AWHONN Research Team

Safety Consequences of Inadequate Staffing during Labor and Birth Audrey Lyndon, PhD, RN Associate Professor Department of Family Health Care Nursing UCSF School of Nursing This research was supported by the Association of Women s Health, Obstetric and Neonatal Nurses AWHONN Research Team Kathleen Simpson Audrey Lyndon Joanne Spetz Gay Landstrom AWHONN staff: Catherine Ruhl Debra Bingham, Ben Scheich, Brea Onokpise, & Kirsten Wisner also provided support for this work. 1

Background: Nsg Care and Outcomes Higher nurse staffing rates associated with: Fewer medication errors Decrease in patient mortality Fewer missed crucial aspects of care Lower rates of adverse outcomes Less patient falls Less failure to rescue / mortality Higher patient satisfaction Sources: Aiken 2002, 2011; Dabney, 2015; Kalisch 2009, 2011, 2012; Schubert 2012 Missed Nursing Care RN hours per patient day (nurse staffing levels) are a significant predictor of missed care Patients who are mentally alert are aware of missed (or delayed) essential care; consistent with nurses on the same unit Sub optimal staffing / HPPD, communication, collaboration, trust / accountability, orientation, teamwork Patient falls, pressure ulcers, infections Magnet hospital designation Perceptions of staff nurses and nurse leaders 2

Perinatal Nursing Care & Patient Outcomes Influence of nursing care in the perinatal setting has not been studied Data are limited to medical surgical units, ICUs in acute care hospitals We conducted a series of studies to develop groundwork for examining perinatal staffing Secondary Analysis of AWHONN member survey on staffing 2010 AWHONN member survey Please give the staffing task force your input on what they should consider in the development of recommendations for staffing of perinatal units N = 884 members participated 3

Themes Care that could not be done at all or could not be done as completely as needed when there were not enough nurses Potential for adverse outcomes because nurses could not carefully assess, monitor, or identify changes or deterioration in patients conditions in a timely manner Negative professional implications for nurses Comparable to existing data Consistent with those identified in the literature related to inadequate nurse staffing Themes names as per existing staffing research: Missed care (Kalisch et al., 2009) Failure to rescue (Aiken et al., Clarke, 2004) Job related stress and dissatisfaction (Aiken et al., 2002; Purcell et al., 2011) 4

Low resources Inadequate nurse staffing Nurses too busy 1 nurse is responsible for 2 women in labor receiving oxytocin 1 nurse is responsible for 2 mothers / 2 babies in the OB PACU 1 nurse is responsible for 5 mother baby couplets Decision making about care (What absolutely needs to be done?; What can wait?; What can be skipped?) Prioritizing Rationing Patient care prioritized over medical record documentation Less frequent assessments Less comprehensive assessments Less emotional and physical supportive care Less teaching to prepare for discharge Delayed care Unfinished care Missed care Incomplete or inadequate maternal fetal assessment during labor labor progress evaluation assessment of effect of medication on uterine activity and fetal wellbeing breastfeeding support and teaching assessment of maternal status and newborn status immediately after birth maternal and newborn care during postpartum maternal teaching prior to discharge Reduced Opportunity to identify problems Ability to intervene as necessary Risk of failure to rescue and subsequent preventable patient harm Adapted from Simpson, Lyndon & Ruhl, 2016. Consequences of Inadequate staffing include Missed care, potential failure to rescue, and job stress and dissatisfaction. JOGNN, 45, 481 490 Tachysystole Deteriorating fetal status Depressed baby at birth Postpartum hemorrhage Newborn hypoglycemia Unsuccessful breastfeeding Newborn hyperbilirubinemia Mother or infant falls Inadequate knowledge for self care and/or baby care Low resources Inadequate nurse staffing Nurses too busy 1 nurse for 2 women in labor receiving oxytocin 1 nurse for 2 mothers / 2 babies in the OB PACU 1 nurse for 5 mother baby couplets Decision making about care (What absolutely needs to be done?; What can wait?; What can be skipped?) Prioritizing Rationing Patient care prioritized over medical record documentation Less frequent assessments Less comprehensive assessments Less emotional/physical supportive care Less teaching to prepare for discharge 5

Delayed care Unfinished care Missed care Reduced Opportunity to identify problems Ability to intervene as necessary Risk of failure to rescue and subsequent preventable patient harm Incomplete or inadequate: maternal fetal assessment during labor labor progress evaluation assessment of effect of medication on uterine activity and fetal wellbeing breastfeeding support and teaching assessment of maternal status and newborn status immediately after birth maternal and newborn care during postpartum maternal teaching prior to discharge Tachysystole Deteriorating fetal status Depressed baby at birth Postpartum hemorrhage Newborn hypoglycemia Unsuccessful breastfeeding Newborn hyperbilirubinemia Mother or infant falls Inadequate knowledge for self care / baby care Instrument Modification Adapted an established tool for med surg nursing care (Kalisch et al., 2009) to nursing care during labor and birth 21 essential aspects of medsurg care Extensive psychometric testing / validity and reliability evaluated 6

Instrument Modification 95 labor nurses, 23 new mothers, 9 physicians participated in 17 focus groups to provide feedback re: the role of labor nurse e.g., most important aspects of care, what they do to influence outcomes Survey was tested by 24 labor nurses to help to refine final version; estimated time to complete was 10 to 15 minutes Settings Washington DC & Baltimore Region: 2RN groups per site at 4 hospitals 3500 8500 births, urban & suburban, diverse patient populations Rural Missouri: 1 group in hospital with 750 births St. Louis: 2 groups with RNs, 2 groups with mothers; 8500 births, suburban Northern CA: 2 groups with physicians; teaching & community 7

RNs: Missed Care &Consequences Adapted from Simpson & Lyndon. Consequences of delayed, unfinished, or missed nursing care during labor and birth. JPNN 2017 Jan/Mar;31(1):32 40. All Groups: What is Important? (RNs) What specific aspects of care during labor and birth contribute to patient outcomes? Tell us some of the specific things you do that make a difference for patients (Mothers) What did you think made a difference in your outcomes? (Physicians) What aspects of nursing care do you consider most important to influencing outcomes during labor and birth? Are the Joint Commission Perinatal Care Measures nurse sensitive? 8

Support and Advocacy Keeping women and their families informed Being present with women Setting the emotional tone Knowing and advocating for women s wishes Avoiding cesarean birth New Mothers To me it was being informed. I just really wanted to know what was going on I was concerned and the nurses informing you of where you should be and what you re doing was very helpful. Someone else mentioned cheerleader. She was definitely a super cheerleader I felt very empowered and encouraged. 9

Nurses & Physicians A good partner will lower your C section rate, no question. A good partner [will] facilitate vaginal delivery. Not just Pitocin; it may be a nurse who s comfortable with patients in different positions. [Physician] When you can answer all their questions or help [women] work through the process, that gives them a lot of confidence. [RN] Sometimes [women are] just not comfortable telling the doctor what they really want.they feel like they can t say Well, can we not do that?.i think [advocating for them] that s a big thing, a big part of what we do. [RN] Existing Measure Nurse Sensitivity 10

Nursing Role in Mode of Birth Convened to query specifically about potential influence on cesarean birth N = 24 experienced labor nurses via 2 focus groups Sequential questions for discussion: Do labor nurses influence whether a woman has a cesarean? What specific things do you do as labor nurse to help a woman avoid a cesarean? (Simpson & Lyndon, 2016) Results Nurses overwhelmingly felt they contribute to whether a woman has a cesarean birth Offered list of factors and list of things they routinely do to mitigate risk Themes: support, advocacy, interactions with physicians 11

Support: emotional, informational, physical just being continually present with mom can really help her psychologically with her pain Definitely position change works. That peanut ball is awesome.you do things to assist that baby s rotation coming down use of Pitocin effectively and correctly, not oversaturating her uterus but giving her enough Advocacy Advocating for women s wishes Speaking up on women s behalf Coaching & Empowering Advocating not to admit them too early The more you encourage her that she can do it they feel empowered to say I m doing fine, I want to keep going 12

Nurse Physician Interactions Working around them rather than with them Mistrust, withholding information, keeping physicians out of the room Wanting more autonomy on labor management Negotiations Physicians should not be micromanaging the labor ( Why is she on her side? Why does she have that ball? ) There are some doctors I can sit with and talk to and they will listen to me. Then there are others that say, I m the doctor. Consult with them away from the patient. They re more open to suggestion when you discuss things in private. 13

Withholding Information You have to tell them nursing lies, you learn, pretty early on that technically she s complete but I m going to say that she s 9 because she can labor down and I don t have somebody coming in and making me push. So you learn to bend the truth a little bit to advocate for your patient.i hate that we re tricking them, but Conclusions New mothers, nurses, and physicians value having nurses engaged in individualized supportive care during labor Remarkable level of consensus on this point Most stakeholders believe cesarean rates and breastfeeding may be nurse sensitive Nurses believe that understaffing can have significant consequences for patient outcomes 14

In Process Initial study using the Nursing Care During Labor Survey, capturing frequency of: Nurse reported missed care in labor and birth Nurse reported staffing relative to AWHONN guidelines Safety culture, burnout, decisional regret Hopefully Coming Next Year The LABOR RNs Study: Looking at Birth Outcomes and their Relationship to Registered Nurse Staffing We will need your help! 15

Questions & Discussion Thank you! audrey.lyndon@ucsf.edu 16

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