need to know when the pt. last had a bowel movement? What is your focus?) Here's an example of the list I made for myself when I was new and wanted to remember everything that I needed to do for a basic admit... it's crazy detailed because I needed it to be (so I didn't forget a ton of stupid little things): Initial: Run test and push record button on monitor Have pt. provide urine sample if they haven't already / gown if desired Check equipment (O2, suction, etc. - tox. kit for preeclampsia, etc.) Get pt. some water to drink & linens for SO if needed. Put bath blanket on chux if pt. has ROM or is expected to do so during night Initiate orders if pt. is here for induction. Confirm GBS status and order abx if positive and in active labor or ROM. Position pt. on side and monitor FHR and UC's for 20 mins. Note: For an induction, do the above items, then warm pack arm for IV, get quick VS and Head/Toe assessment, start IV, perform SVE (verify vertex), calculate Bishop's score, note frequency of UC's and verify that the correct method is being used (cervidil/misoprostol/pitocin) per protocol. Start medication and then finish full admission assessment, tasks, & documentation. Induction should be started within 30 mins. to 1 hour of pt. arrival. VS, pain Maternal Head to Toe Assessment Current/Past issues: bleeding, discharge, fluid leakage, UC's (frequency & time they began), epigastric pain, H/A, N/V, dizziness, vision changes (blurry, spots), swelling, SOB, frequency/burning when urinating, UTI's, STI's, how much water pt. has been drinking (dehydrated?). Alcohol/tobacco/drug use, medications, allergies, last time ate/drank. Problems with this pregnancy or previous pregnancies, significant medical hx, etc. (HTN, Diabetes, preeclampsia, previous difficult delivery, etc,) If diabetic, find out last blood sugar. (Many of these questions are in the PDP). GBS Status - order meds if needed SVE & Nitrazine for suspected ROM, if needed. DO NOT PERFORM SVE IF PT IS BLEEDING Discuss plan of care (Birth plan, Pain meds, epidural, natural labor, labor process, support, who pt. wants in room for delivery, etc.) Documentation: Antepartum triage, cervical exam, presentation, membranes, PIH screening, Urine dip stick, Vital Signs, Systems Assessment. Check urine for protein/glucose. Send clean catch to lab if indicated and put in order. Orient pt. to the room, white board, remote, call light, rounding schedule If time permits, add pregnancies into pregnancy summary Associate monitor with FetalLink when band comes up Call provider if needed with update and any questions/concerns. Cerner: Orders (Initiate). (Ensure that the proper blood orders are in computer per PPH protocol) Antepartum Triage, PIH screen, POC Testing (Urine dipstick) VS, Systems Assessment Perinatal PDP - Be sure to do social hx and ask pt. if they have help available at home after delivery. Also verify that pt. is okay with receiving blood products if needed in an emergency. Fall Risk Skin Risk Valuables/Medications Immunizations Care Plan Pregnancy Summary Document phone call with physician, pt. education Tasks: Get Blood Band and allergy band, if needed Start IV (18 gauge preferred) Draw Labs from IV start (611, date and time go on lab labels.) Document IV start, lab collection and IV fluids in Cerner Start Abx if indicated for GBS prophylaxis Put hat in toilet to track I/O Notify Anesthesia if pt. is going to want an epidural Pull out foley catheter for after epidural placement (No foley for Dr. X's patients!) Fill out Pink Sheet Information to go over & Paperwork to Sign: Conditions of Registration (sign, initial) Visitation and Security Policy (sign) Hepatitis B Vaccine, baby (sign) Make sure they are okay with baby admit meds (Vitamin K & Erythromycin) Document in computer Infant Tracking Log Blue Folder with birth certificate info. Paternity Affidavit Pt. Education: Fetal moniitoring: continuous vs. intermittent, telemetry, characteristics: baseline rate, baseline variability, accelerations, decelerations, and possible interventions: lady partsl exam (why), reposition (why), start/increase fluids, medication off, pulse ox on finger or toe, O2 mask Plan of care with interventions (SVE's, AROM, VS schedule, GBS prophylaxis, FSE, IUPC, UDS, DAU/DAM, etc.) What to expect: Labor process, support, positions, medications, delivery info. & staff, breastfeeding & breast massage, golden hour, fundal massage and assessments after delivery, preeclampsia, etc.... whatever is applicable that the pt. is receptive to discussing.) Obviously, a lot of this doesn't make sense to you because it was specific to my facility and my computer system. But it shows you the kinds of tasks that I needed to remind myself of because it is easy to miss something. Again, you can't just go down your checklists item by item... sometimes you need to jump around, but having outlines for the various aspects of care: triage, admissions, epidural procedures, preparing for delivery, etc. really helped me to think through things in my mind to organize my care so I didn't forget as much. Another thing I did was had a basic "report" format for the doctor... I didn't always have time to plan/prepare all of the time and some things weren't always applicable, but here is my initial triage call format: Initial Provider Report: Hi, this is ____, RN at (your hospital name). We have Dr. _____'s patient _____ here. She is a G __ P ___ with an EDC of ______. (Verbalize pt. hx, allergies, complications, assessment s/sx variations from normal, if needed) Dilitation: Effaced: Station: Firm / Med / Soft Post / Mid / Ant Vertex / Other: Membranes: Intact / SROM @ / Bulging Clear / Mec / Blood / Odor Ctx Onset: Frequency Duration Pain Mild / Mod / Strong FHR Baseline Rate: FHR Variability: Periodic / Episodic / Accels / Decels: Early / Late / Variable GBS: Pos / Neg Abnormal VS, interventions. If GDM: FSBS (Finger stick blood sugar) status Again, we often have to move fast and can't take the time to sit and write every little thing out, but this will help you think about those things that you need to communicate. Anyway, that's my 2 cents for now... I've gotta run, but I hope some of this helps!!! Best of luck!!!

Heya pnlu007.... a little OT, but please clear out your private messages... I tried to respond to your message but couldn't because your box is full! ;-)

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Linfield has changed their curriculum and increased their clinical hours. I graduated in December 2011 and all of the students starting Fall 2011 and afterwards are using the new curriculum and increased clinical hours, though I don't know what they are. We all learned how to insert catheters in the lab, though whether we got experience on the job really depended on your clinical placements and what opportunities you had. But, I expect that's the same for all schools. I actually talked with a MedSurg manager recently and she didn't seem to think it was an issue, anyway, because foleys are a lot more rare these days since medicare won't pay for hospital acquired UTI's anymore and it's an easy skill to practice on the job. Unfortunately, in the current market, most hospitals are requiring a minimum of a year's work as an RN... student clinicals do not count because you are not a RN while you are a student. A few jobs at Kaiser only require 9 months experience. Jobs for all new grads are rare and are equally hard to find, because all new grads lack any experience as an RN. Linfield is far from perfect, but this was not my experience at all. My core instructors who taught the most important classes were excellent. Others were hit and miss. Clinical instructors are hit and miss, too, but for the most part I had really good instructors. I actually felt like we had a lot more student support through Linfield than I would have received at OHSU. Ken offers student academic support and helps all of the students get through the first couple of semesters with tips/tricks for the monster papers, APA, med calcs, etc. I thought that kind of support is pretty unique to Linfield and he was fabulous. Interesting. You obviously have had a different instructor than I had... I'm sorry that you had such a bad experience... my med surg instructor was absolutely fabulous. There's no doubt it is an expensive program, although all students do receive transfer scholarships (or did as of a year and a half ago)... so it's really not as expensive as it looks. I do think that they have not put the nursing students' tuition money towards the equipment and found that very frustrating. The labs definitely did not have the equipment that they should have had when you consider the amount of $$$ we paid in tuition. I think that our tuition funds primarily went to the MAC campus and don't think that we got what we paid for... but I don't know any student who pays that kind of money for their education and really feels like it was utilized the best way possible. I agree that it is best if you can work as a CNA2 or something while you are in school - specifically at the VA. In this market, jobs are very very difficult to find. The students who worked at the VA all got jobs. Several others got hired for the Salem residency... but the majority of us have either had to leave the state or are still looking for work. I have frustrations with the program, too, and was incredibly frustrated that I didn't get more clinical experience, but apparently it is still perceived as a good program within the medical community. I have been told by multiple physicians that Linfield has a good reputation. It is my hope that the new curriculum is solving some of these issues.

Wow, really? That's pretty incredible to me. What hospital is this? I graduated in December 2011 and the majority of my cohort members have not been able to find jobs. We're all second degree students and have our BSN's. The market is practically impossible for new grads in the Portland area right now... it's extremely frustrating.

Here is an interesting thread re: new grads today vs. years ago. https://allnurses.com/first-year-after/new-grads-today-527890.html