New AWHONN Guidelines for Staffing Perinatal Units Focus on Nurses’ Achievements
New perinatal staffing guidelines issued by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) were met with a standing ovation when presented to nurses attending the annual AWHONN meeting.
The guidelines were presented by perinatal nurse specialists Linda Schofield, RN, MSN, NEA-BC, of Florida Hospital, Orlando, and Kathleen Rice Simpson, PhD, RNC, FAAN, of St. John’s Mercy Medical Center, St. Louis, MO.
“The guidelines are intended to allow you to leave work saying ‘I did good work today,’ rather than worrying about what you could not get done,” Dr Simpson said. “We know you are capable of doing the right things in the right context if you only have enough people.”
Ms Schofield echoed her sentiments. “We have been fighting for optimal staffing in perinatal units for years,” she added. “Nurses want to provide the best care possible, but are challenged to do so under existing staffing guidelines.”
Previous guidelines from other organizations were developed decades ago and do not reflect today’s realities, which include more births by cesarean section; frequent use of high-alert medications, such as oxytocin; and increasingly burdensome regulatory and accreditation standards.
In addition, previous guidelines were based on medical/surgical patients and did not reflect the “dynamic” clinical environment of perinatal care, she added. “Our variance is much higher. Don’t make me fit perinatal nursing into a med-surg model,” Ms Schofield said, to audience applause.
Survey of 900 Nurses Was Basis for Recommendations
An AWHONN task force developed the guidelines after surveying almost 900 perinatal nurses about their concerns. “We used open-ended questions to avoid the bias inherent in predetermined content of structured survey items. The care taken and details provided in their responses were amazing,” Dr Simpson noted.
The key concepts used for determining safe staffing ratios were classification of patients and description of likely clinical situations, she said. The key staffing recommendations are:
- 1 registered nurse (RN) to 3 antepartum women with complications
- 1 RN to 1 woman receiving oxytocin for labor induction or augmentation
- 1 RN to 3 healthy mother–baby couplets.
The full recommendations are available online at www.awhonn.org. Examples include:
- Couplet care assignments: nurses should not have more than 2 women recovering from cesarean birth on the immediate postoperative day
- Assignments that include only new mothers: nurses should not have more than 5 to 6 postpartum women without complications, with no more than 2 to 3 women on the immediate postoperative day who are recovering from cesarean birth
- Assignments that include only babies: 1 nurse should be physically present in the nursery when there are babies in the nursery; nurses should not have more than 5 to 6 newborns requiring routine care.
A number of factors make these ratios reasonable, according to Dr Simpson. “In some centers, 50% of births are by cesarean,” Dr Simpson said. “We used to keep these mothers nearly a week. Now they are there a couple of days and there is higher acuity. A 1:3 mother–baby couplet ratio is not okay if they all had cesareans that morning. It’s important to look at the acuity, and the documents contain those details.”
Other Recommendations
The guidelines also contain staffing recommendations for antepartum testing (1 RN to 2-3 women during nonstress testing), obstetrical triage (1 RN to 2-3 women after initial assessment and in stable condition), and cervical ripening (1 RN to 2 women), and they clarify high-risk status and obstetric and medical complications, recommending 1 RN to 1 woman in labor with such complications.
The new recommendations allow for the inclusion of lactation consultants— 1.9 full-time staff for every 1000 births in level 3 perinatal centers, 1.6 in level 2 centers, and 1.3 in level 1 centers.
The critical elements of postpartum recovery and the number of nurses needed for each step are also included, as well as recommendations for contingency planning. “We felt that during the immediate postpartum recovery period, there should be 1 nurse for the mother and 1 nurse for the baby,” Dr Simpson said. “When both are stable, and critical elements of recovery have been met (listed in detail in the document), 1 nurse can care for both. You cannot accept another patient until this occurs.”
Finally, AWHONN recommends that 2 RNs be on board even when there are no perinatal patients, so that women presenting with obstetric emergencies can be attended to safely. Contingency plans should be in place to cover situations when existing staffing is inadequate, and elective procedures should be deferred until nursing staff are adequate.
“This may include discontinuing the oxytocin infusion for women having elective labor induction. When other patients are coming in, shut off the pit,” she said, as the nurses cheered.
Although these staffing improvements cannot be implemented immediately, they should be incorporated into planning now, she said. “In 12 to 18 months, you may be able to do this,” Dr Simpson predicted.