Standards for Professional Registered Nurse Staffing for Perinatal Units
EXECUTIVE SUMMARY
These updated nurse staffing standards from the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) are the result of more than three decades of evidence that appropriate nurse staffing based on acuity and census supports high quality nursing care and positively influences patient outcomes. Since its founding in 1969, AWHONN (formerly known as the Nurses’ Association of the American College of Obstetricians and Gynecologists until 1992) has set the standard of care for women’s health, obstetric, and neonatal nursing in the United States. The staffing standards reflect AWHONN’s continued responsibility and leadership in standard setting.
Since 2010, when the first edition of the AWHONN nurse staffing guidelines was published, there has been an extensive amount of nursing research disseminated about nurse staffing and patient outcomes, building on and supporting previous studies. There is strong and consistent evidence that inadequate nurse staffing has an adverse effect on inpatient hospital morbidity and mortality. The business case for adequate nurse staffing to meet the needs of the patient is robust (American Nurses Association, 2018; Begley et al., 2020).
Attention to nurse well-being is critical to the safety and quality of hospital care and the financial strength of health care organizations.
A summary of the nurse staffing standards is presented in Table 1. A detailed background and rationale for each of the standard nurse-to-patient ratios for professional registered nurse staffing for perinatal units based on acuity (i.e., the dose of nursing care required for safe and effective care) and all of the associated aspects of care recommended by professional and regulatory associations are presented in Table 2.
Hospitalization for labor, birth, and postpartum is the most concentrated activity-intense part of the childbirth continuum, with significant implications for immediate and future health. Childbirth and newborn care in the hospital setting deserve careful attention to appropriate nurse staffing based on individual patient characteristics and clinical situations to promote safe, high-quality nursing care and optimal patient outcomes.
The context for the hospital portion of contemporary perinatal care includes the following:
- Being born, giving birth, and having complications of childbirth remain the most common diagnoses for national inpatient hospital stays in the United States, with liveborn being nearly double that of the next common diagnosis, accounting for more than 10% of all U.S. hospital stays.
- Cesarean birth continues to be the most common surgery by far in the United States; the third-most common is perineal muscle laceration repair at birth.
- Conditions related to pregnancy and childbirth accounted for 4 of the top 20 most expensive conditions paid for by Medicaid.
- There is increased need for support related to social determinants of health, including social and economic disadvantages, drug and alcohol use, and language barriers.
- There must be recognition of the impact of long-standing structural racism embedded in the health care system on perinatal outcomes and the need for comprehensive changes.
- In 2019, 9.3% of babies born in the United States were admitted to a neonatal intensive care unit.
- Maternal morbidity and mortality in the United States are higher than other peer countries and disproportionately affect minoritized women.
- Delays in recognition and diagnosis are associated with failure to rescue and preventable maternal deaths. There are a number of nursing interventions that have the potential to save lives that require adequate nurse staffing to promote bedside presence for patients who need more attention for a variety of reasons during the childbirth hospitalization.
For example, enough nurses to timely recognize and initiate appropriate treatment for patients experiencing evolving severe maternal morbidity in the inpatient setting and to allow sufficient time for a thorough discussion of early maternal and newborn warning signs during hospital discharge teaching with confirmation of patient understanding are essential aspects of safe, high-quality perinatal nursing care.
Classification of patients and clinical situations help determine the adequacy of nurse staffing by establishing the nursing effort required for safe and effective care and are based on acuity. For example, the frequent required assessments and documentation of maternal and fetal status and the administration of a high-alert medication are the basis for the standard nurse-to-patient ratio of 1 nurse to 1 woman (2 patients, woman and fetus) receiving oxytocin for induction or augmentation of labor. The multiple and ongoing required assessments and documentation of maternal and newborn status and associated interventions, critical support, and teaching during the postpartum and newborn stay are the basis for the standard nurse-to-couplet ratio of 1 nurse to no more than 3 mother–baby couplets (1 couplet is 2 patients, mother and newborn; 3 couplets are 6 patients).
Historically, the fetus and newborn have been somewhat invisible patients, not considered or counted in patient acuity, yet they account for a significant amount of nursing care and documentation. When calculating the number of licensed beds and patient census reported by hospitals, well-baby bassinets and healthy newborns are not included, yet newborns require an enormous amount of close assessment, screening, feeding support, medical record documentation, and discharge teaching for the parents. Continuing as per the 2010 AWHONN nurse staffing standards, the fetus and the newborn must be considered when determining patient acuity and nurse staffing requirements.
As per the nurse staffing standards published by our colleagues (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 1983–2007) in consultation with AWHONN, it is presumed that there are ancillary personnel to perform nonnursing duties as well as provide support and comfort to perinatal patients. Adding licensed practical nurses, licensed vocational nurses, doulas, obstetric technicians, or nurses’ aides to the staffing numbers does not preclude requirements to meet staffing standards for registered nurses. Other personnel, including those who provide clerical support, are necessary for indirect patient care activities (AAP & ACOG, 1983–2007). Without ancillary support personnel, more nurses may be needed than are indicated in these standards.
Quality improvement is a vital part of keeping patients and team members safe (AAP & ACOG, 2017; Centers for Disease Control and Prevention, 2016; U.S. Department of Health and Human Services, 2021). Central to the success of perinatal quality improvement is allocated nursing time and funding to develop, conduct, and participate in quality improvement projects; analyze results; and make changes as needed based on the findings (CDC, 2016). Quality improvement activities should be included in the unit staffing budget and acknowledged as an essential part of unit operations to support participation of clinicians, including nurses, to promote perinatal patient safety (American Nurses Association, 2020; Begley et al., 2020).
Adequate staffing is critical to providing safe, high-quality nursing care for all those who give birth and their babies. Staffing needs in perinatal units are dynamic, consistent with the various types of patients and clinical situations encountered in a perinatal service. Included are two tables that detail the appropriate nurse-to-patient ratio in each phase of care during the perinatal hospital stay, from obstetric triage through antepartum, labor, vaginal birth, and cesarean birth; postanesthesia recovery; mother–baby care; and the neonatal intensive care unit. An appendix is included with sample staffing grids that can be applied to units with maternal levels of care (I–IV); suggestions for contingency planning, patient surges, gaps in nurse staffing, and disaster events; and tools for predicting nurse staffing levels.
Health care leaders are responsible for ensuring that adequate nurse staffing is budgeted and resourced to promote the best outcomes for all those who give birth and their babies. Ultimate outcomes are best optimized by making sure that childbearing women are well cared for and supported and that their babies at the beginning of life have the best start we can provide. Our vision for the care of childbearing women and their babies includes making sure that all patients in the perinatal setting are provided with safe and appropriate nurse staffing to promote high-quality nursing care and the best possible outcomes.
