Transitioning to mother/baby couplet care

[Baby1nurse]

I am a clinical supervisor at a Level II LDRP. My position is basically a permanent charge nurse with mandatory meetings I have to attend. We have recently changed to "Family Centered Care" where the M/B nurses assume entire care of the baby. We are doing away with the "normal" nursery and concentrating on building up our NICU. We are a smaller community hospital, doing about 1,500 deliveries a year. We have in-house neonatologists and pediatricians available for all c/section and meconium or high risk deliveries. The problem we are facing right now is the actual transition from a regular LDRP to the Family Centered Care module. We are now encouraging all mothers to keep their babies in the rooms at all times. They are seen by the pediatricians in their rooms and all labs are being drawn in the room. The M/B nurses are having difficulty transitioning because they are now being asked to not only check the mother's charts, but now the babies charts, order labs for the moms and babies, and call the pediatricians with the bili results and problems with the babies, and assist with all circumcisions. Nursery nurses do the "catches" and admissions of the babies in the patient's rooms but then turn over total care to the M/B nurses. They are all extremely worried about missing something, such as a murmur, with the baby. These are all girls with a minimum of three years experience up to thirty years of experience. They have all had many seminars on M/B couplet care, which is something we have been doing all along, neonatal assessments, dealing with physicians, and coping with change. The nursery nurses are having a hard time, also, because they cannot deal with letting go of their control of the babies. They also do not know what their roles are to be and feel that they are being forced out of their positions. It is particularly difficult for the older nurses with 15 to 20 years of normal nursery experience and are reluctant to change over to the NICU as they are not as comfortable with the skills involved. We have also given them seminars to help with their transition as well. We try very hard to keep to a 3:1 M/B assignment, although we all know that there are times when that is impossible. One of the big problems we have with administration is having them realize that when we have a census of 18 mothers on the unit, we actually have 36 patients! They refuse to acknowledge that fact. Giving a nurse a 3:1 M/B ratio gives them six patients, not three! This hinders the amount of nurses we are allowed to hire. We have a 22 bed unit, consisting of 11 LDRP rooms and the rest are antepartum rooms. We usually staff with 7 nurses, covering both LDRP and M/B and 2 nursery nurses. I am on the floor as lunch and break relief, relief when a nurse with 2 labor patients is initiating an epidural or pushing with a patient, and extra pair of hands when things get really hectic. We also have a problem with the patients themselves, some of who do not want to keep their baby in the room with them 24 hrs a day. We are in the process of establishing a "Baby Lounge" where the mothers can park their babies for a couple of hours in order to catch a little much needed sleep. We do not limit the amount of visitors, either in labor or post partum and this has really increased our patient satisfaction surveys. Last week we had a "grief councillor" come in to meet with the nurses, sort of like a therapist, so the the nurses can vent their feelings about the transition without management being present. We were completely surprised to hear of the anger still present among the staff over the new changes. I honestly thought that they were starting to cope. Has anyone else gone through transition from a regular LDRP to Family Centered Care? What problems have you encountered and how have you handled them?

[bagladyrn, RN]

Of course your staff are still angry. They are being handed a major change with no say in the matter. You are absolutely right that they are being given double the patients with couplet care. I see this is many hospitals ( I'm a traveler). I can tell you that everywhere I see this mothers do not want to keep their babies 24/7, with rare exceptions. When there is no normal nb nursery babies end up at the nurses station at night. Most family members (especially fathers) do not help with baby care at night - they sleep! I've had mom's call me to care for baby with dad snoring right beside them, saying "Oh, but he's so tired". And what about your sick pp moms, especially those with no family - who is going to take care of those babies, and where?

I hope your staff are being offered lots of time and training for the transition -especially the nursery nurses. Switching to NICU is the equivalent of taking long term m/s nurses and saying "Oh, you are going to be an ICU nurse now". Scary for many.

It is good that you are recognizing these issues and addressing them. I'm sure the nurses on your staff do appreciate that.

[Jolie, BSN]

Bless you for undertaking this challenge. I know it's not an easy one, but I believe you and your patients will find it rewarding.

IMO, you will not be successful in implementing m-b care as long as you have "mom" nurses and "baby" nurses. I think you need to find a way to integrate these roles so that everyone comes to accept responsibility for both moms and babies. I also firmly believe that some type of holding area is necessary for exhausted moms who need a chance to rest and sleep before taking their babies home. 24 hour rooming in is an admirable goal, but not realistic for some patients with exhaustion or complications.

I've worked in 3 facilities which offered m-b care. One was in name only, with a fully functioning and separately staffed newborn nursery. Care was poorly-coordinated and lousy.

The second facility had an LDRP set-up with a separate NICU. All of the nurses on LDRP provided ante-partum, L&D, post-partum and well-baby care. The NICU was staffed with a separate staff that attended deliveries, did initial newborn assessments and baths on well-babies (either in mom's room or a small holding area) and provided NICU care. After a delivery was complete, the labor nurse assumed care of the couplet. When the NICU census was low, the NICU nurses took m-b couplets on the floor. This set-up worked pretty well. There was good communication and cooperation between the 2 units because we all worked together on a daily basis, even though we were technically 2 separate units.

The last hospital practiced true m-b care. It was a 16-bed LDRP unit with a separate NICU. Each nurse was trained to 2 areas of care, either NICU and m-b or ante-partum and L&D. A nurse with a light assignment was assigned to be the "baby nurse" at the deliveries on that shift. She attended all deliveries and remained in the room for about 2 hours post delivery to assist the delivery nurse, assess and provide immediate care for the newborn, establish breastfeeding, etc. When mom and baby were stable, she picked up the couplet, and the delivery nurse moved on to another labor patient. If a mom needed time away from her baby, it was pushed into the NICU (which was always staffed) to be "babysat", but went back to Mom's room for care and feeding.

It sounds as if your nursing staff is having a hard time accepting responsibility for the patients with whom they have little experience. Perhaps pairing a "mom" nurse with a "baby" nurse for the next few weeks and having them work together will help them both to gain confidence in caring for the entire patient population.

As for your administration failing to recognize that a couplet = 2 patients, I don't know how to respond, except to direct you to AWHONN staffing guidelines.

Good luck!

[TCRNCOB61]

I can't help you at all as we have to take 5 (yes I said five) couplets everynight on our M/B unit. At times we go to 6. Our mothers do not keep their babies in their rooms at night, we have at least half of them in the "holding nursery" each night. We do try to staff the nursery with a RN, she does all the admits of newborns, C/S's baby assessments and helps our 2 PCA's with nightly wts. If we can't have a RN in the nsy. we put a PCA in there just to sit with the babies.

Our administration does not count the babies either.

[Elvish, BSN, DNP, RN, NP]

Our place made the switch about 3 years ago, and this is how we do things - admittedly not perfect but we're still working on it.

L/D is a separate unit, separately staffed. NICU is a separate unit, separately staffed.

Mother/baby and stable antepartum (and the occasional gynie thrown in for good measure) are all one unit. Nursery is a distinct place with assigned staff but is on the same unit & under same mgmt as m/b/ante. We are all crosstrained to work in all areas.

If I'm on the floor, I have whatever couplets (or APs, or gynies) are assigned to me. I am responsible for caring for baby and mom, helping breastfeed, do assessments, doing bilicheks, bath/weight/HepB etc. When I give report, I give report on mom and baby.

Nursery receives new admit babies for bath/weight/assessment/shots & drops. We keep babies whose moms have gone home but baby needs to stay and isn't critical enough for NICU (IV antibiotics but otherwise well, bilibeds, etc.) Often we withdraw drug babies in there as well. The charge nurse in the nursery is responsible for communicating problems with the babies to peds, and for communicating any new orders from peds to the floor nurse. Nursery reports on all the babies at report time.

Now, if I'm on the floor and I have a mom who wants her baby in the nsy for a couple hours, the baby can go. If nursery is slammed, though, they reserve the right to call me and ask me to come feed or hold or otherwise take care of my baby. We generally staff our nursery with 2 RNs and a tech, although if there are a lot of convalescing babies or L/D is packed, we sometimes have 3.

Some nurses are more on board with this than others. We have some that refuse to take baby from the room no matter what, and some that take baby to the nursery without any questions asked. Most of us, however, fall somewhere in the middle. We encourage moms to keep baby with them and offer to do all we can to help make that happen. If mom just can't for whatever reason, or is on the verge of a meltdown, we take the baby.

I have found that most moms/families, given enough support, will keep their babies with them. I had a 17yo primip last night who, when I went in to check on something else, had to get up to the BR but baby needed a diaper change. I offered to change the diaper while mom got up. I had baby all clean & rewrapped when she got out and she kinda confusedly (?) says, "Are you going to bring her back in the morning?" Me: "She can stay in here with you." This girl broke into the biggest grin, like she had been given a million dollars. And that baby never left her side the rest of the night. It is things like that that make me believe that when couplet care works, it is a wonderful thing.

[bcyogi]

My hospital does not have a nursery at all. We have a separate NICU (totally different department and floor) and we have L&D (sister department but separate floor), but we get all the M/B patients.

We typically take 4 couplets as our assignment. Our babies are in the room 100% of the time. We do have a treatment room that we take the babies for bath, hearing screens, PKU and HepB, but those don't take too long, and baby is quickly back with mom (if mom didn't accompany us to the the treatment room!).

For the most part, I think most of our mom's like the "rooming in" with baby, but there are a few that could use a few good hours of continuous sleep, but we nurses look after baby when time allows for those exhausted moms! :zzzzz

I love my unit. I love caring for the babies and the moms together! :heartbeat

[chris724]

Very educational replies. Our unit is embarking on doing M/B care and of course everyone is very upset and apprehensive. How did you manage the pediatricians? Did you insist they do exams in the room? Did you have a specific room for exams? Or just brought the baby to the nursery?

[Elvish, BSN, DNP, RN, NP]

By and large, peds does the exams in the rooms. First, the pediatrician comes to the nursery to review the chart, then out to the room. Of course, if there are any of their babies in the nursery (big hospital = lots of different pedi groups), they'll look at them in there and then go talk to mom out in the room.