Safe Nurse Staffing is More than Numbers and Ratios
When a woman is receiving oxytocin during labor, frequent assessment of maternal and fetal status is necessary to make sure both patients are doing well. Assessment and documentation of the following parameters are required every 15 minutes: fetal heart rate baseline, variability, presence or absence of accelerations and decelerations, contraction frequency, intensity, and duration, uterine resting tone, and oxytocin dose in milliunits per minute. Emotional, informational, and physical support are essential and much appreciated by laboring women (Lyndon, Simpson, & Spetz, 2017). These critical aspects of nursing care for women having induction or augmentation of labor cannot be done adequately if the nurse has an additional patient assignment. Likewise, to be able to do all that is necessary to meet their clinical and safety needs, women with pregnancy complications such as preeclampsia receiving intravenous magnesium sulfate require one-to-one care.
Active pushing during second-stage labor requires continuous bedside attendance with complete handoff of care of other patient assignments (e.g., another nurse is actively monitoring, caring for, and documenting such in the medical record for the second patient). During the birth process, one nurse for the mother and one nurse whose sole responsibility is the newborn baby are required (AAP & American Heart Association, 2016; AWHONN, 2010). The baby needs comprehensive initial assessment, Apgar scores, and ongoing surveillance during the transition to extrauterine life. Breastfeeding should be initiated if the woman has chosen to breastfeed. Assisting a first-time mother with breastfeeding often involves intensive nursing efforts. As the 2-hour recovery period evolves, multiple maternal safety assessments are needed every 15 minutes including vital signs, fundal checks, and evaluation of bleeding. The healthy newborn should be positioned skin-to-skin on the mother's chest with the baby's face able to be seen, the nose and mouth uncovered, head turned to one side with the neck straight, and under continued surveillance by the nurse (AAP, 2016). Once the critical aspects of care for the mother and baby are completed, one nurse can care for the healthy mother–baby couplet (AWHONN). The recovery period is a time of great joy and relief, but also a time of risk. Postpartum hemorrhage must be actively prevented. Newborn transition assessments every 30 minutes for at least 2 hours should be performed (AAP & ACOG, 2012). Continued attendance to the mother and baby is vital to safety. If the nurse responsible for postpartum recovery is given a new patient assignment before the 2-hour recovery is completed, mother and baby are at risk for preventable harm. The sheer volume of assessment, care, support, and information needed by the new mother to care for herself and her newborn mandates no more than three mother–baby couplets per nurse.
Safe staffing is not numbers or ratios, rather the essential nursing care for optimal outcomes. Productivity targets should financially support enough nurses to provide that care that is required based on national standards and guidelines. The numbers recommended in the AWHONN (2010) staffing guidelines represent the ability to perform that requisite nursing care.