#17 AWHONN Staffing Standards

Justine:

Welcome back to Happy Hour with Bundle Birth Nurses. Today we are going to be talking about an amazing tool that you have available to you and we wanted to make sure you knew what it was and that is AWHONN’s Standards for Professional Registered Nurse Staffing for Perinatal Nurses. I’m excited to talk about it.

I’m excited to talk about it. I was excited to see that this was coming out. So we were at Convention… If you don’t know, AWHONN has a national convention where thousands and thousands of nurses come together. Next year it’s in New Orleans. We are going to be there. I’ve never been to New Orleans, so I’m excited. And we’re going to do a Bundle Birth event, so stay tuned for more on that.

So we were there last year when they rolled this out as the new big document and evidence slash standards, to help guide our care and guide those that are staffing units, the charge nurse managers, et cetera. And so this was super interesting to learn about in real time. And now we have the… I don’t know, I was going to say chunky document. It’s a thick document.

It is, it’s chunky. It’s over 80 pages, right?

Totally.

What I found interesting was, one, they’ve been working really hard on this. There was a big team that put this together. And two, they did a survey where they wanted to know where are we at. After they released the 2010 guidelines, they had renamed it. So it used to be called guidelines, now it’s called standards.

They did a survey a few years ago to be like, “Hey, where are we at? How’s it working? What do you think of it?” 1800 nurses replied, meaning members, which is crazy to me. Guys, we need to be replying to these surveys. It actually made me realize like, “I need to reply to these surveys”, because there’s more numbers that we have there. 1800 nurses replied and they found that many of them did not know what was in the packet. Many of them were asking for things that the guidelines already had, like “How many nurses do I need on my unit?” Or, “Should Pitocin patient be one-to-one,” or whatever. They had that already.

So I think the big thing with the standards is to know that they exist. They are here. I recently printed it out on my unit the other day because I had a TOLAC patient and people were arguing that TOLAC patient was not supposed to be one-to-one and so I printed out the entire 80-page document and I brought it over and I was like, “Listen, look what we have,” and all the nurses are like, “I didn’t know this existed”. So point of this episode, an amazing document exists.

And if you get a chance to read it, if you’re an AWHONN member by the way, so you can access this document for free if you’re an AWHONN member. We’ve been AWHONN members for my entire career. I was told in the beginning that it was part of protecting your license. If you were ever deposed, they ask like, “She’s a part of AWHONN. That’s helpful.”

We’ve been members forever. You need to be members. That’s the expectation, this is our specialty that, for perinatal nurses, that we need to be involved, we need to be paying attention, and we need to know what’s out there for research to help us with their jobs. And so that was for me. I actually didn’t know it existed in 2010. I was a nurse in 2010. And so now to hear that they have not only shifted the terminology, which I think is a powerful shift from guidelines to standards of this is the standard, this is the expectation. And the reason for that is because the literature is so incredibly clear on what it needs to be. And so we’re going to talk through this document, we’re going to give you a little bit of an insight into it. When you become a member, if you’re not already, if you are, just go online and search staffing standards and you can find this document for yourself and bring it to your units, initiate discussion, talk to your managers on how are we trying to keep our units most safe?

Because I do want to say that when we’re talking staffing, all of you, if you’re a labor nurse and maybe not a manager, I’m speaking from the floor nurse perspective, that staffing has been frustrating recently. That between travel nursing and retention and burnout, that units are strapped. And it’s hard to know how to advocate for yourself when there just aren’t enough nurses. And potentially, as a floor nurse, you feel like you can’t do anything. And so first of all, we have to know the literature. Second of all, we can initiate these conversations. Obviously you can’t create a warm body out of thin air, but anytime we’re trying to move anything forward in the medical world, if there’s no evidence behind it, nothing’s ever going to move. We know this. “What’s the evidence say? Show me the evidence.” And in this, one of my favorite parts and I’m an evidence nerd, their reference page, or their references, was 10 pages thick when they summarize the data-

It’s like your love language.

It is my love language. You know when you used to print out your articles and then I would always print it until the reference page just to read the article and save paper? Now I’m like, “All I want is the references.”

Yeah, exactly.

And then I end up going on a deep dive into all the other references, which I don’t intend to do for this because I’m not staffing a unit, but I think it’s really important when we can just look at the summary and know what the evidence says. You can bring it to your units. So what does the evidence say?

When you become a member, or if you are, and you search this up, right on page 10 there’s this beautiful chart that shows, what are the standards? So it’s really nice they break it down. There are only 13 states that have state ratios. I didn’t know if you knew this. And California is the only one that even breaks it down to perinatal. I didn’t know that until we were looking up. And so New York is fighting to do that. And I think one of the other states, and maybe it was Texas, has an ICU ratio, but California’s the only one for perinatal. And in California it’s one-to-two for labor, one-to-four for anti, one-to-four for postpartum. And so, what’s interesting about AWHONN’s is they go so in depth. So they’ll say, “One-to-one for patients presenting for initial obstetric triage, one-to-one for patients that are on oxytocin, one-to-one if your patient has minimal to no pain relief.” I love that. That should be one-to-one, helping your patients cope.”One-to-one if your patient is actively pushing,” and that means that you should not be looking at another patient’s strip on the monitor. That’s not evidence based. We shouldn’t be doing that. They say one-to-three couplets, which I love. I know on my unit it’s always one-to-four and I was like, “Man, one-to-three would be so nice for those nurses.” They say one-to-two for patients receiving pharmacologic agents for cervical ripening, which I feel like is really nice, that’s realistic. You have two early inductions and so it doesn’t feel like they’re being unrealistic for hospitals to follow these rules.

Obviously they’re not being anything but evidence based, but I just thought that was nice to be like, “Okay, so you can do some one-to-twos.” So that is just a really quick hit to print this off, put it on your unit just as a reference. If you have a charge binder or something, put it in there. Because sometimes it’s hard to be like, “What were they, what are they doing?” They also have research for our patients with medical issues such as hypertension, preeclampsia, VBAC, et cetera. And all of those should be one-to-one as well. So you have a lot, it’s really nice. It’s all laid out.

I have a few thoughts about this, actually. Of course. We’re so surprised. One is, I’m sure there are people out there listening to this and going, “That sounds so good. I’m so excited by the thought of that, but it will never happen on my unit. This is so unrealistic.” So we’re going to get to the challenges at the end of this episode, so stay tuned on that. I think also one of the challenges that when I remember sitting in convention and being like… So let’s just say that you have a manager who reads the staffing standard and goes to bat because there are managers out there that care this much and they are fighting for these staffing standards and they’re in the back office meetings that they’re in all day. And so they go to bat and they have upper management leadership that says, “We are going to follow this as close as humanly possible.” I had a thought that, do we know how to give one-on-one nursing care?

No. No, we don’t. No, we’re awkward about it. We’re like, “Okay, I’m going to go to the nursing station.”

You go to the nurses and that completely defeats the purpose because the entire point of one-to-one nursing care, which I’m looking at this table and being mostly one-to-one, and honestly when I look at this it is so incredibly realistic and so incredibly up to date with what is from a bedside nurse perspective, that’s doable. Two Cytotec inductions, I got it. And then one will take off and the other one will sleep and then you’ll pass them off and they’ll deliver and blah, blah, blah. Versus one-to-one with a MAG patient and an insulin drip of course you need to be one-to-one. Or the continuous labor support. This, to me, is so incredibly relevant to the bedside nurse, but do we know how to give one-to-one care? Because the expectation would be that you’re at the bedside actually doing full head-to-toes, actually palpating contractions every single time you chart on the tracing, actually building rapport, actually doing all the education.

And I think for many of you, especially if you’re listening to this podcast, that’s the dream that you’re like, “I want to do better.” And you walk away being like, “I was so slammed and I was so pulled between so many different rooms and I couldn’t give my best. I couldn’t educate in the same way.” But my challenge to us here and where my mind goes is, even if you were one-to-one, and there are times that people are one-to-one, and I know it’s easy to be like, “I’m never one-to-one, we’re always…” And there may be units like that, but I would bet a whole lot of money that there is a time when you are one-to-one and are you actually applying yourself in the way that you can, as nurses, to offer your best to that patient and actually do all the things that, in theory, you want to do slash were taught to do in order to actually provide the care necessary?

And here’s where I would almost beg to differ that if we were all doing that with one-to-one care, first of all, outcomes would shift. Because when we’re looking at the evidence here, it’s all about morbidity, mortality, talking all the stats that we’ve talked about and we’ve heard about about C-section rates and outcomes and neonatal stuff and blah, blah, blah. All the things which we’ll get into the lit in a second, but patient satisfaction, all the things that all of us are trying to increase, and yet it’s not happening and we’re behind on the stats in the world. But if we were to apply ourselves, I think we would start to see a difference in those outcomes. Which actually, I say I think that like I’m some genius but I’m not because that’s what the literature says. So the expectation is, if your unit is staffing like this, your nursing care has to improve.

For sure. That’s a lot of challenge.

I know. Love you, love you. You can do it.

But there are hospitals and units out there and if you work, I think it’s the University of Birmingham, somewhere in Alabama where their patients are one-to-one and the nurse is in the room the entire shift. Required. Can you imagine?

I want to hear from one of them. If you are from that hospital, DM Justine with some voice notes on what it’s like. Can I just give some little, quick quotes from this, from the lit review and then you guys can go find the 10 page. They said that they analyzed over a thousand articles. So we’re going to fly through some research here and just some quotes from this that we have pulled out that we think are really interesting for you to know. First of all, this comes from the ANA. So remember we also have, we have AWHONN, but we also have the ANA, the American Nurses Association, we’re part of this whole big group of nurses nationwide. And so they outline the core components of appropriate nurse staffing and they’re defined as a match of a registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice, setting, and situation.

So that is the entire basis of how this was decided, that we have to match how much nursing care do they need. And it goes back to my initial challenge of, if they’re saying we’re one-to-one, they need high-level nursing care, this is not CNA work, this is nursing critical thinking brains on those cases. So when we review the literature, what does the literature say about these particular staffing standards? One, that the relationship between inpatient mortality and inadequate nurse staffing have been substantiated by numerous studies in the last several years across many inpatient settings. There is a relationship between mortality and staffing. Patients die more when our staffing isn’t as good. There is research linking to falls, healthcare-associated infections, failure to rescue, and other types of morbidity that’s been published in various, literally the whole article is just references instead of words telling us about it because there’s so much evidence on this stuff.

It has implications for patient satisfaction, neonatal morbidity, hospital readmission rates, all of which play together, and that’s really what we’re all trying to fix in this country. Another thing they looked at was just miss nursing care. There’s morbidity, mortality, of course we care about that, but I think the little things, and this just becomes to me, sloppy nursing care. And it’s not your fault, but it’s when there isn’t adequate staffing, what happens? You miss their vital signs. There’s regular and comprehensive assessments that are missed, reposition, ambulation, oral care, pain management, timely medication administration, communication with the patient and family, patient education, emotional, physical, psychological support, discharge planning and teaching, all of which are considered safe, high-quality nursing care and can contribute to optimal patient outcomes. If my patient’s blood pressure is increasing or their temperature is increasing, you look back and sometimes you’re like, “Shoot, it’s been like four hours. Whoopsies.” And you’re trying to do the right thing by not strapping them down with all the monitors on them, but it’s easy to get behind when we’re strapped from a staffing perspective.

So those things contribute to poorer outcomes, which none of us want. I love that they also looked at nurse outcomes, so how we feel in our satisfaction, and they said that attention to nurse wellbeing is critical to the safety and quality of hospital care and the financial strength of healthcare organizations. I highlighted that and circled it because I think, partially, if you are a manager, you are a leader on your unit, you have an assistant nurse manager role that, for me, and this is an entire other talk slash class slash chat that I will give someday, that I think a lot of this is just a failure of leadership to understand the priority. We all talk about patient-centered care and patient experience and whatnot, but if our nurses are not well, if they are not healthy, if they are burnt out, if they’re constantly on leave, if they’re having mental health problems because they’re being so worn dry from the bedside, they are not providing the best care they can to the patient, which leads to moral injury.

We’ve been talking a lot about this in the last couple of weeks here at Bundle Birth of this idea that you’re trying to do the right thing and you’re watching care happen either by somebody else or by yourself because you’re giving your best but unable to do better, and knowing you can do better, but not able to based on your resources or your staffing. And then you walk away feeling like, “I don’t feel good about my job.” Who wants to feel that way? I definitely don’t want to feel that way. And so we need to understand that nursing outcomes such as fatigue, burnout, job satisfaction, and retention are negatively affected by inadequate nursing staffing. I’m sure there are people and there… Floor nurses are hearing this and going, “Hallelujah. Where is my upper management? Where is my leadership team that is acknowledging this?”

So if you are a manager, acknowledge this with your team. You may not be able to do anything about it, but even to come to the unit and go, “Guys, I know you’re strapped and I know it’s hard and I know you’re tired and I am trying. We have to bind together in this moment and care for one another. I’m really trying in XYZ amounts of way to help make it better. This is what we got today.” Acknowledging it versus not being visible is helpful. It’s small, but it’s helpful and it’s better than nothing.

And speaking of retention, they even break it down price wise. They talk about how it’s an average of $44,000 for the turnover of a nurse. They talk about how it costs the hospital approximately 3.6 million to 6.5 million. That is a ton of money. We need to be staffing our units appropriately and then maybe our nurses will stay.

Yeah. And those numbers are great for you managers when you’re trying to advocate for better staffing.

But after that it breaks down all of those ratios I talked about earlier with the evidence for each one of those. They definitely don’t leave you hanging. And one of the ones I really liked was on page 33, but it talks about, during a vaginal birth, how many nurses should be there. And I have heard recently in my DMs that there is only one nurse in the deliveries, not even a baby nurse, not even whatever. This is something my hospital does well, we will always have two nurses attend every vaginal birth. One is for the mother and one is for the baby. And the reason, they say, is that the presence of the second nurse to attend the baby is essential for safety of both patients. Within 30 seconds of birth, 85% of term newborns will begin breathing, 5% of term newborns will receive PPV, 2% of term newborns will be intubated, and three of those thousand newborns will receive chest compressions or emergency medications.

That’s more than enough reason to have another nurse at birth. They also did not forget you rural nurses out there, they have a whole section for you guys on how many nurses should be available. They do mention that every unit should be able to perform and crash this area right away, that everyone should be available in there. And so that would be your hospitalist, that would be your anesthesia on board, but they do have a phrase that says “Readily available,” so I can see a lot of hospitals saying, “They are readily available next to their phone at home.” But it’s just not feasible for many hospitals to pay those costs to have the staff sleeping there. But rural nurses, they have you covered as well, but then they do say to always have two RNs. I have talked to nurses that say it’s only one RN. You have to have two for those critical access hospitals. And to be considered a critical access hospital, you have to have 25 beds or less in your whole hospital. So if you are one of those, they have you in there as well.

I think what’s so, and this is a total tangent, but when you say that I’m like, this I also have learned from our mentorship calls because I think it’s easy to be siloed as labor and delivery nurses. There’s so much about our care that connects us. I can use all sorts of terminology. I just taught a physiologic birth class yesterday and it was like, this lingo, Brian, our COO who is not a nurse, was like, “I don’t know at all what you’re saying, but they seem to be really into it.” And so I think there’s a lot that connects us, but I think also our own unit’s environment and where we were trained, I know for me, I’ve only worked in high-risk units, only worked with all the resources, NICU, anesthesia readily available meaning literally down the hall. And so I don’t know what it’s like to work in a critical access hospital. I didn’t even hardly know that was a thing. Or a flight nurse, I met some at the AWHONN convention last time and we had all these so many conversations where I was like, “What? Oh my gosh, this-”

We should have those people on.

We absolutely should.

That would be so fun.

Please reach out if you want to be on the podcast and explain your experience in each of these different types of places. But I think it’s good for us to realize that the scope of nursing care, I’m going to say obstetric care, is different based on your environment. And there are environments that are, I’m in the heart of LA, I worked in Beverly Hills, to the less-than-25-bed hospital with these nurses. All of us speak the same language, but there’s also so much that we can learn from those environments.

Okay so then, in the document, we have all of the reference pages like you said, but then at the back they have even more in their appendix. And what I really liked was, I liked it all, but they even have sample staffing charge nurse assignments. So I thought that was really interesting. I’m trying to figure out how I would use that. Maybe that’s just really helpful for a new person training to be charged. There’s also the disaster plan. So I don’t know about you, but sometimes I’ll think about that. I’ll be like, “If there was a fire right now and I had to take my patient downstairs, I don’t know what I would do.” So they have, in here, they have, if your patient is laboring patient in second stage or they have an epidural or they’re unable to ambulate, so like 89% of our patients, they are going to go horizontal. They are going to go on their bed, they’re going to go, and how to do that. It’s really interesting. So I thought that was really cool that they added that.

And then what I loved at the end, and this is leading us into the challenges conversation is, first of all, there’s all of the resources and different worksheets that you can use for how to staff for what and how to get to your certain numbers of nurses you need to have on your unit, et cetera. But there is, and it’s actually, if you’re following along, Appendix D, a temporary nurse staffing contingency plan due to unexpected increases in census and acuity. And honestly if this wasn’t in there, I’d be like, “Okay, but nice, what a dreamland.” And we all know that there’s increases in census and acuity, there’s also staffing situations, and so they talk about communication, asking for help, how to reassign, how to prioritize, and then they give you potential solutions for how to manage when you don’t have adequate staffing and you really truly can’t staff your unit.

Now I totally understand why units do on call. We had on call, we had mandatory, and then they got rid of it. And now I’m like, “As a leader, on call is so nice to be able to have those nurses.”

On call, to me, I always thought it made the most sense in the world. I’m like, “Why isn’t this just a standard thing?” And I understand it’s cost you’re paying people to be home when, if they were home, you potentially could not pay them, but I just think with how flex and flow the units are and you can have one patient beginning and be over capacity by the end of the shift that it just doesn’t… I don’t know, on call makes a lot of sense.

And even it says, like you said, the potential solutions. And so reassigning nurses, I see that as charge I’m like, “Man,” it’s taboo. But that could be something that you have to do to make ratios work out.

And you can say too, I’m really trying to follow the AWHONN standards for staffing. And all of a sudden you throw evidence in, “I’m following this guideline guys, I’m not just pulling this out of nowhere and I’m not just doing this because I’m out to get you. I’m really trying to keep the units safe.”

And then I’m thinking too for the units that have to hold postpartum patients because the delay in discharges on postpartum. It even says here, early discharge of the diad with follow-up virtual care via telehealth visits and telephone calls. I’m like, that’s really interesting. And that’s really interesting to bring to your unit to be like, “What could we do with that? Because we’re backing up.” And I will say a little side note, it does say that July, September, and August are the busiest months. And I think it was in that order July, September, August. Or August, July, Sepetember

It’s just when residents start.

Is that why they [inaudible 00:24:56]. It’s perfect timing. Get all the experience.

Maybe it’s because the residents slow things down.

Feels busier.

We love you residents, we love you, but you are slowing July.

Right, it was good to know. I was like, “That’s a real thing.”

Yeah, it’s true. I like that.

Okay, that’s all good and said and done, but what do we do about it? I will say, from my perspective on my unit, I see it and I’m like, “I don’t know what I’m going to do about it.” I’m going to bring up this early discharge idea. I think that’s really cool. And I’m going to talk to charge nurses and myself, talk to myself about reassigning patients to different nurses if it makes more sense.

I remember sitting at convention and listening to the audience because it was an open forum. They opened it up to the audience and people were giving perspective and there was all sorts of discipline, not disciplines, they were all nurses, but different titles that were responding and a lot of frustration. Even just the whispers around us of like, “This would never happen,” or like… And I think a lot of times, when you hear this, it’s like AWHONN has to create the ideal evidence-based situation for us. Is it realistic at all times? No, but I think that the standard has been set and we all need to be striving towards it rather than just going, “That’ll never happen.” Instead, that on the beginning of every shift, every charge nurse needs to be trained in this document. This needs to be a part of staff meetings.

This needs to be into upper management meetings of, how do we pursue the goal of setting this standard? Pull in the data on numbers. I know I was in management and I know there’s a lot of numbers happening in those conversations, and whatever angle you have to pull to start shifting the narrative towards that place. And then even talking to your nurses, What does one-on-one nursing care look like? What are the expectations? If I put you one-on-one, this is what’s expected of you. And even then, I know for me, if I’m really honest, there might be times when I’m like, “Then I don’t really want to be one-on-one. I don’t want to sit there and stare at them all night.”

I want those two real easy early inductions.

That I can pop between rooms and then go hang out with my friends at the nurses station and watch the tracing and watch the decels for 15 minutes and before the 20-minute mark go turn them. Let’s be honest. But that’s lazy nursing care. It is. And you are there to work, we are there to give our best to our patients. And so I like it for the sake of the standard has been set and every unit needs to be moving towards the standard. And maybe you start with MAG. That’s an easy one. Rate them from most important to least important.

A MAG patient on PIT versus a PIT patient on PIT. The MAG needs to be one-on-one, maybe starting to say they’re unblocked, they’re without an epidural, they’re not coping. That nurse needs to go one-to-one. And you charge nurses, you leaders, all of us nurses can initiate these conversations and start pushing in that direction, elevating our nursing care. It’s the same conversation about morbidity, mortality of, together we can make a difference. But when most of us throw our hands up in the air and go, “I can’t do anything about that.” It’s like, we all need to claim our role in the bigger picture. And that’s when change can really happen.

I love that. And I think that if you’re out there and you’re like, “I’m not a manager, I’m not a charge nurse, how do I do this?” First of all, download the document and get it printed and start conversations on your unit and be like, “So have you ever seen this before?” Because you might have a charge nurse that has never seen it and you can present it to them in a non-hostile way, just a loving way, “Look what I learned. I listened to Sarah and Justine on this podcast.” And that might trigger them to be like, “Maybe I need to stop calling this induction in,” or, “I don’t need to cram in all these things. I should create a safer environment.”

And we’re all responsible to do that. I think too, there’s an element, and this is one of my biggest takeaways from convention when we were at this session, this session was very impactful for me, all of them were, but this one particularly, I was like, “I feel for people.” And there was a CNO that stood up and spoke and basically just shared her challenges with implementing this. And I’m going to bat for my staff. I am trying, but this is what I’m hearing with budget cuts and with the change in the unit, the unit’s acuity and capacity at times. And I walked to the end of that conversation just going, we just don’t understand each other. We don’t understand each other’s roles. We make so many assumptions about the stress that different people are under. And I hear it all the time from floor, when I was a floor nurse, I was one of those people. I apologized to all of my managers of like, “They just sit in meetings all day, What are they doing? We’re drowning over here. You need to come to the unit and help.”

When, to be honest, that’s not their role. They’re not there to be a floor nurse. And many of them haven’t for a while. And I think there is a balance because I think your nurses need to see you as management. And if they are drowning, they need compassion and they may need help, and it goes a long way to step in when you can. But also, we need to give some grace to understand that our managers, our leaders, are under a enormous amount of pressure. And those meetings, I remember when I started going to meetings like that, I’m like, “I need to be in this. This is a big deal. This actually makes a difference in terms of how people are cared for, how people get paid, et cetera.” And so we just don’t understand each other.

And there are so many leaders out there that are going to bat for you. They feel you, they know you, they are trying, and we need to give a little bit more grace to our leadership team. I say that within reason, obviously still advocating for yourself and not just going like, “Your job is hard. Thanks so much,” and that’s it. Let’s work together to help understand each other, not write each other’s stories and everybody move the dial closer to better, more evidence-based practice that is safer for our families and, ultimately, for patient outcomes, and that’s what AWHONN has done for us here.

Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us if you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram.

We will link everything that we talked about, including the staffing standards, AWHONN’s website, how to become a member. If you’re not already, we highly recommend that you join at least an online membership. I like the hard copy membership because you do get journals in the mail and that helps you to stay up to date and growing in your career, which is ultimately the goal. So we’ll link everything in the show notes down below for you to check out.

Now it’s your turn to take what you learned today, apply it to your life, try to stay in ratio, and we’ll see you next time.