Optimizing Care for Expectant Moms: New Research Seeks to Determine Optimal Nurse-Patient Ratios in Labor and Delivery
Dec 15, 2016 11:00 AM
New Research Seeks to Determine Optimal Nurse-Patient Ratios in Labor and Delivery
Almost 20 years ago, a groundbreaking study of acute care nursing units found that the number of patients a nurse was responsible for directly affected that patient’s chance of complications, influencing the way hospitals units are staffed. Now, the University of Utah College of Nursing’s Barbara Wilson, PhD, RNC-OB is working to understand how these ratios impact care in labor and delivery units.
Supported by a grant from the Agency for Healthcare Research and Quality, Wilson is analyzing 12 of Intermountain Healthcare’s 22 hospitals, comparing staff levels with patient outcomes. The impact that a hospital or delivery setting has on birth outcomes is a longtime research interest of Wilson’s, a maternal child nurse. Wilson moved from Utah to Arizona to study for her PhD. The move allowed her to experience working in a variety of health care settings, and she saw how system-level factors influenced patients.
“I started as a staff RN and then as a charge nurse, head nurse, a director for a women’s center, and finally as the Nurse Administrator over a region of women’s hospitals. I’m absolutely convinced that there is a direct link between how hospitals staff and how patients fare.” One of a labor and delivery nurse’s key responsibilities is to monitor a woman in labor from the time she is admitted until the baby is born to head off potential complications. If, for example, the fetal heart rate drops, the nurse can bring it back up by repositioning the mother, giving her oxygen, or ensuring that the fetus’ head isn’t pinching the umbilical cord. Nurses do a great deal to help the mother through labor, explains Wilson, but if they are caring for too many women at once, they lose the ability to closely monitor each patient.
Wilson hopes the study will confirm what she has long suspected—that higher nursing ratios lead to better outcomes for mothers and newborns—and to use that information to make staffing ratio recommendations for labor and delivery departments.
Wilson and her research partner Dr. Mary Blegen, a professor at UCSF, previously created a predictive model to figure out how many patient care hours per day a birth requires an RN to be present. The model, which has been independently tested and validated, will be applied Intermountain Health Care’s real-time documentation system of patient conditions along with the staffing reports to compare the two as the mother progresses through labor and delivery. The model also measures and analyzes the time when a labor and delivery nurse is away from her primary patients (for example, conducting fetal monitoring when a pregnant patient comes into the emergency room after a car accident).
This is the first study of its kind in childbearing women, largely because so many factors contribute to outcomes in birth. These include the mother’s health status, the level of prenatal care she received, and whether the baby is premature. Wilson plans to control for these variables by limiting the study to first-time mothers with a single baby who are low risk and are delivering at term. The two outcomes she and her partners will compare are the chances of delivery via caesarian section and of the baby being admitted to the Neonatal Intensive Care Unit (NICU).
As health care reform changes the way that hospitals is reimbursed, Wilson is hopeful that the findings of her study will influence staffing levels for the childbearing family. “In the previous healthcare model, hospitals weren’t especially interested in your health until you got admitted, and then the focus was on making you better rather than keeping you out of there in the first place. With healthcare now moving away from fee-for service, I think we’re much more focused on prevention, so we are looking at upstream factors that can reduce adverse outcomes for patients, including childbearing women.” A similar, earlier study looked at nurse staffing levels for medical surgical patients to determine how nurse-to-patient ratios impacted the likelihood of the patient facing a complication like a pressure ulcer or contracting pneumonia, or the nurse failing to recognize early signs of significant patient decline. This research eventually led to staffing laws in California that limited the number of patients each nurse could be responsible for at a given time.
The labor and delivery study, which began in August 2016, is expected to last two years, with the first year spent gathering data, and the second evaluating the results. Wilson’s partners in the project also include Kristy Nelson, program manager for the women and newborns service line at Intermountain Health Care, and Dr. Richard Butler, an economist at Brigham Young University who is serving as the statistician for the project.