Welcome to part three of Three Trailblazing Hawaiian Nurses blog series – Alice Ting Hong Young – 1911- 1992: Hawaii’s First Nurse Midwife.
In honor of Asian American and Pacific Islander Heritage Month, Minority Nurse is republishing the Three Trailblazing Hawaiian Nurses blog series from October 2022.
Hawai’i’ is one of the most multicultural and ethnically diverse places on Earth. This rich blend is reflective of its nursing history. Pioneer Registered Nurses in Hawaii include nurses of Native Hawaiian, English, Chinese, Japanese, and Filipino heritage. Their lives and work create a beautiful kaleidoscope of service that has improved the lives of residents in this tropical paradise for over 100 years. The life stories of three groundbreaking Hawaiian RNs can inspire us all.
Alice Ting Hong Young – 1911- 1992: Hawaii’s first Nurse Midwife
Alice Ting Hong Young was born on October 24, 1911, in the Chinatown section of Honolulu. Her father, Wah Kam Young, was a Chinese immigrant and fish merchant. Her mother, Bow Ngan Sum, was of Chinese and Hawaiian descent. Mr. Young died when Alice was twelve, leaving her mother with nine young children to raise.
Alice’s hopes to attend medical school were dashed due to the family’s financial hardships. Instead, after graduating from McKinley High School in 1929, at age 18, Alice entered nursing school at the St. Luke’s Hospital School of Nursing in San Francisco. There, students exchanged their labor for tuition, making it possible for poor students like Young to become RNs. In 1932, Young graduated, passed the Registered Nurse examinations, and returned home. She quickly entered the one-year public health nursing course at the University of Hawaii that Mable Smyth had co-founded six years earlier.
The Palama Settlement hired young to provide various public health nursing services upon graduation. After two years, Smyth, then the Territorial Board of Health Nursing Director, hired Young to be a public health nurse with the Territorial Board of Health on the island of Molokai. Young worked in the maternal-child, school, home health, and tubercular nursing programs.
In 1900, the population of Hawaii was 154,001. Hawaii’s four most prominent ethnic groups listed in that year’s census (in round numbers) were Japanese – 61,000, Native Hawaiians – 38,000, Caucasians – 29,000, and Chinese – 26,000. By 1930, the Territory’s population had more than doubled to 368,336, and new ethnic groups appeared in the census.
alice-ting-hong-young-hawaiis-first-nurse-midwife
The 1930 Hawaiian Census listed 140,000 Japanese, 80,000 Caucasians, 63,000 Filipinos (none were listed in 1900), 51,000 Native Hawaiians, 27,000 Chinese, and 6,000 Koreans (also newly listed since 1900), while African Americans and Other groups combined made up fewer than 1,000 residents. This growth and change reflected the large number of Asians immigrating to Hawaii for work, primarily as plantation laborers. Among each ethnic group were educated and skilled midwives and untrained and dangerous midwives, all of whom attended home births.
In 1931 the Territorial Legislature passed Act 67, the first law to regulate the practice of midwifery in Hawaii. Midwives were required to register with the Board of Health. They were required to show proof of “being reasonably skilled and competent” in delivering babies and post-partum care, be of good moral character, and be at least 21 years old. In addition, they could only attend to women with no significant health problems and with no difficulties during their pregnancies.
Each registered midwife was issued a standard set of supplies and lengthy instructions by the Board of Health. In the first year, 168 midwives registered. Most were Japanese. Others were Filipino, Hawaiian, and Portuguese. During the 1930s, approximately a quarter of babies born in Hawaii were attended by midwives. While the law was generally successful in upgrading midwifery practice in Hawaii, there was no provision for supervision to ensure the regulations were being observed.
Young Becomes Hawaii’s First Nurse Midwife
In 1935, the U.S. Congress passed the Social Security Act, which provided funds to enhance maternal-child health services by expanding public health nurses’ skills and education. In 1936 the Hawaiian Territorial Board of Health selected Young to become the first Nurse Midwife and Midwife Supervisor for the Territory. It paid for her to go to the mainland for advanced education.
Young spent the academic year 1936-37 in New York City, earning a certificate in midwifery from a combined program sponsored by the Maternity Center Association of New York, Teacher’s College, Columbia University, and the Lobenstine Clinic in Harlem. In 1937, Young was awarded her Nurse-Midwife certificate and returned home to start her new duties.
Young visited every midwife in the Territory at least twice a year, observing and demonstrating new techniques. She inspected midwife bags to ensure all the necessary equipment was present and clean, and she followed up on reports of lay midwives practicing without a license. In addition, Young taught classes for midwives on each island. Although she spoke English, Cantonese, and Pidgin, she did not speak Japanese, so public health nurses fluent in Japanese taught the Japanese midwives. In 1940, Young wrote a manual for midwives, drawing on materials used in other states but adapting it to Hawaiian mores.
By 1940, maternal and infant mortality and morbidity rates were improving on the island, due in no small part to Young’s work. However, things changed drastically on December 7, 1941, when the Japanese attacked Pearl Harbor. Within hours, martial law was declared in the Territory; it stayed in effect until 1944. Travel was restricted, especially for Japanese residents. Because most midwives were Japanese, this forced many women to deliver babies without help or in a hospital. She told a reporter in a 1984 interview that World War II “wiped out” midwifery on the islands and that all births were mandated to occur in a hospital under martial law.
Soon after WWII began, Young met Lieutenant Commander Drew Kohler, a Caucasian from Minnesota working in naval intelligence stationed at Pearl Harbor. They fell in love and married on November 14, 1942. She continued her work with the Board of Health until she became pregnant in 1943. For several years she focused on being a new wife and mother of three small children.
Alice Ting Hong Young Kohler on left giving advice to another nurse circa 1950s
Although she was no longer with the Board of Health, Kohler’s pioneering work as a nurse midwife continued. As she documented in her 1953 article in Nursing Outlook, Kohler initiated and coordinated the first childbirth education classes in Hawaii with obstetricians in private practice. In 1949, she approached a busy obstetrical office in Honolulu and was hired to create a series of six two-hour classes about pregnancy, labor and delivery, and infant care. Attendance was always high. There was a morning and afternoon class, but soon an evening class was added to include expectant fathers.
In the first 30 months of the program, 1,338 people attended the sessions. Kohler used materials from the Board of Health and the Red Cross, but, as with the Midwife Manual a decade earlier, she adapted the information to meet the cultural needs of her patients. Kohler sought donations of materials and equipment, wrote the course curriculum, and recruited public health nurses to teach the classes.
Over the following decades, Lieutenant Commander Koher’s career took the family to Japan, Taiwan, and Washington, DC. While in Taiwan, Alice Kohler worked in the obstetrics ward at the U.S. Navy Hospital.
The Kohlers retired to Hawaii in the mid-1960s. In 1984, the University of Hawaii honored Kohler with the first Distinguished Alumna Award for her commitment to nursing and the people of Hawaii. She passed away in 1992 and is buried in Honolulu.
Mabel Isabel Wilcox, Mabel Leilani Smyth, and Alice Ting Hong Young are three pioneer nurses that broke new ground in a new profession to help the people of Hawaii. They freely gave their time, energy, money, and knowledge to ensure care for the most vulnerable. Their lives and careers illuminate the best of nursing. All nurses can benefit from their examples of extraordinary service.
Welcome to part two of Three Trailblazing Hawaiian Nurses blog series – Mabel Leilani Smyth,First Hawaiian Registered Nurse with Hawaiian ancestry, often referred to as “Hawaiʻi’s Florence Nightingale.”
In honor of Asian American and Pacific Islander Heritage Month, Minority Nurse is republishing the Three Trailblazing Hawaiian Nurses blog series from October 2022.
Hawai’i’ is one of the most multicultural and ethnically diverse places on Earth. This rich blend is reflective of its nursing history. Pioneer Registered Nurses in Hawaii include nurses of Native Hawaiian, English, Chinese, Japanese, and Filipino heritage. Their lives and work create a beautiful kaleidoscope of service that has improved the lives of residents in this tropical paradise for over 100 years. The life stories of three groundbreaking Hawaiian RNs can inspire us all.
Mabel Leilani Smyth 1892 – 1936 First Hawaiian Registered Nurse with Hawaiian Ancestry “Hawaiʻi’s Florence Nightingale”
Mabel Leilani Smyth was born in Honolulu on September 1. 1892, to Julia Goo and Halford Hamill Smyth. Like many Hawai’ians, she had an ethnically mixed lineage. Smyth’s ancestors included people from Hawai’i, England, China, and Ireland. Smyth’s older sister Eva was born visually impaired, and from a young age, Mabel was Eva’s companion and guide while her mother tended to the three younger children and her father was at sea. Caring for her sister foreshadowed a lifetime of caring for others.
Smyth spent her childhood on her mother’s Kona coffee farm in Hawaii. All the Smyth children worked hard picking and cleaning coffee beans and cultivating and pounding taro root to make poi, a national dish of Hawai’i. Julia Smyth earned additional money weaving and selling lauhala hats. The family was trilingual, speaking Hawaiian, English, and Pidgin in the home. Being fluent in three languages helped her cross racial and ethnic boundaries and gain acceptance in multiple communities. After Smyth’s father died around 1907, the family moved to the Palama neighborhood, a suburb of Honolulu on the island of Oahu. In 1910, Smyth graduated from President William McKinley High School and began working as a nanny for the Rath family.
Mabel Smyth Begins Career as a Nurse
James and Ragna Rath, Caucasian social workers, moved from Massachusetts to Hawaii in 1905 for James to direct the Palama Settlement, a multifaceted community service agency. In 1900 at least five cases of bubonic plague were reported in the Chinatown section of Honolulu. To eradicate the threat, city officials decided to burn the homes of the plague victims. Unfortunately, the fire burned out of control, destroying at least four blocks of Chinatown. As a result, thousands of recent impoverished immigrants were homeless, and many lost their jobs and businesses. The Central Union Church created the Palama Settlement (PS) in response to these dire conditions. Church officials founded and supported many programs, including visiting nurses, a pure milk station, a day camp for children with tuberculosis, an adult night school where English lessons were taught, a day care center for working mothers, and a swimming pool with hot showers. James Rath was busy overseeing these efforts, and Regna Rath worked by his side. The Raths had five children and needed at-home childcare, so they hired Mabel Smyth.
In 1912 the Raths took their five children and Smyth to Massachusetts for a sabbatical. Before the Raths returned to Honolulu, they encouraged and arranged for payment for Smyth to attend the Springfield Hospital Training School for Nurses. Upon her graduation in 1915, Smyth returned to her family in Honolulu. She spent two years as the “agent” of the Hawaiian Humane Society. The Society had a mission to relieve suffering wherever it was found – among children, animals, and even battered wives. Smyth left the Society to become the first nursing supervisor at the PS. Organizationally, the PS divided the city of Honolulu into seven districts, with a nurse assigned to each. Each nurse was responsible for providing their district school nursing, home visiting, and clinic hours. At age 26, Smyth oversaw the entire nursing program.
Mabel Leilani Smyth was the first Hawaiian Registered Nurse with Hawaiian ancestry, often referred to as “Hawaiʻi’s Florence Nightingale”
Smyth is First Hawaiian Nurse to Earn Advanced Certificate in Nursing
Smyth took a year off from the PS, from August 1921 to August 1922, to pursue graduate work in public health nursing at Simmons College in Boston. She was the first Hawaiian nurse to earn an advanced certificate in nursing. After her year of graduate studies, she continued her supervisory work at PS until 1927, when she accepted a position with the Territorial Board of Health as the first Director of the Public Nursing Service for the Territory of Hawaii. Up to that time, the Board of Health had hired nurses in either tuberculosis work or maternal child health work. Under her leadership, these programs merged and expanded to create a generalized public health nursing program covering all the islands in the Territory. Two years later, the nurses at the PS came under the auspices of the Department of Public Health Nursing to better coordinate care and reduced duplication of services.
Smyth gave many lectures to community and professional groups on the islands to increase public understanding and support for public health nursing. She successfully strove to upgrade lay midwives’ skills and standards, instituted immunization drives against diphtheria, coordinated chest x-ray screenings for TB, organized well-baby clinics across the islands, and represented Hawaii at several national public health meetings on the mainland.
In addition to her work, Smyth was a leader in professional nursing organizations. She was a charter member of the Nurse Association of the Territory of Hawaii when it was formed in 1920 and then elected president of the organization in 1925 and 1932. Smyth was also president of the City and County of Honolulu Nurses Association, a leader of the Honolulu Chapter of the American Red Cross, and a member of the Board of Registration of Nurses from 1925 to 1935. In 1926, Smyth was a small group of nurses who created a public health nursing course at the University of Hawaii to prepare nurses who wanted to practice public health nursing.
Hawaiian Florence Nightingale
Sadly, Smyth’s life was cut short at the young age of 43 after spending half her life serving others. A sewing needle had been lodged in her chest since she was a child. On March 24, 1936, she underwent an operation to remove the needle and tragically died of a post-surgical embolism that same day.
Smyth was widely mourned both in Hawaii and in the nursing community. Her obituary in the American Journal of Nursing read in part:
Endowed with charm and a dynamic personality, she had attained a high position in the ranks of Hawaiian women of achievement. Through her devotion, sympathy, keen sense of community responsibility, spirit of cooperation, and intelligently directed energy, Miss Smyth was, at the time of her untimely death, at the very height of her powers, the outstanding leader in nursing in the Territory of Hawaii.
After her death, a committee was formed to establish a memorial to the “Hawaiian Florence Nightingale.” It raised over $110,000 for the Mabel Smyth Memorial Building, with over 4,000 people contributing. The building was dedicated on January 4, 1941, with Hawaiian chants and music. It housed offices of the medical and nursing professional organization on the island, classrooms, a library, and an auditorium. The building was a fitting memorial to a nurse who did so much for her family, neighbors, and all Hawaiians.
Check back next week for part 3 of the Three Trailblazing Hawaiian Nurses blog series – Alice Ting Hong Young, Hawaii’s First Nurse Midwife.
When Nick Escobedo DNP, RN, OCN, NE-BC, director of Inpatient Oncology at Houston Methodist Hospital, started his nursing career, he didn’t expect to land in oncology nursing. During May’s recognition of Oncology Nursing Month, Escobedo says the career has offered distinctive opportunities for personal and professional growth.
“I went into a basic acute care setting right out of nursing school because I wanted to get a good, solid foundation for myself in practice,” Escobedo, a former president of the Oncology Nursing Certification Corporation, says. But the learning process opened up new, and appealing possibilities. “I had an opportunity to learn the skill of chemotherapy,” he says, “and the more I got to learn about it and spend time working with patients, I quickly learned this specialty was for me, and I wanted to do that full time. It chose me.”
What sets it apart from the science and the practice part of nursing, he says, is that cancer affects every body system. Oncology nurses treat patients through a span that lasts from cancer diagnosis to remission or to end of life.
“I got to use my critical thinking skills, and I got to have knowledge of all the latest and greatest therapies available,” he says. Escobedo, a dedicated lifelong learner, says it’s imperative that he stays on top of understanding new technology and the range of cancer drugs and treatment options available to patients and the safest ways to administer them.
Thankfully, oncology nursing is very collaborative, he says, and so nurses work with physicians, frontline providers, therapists, chaplains, nutritionists, clinical pharmacists, and volunteers to understand how the different pieces help drive the care of a patient. Escobedo says a nurse might check in with a clinical pharmacist to find out more about a particular drug to learn about interactions, how a patient might respond to it, and how to use it safely.
Additional education is essential for oncology nurses, he says. “My journey toward certification was big,” he says. “That was one of my ways at looking at my competence as a clinician, to say I was an expert in the care of oncology patients. So my journey to pursue that certification and have knowledge to be successful was key. I’m a big advocate for certification.”
To balance the intensity of understanding the drugs and treatments used for cancer, Escobedo says the relationships oncology nurses develop with their patients is special. “You develop long-term connections with patients and their family members,” he says. “They give so much of themselves.”
Those strong connections can help nurses and patients through the celebrations of successfully completing cancer treatment or the more difficult prognosis or outcome. “This is very hard work,” says Escobedo. “The reward is that we get to do that work, but we need to balance that with resilience. This is tough work and we have to promote and champion a little of that balance. We try to look at the celebrations that happen.”
The success stories are uplifting and have a lasting impact on nurses. “We hear from patients who were treated years ago, and they come back to check in,” he says. Patients relay news of celebrating weddings and anniversaries and the arrival of children and grandchildren. Some have even paid it forward and after being treated for cancer, have embarked on fundraising campaigns to help others.
“Our patients push us to have that drive,” he says, “And we see lots of really good outcomes.” Patients can go through treatment that is long term and so being able to go through the process with them is something oncology nurses find so rewarding, says Escobedo.
Escobedo encourages nurses who are interested in exploring oncology nursing to find a way. “If you think you could be good at it, why don’t you try it?” he says. Find good mentors and be sure to seek out projects and opportunities that will get you out of your comfort zone. “Nurses don’t get lots of oncology nursing experience through training or nursing programs,” he says. “This is a full and rewarding specialty.”
Welcome to part one of Three Trailblazing Hawaiian Nurses blog series – Mabel Isabel Wilcox, First Registered Nurse in Hawaii.
In honor of Asian American and Pacific Islander Heritage Month, Minority Nurse is republishing the Three Trailblazing Hawaiian Nurses blog series from October 2022.
Hawai’i’ is one of the most multicultural and ethnically diverse places on Earth. This rich blend is reflective of its nursing history. Pioneer Registered Nurses in Hawaii include nurses of Native Hawaiian, English, Chinese, Japanese, and Filipino heritage. Their lives and work create a beautiful kaleidoscope of service that has improved the lives of residents in this tropical paradise for over 100 years. The life stories of three groundbreaking Hawaiian RNs can inspire us all.
Mabel Isabel Wilcox 1882-1978 First Registered Nurse in Hawaii
The first Registered Nurse in Hawaii was Mabel Isabel Wilcox. Her maternal (David and Sarah Lyman) and paternal (Abner and Lucy Wilcox) grandparents were Caucasian Christian missionaries who traveled from New England to the Kingdom of Hawaii in the 1830s to establish schools and preach the Gospel.
Mabel was born on the island of Kauai on November 4, 1882, to the Wilcox’s son Samuel and the Lyman’s daughter Emma. She remembered a carefree childhood in a family that valued religion, philanthropy, education, and public service. When Wilcox was in her teens, there were no college preparatory high schools in Hawaii, so her parents sent her to California to complete her high school education. However, she stayed on the mainland, and in 1911 she graduated from the Johns Hopkins School of Nursing in Baltimore and passed her Registered Nurse examinations. Soon after graduation, Wilcox returned to Hawaii and began her career as the resident school nurse at the Kawaiahao Seminary, a Congregational Church-sponsored girls’ school in Honolulu, becoming the first Registered Nurse in Hawaii.
An early photo of Mabel Wilcox Hawaii’s first Registered Nurse
Earned the Moniker “Kauku Wilikoki”
Wilcox missed her extended family on Kauai, so in 1913 she accepted an assignment to begin and head the Territorial Board of Health’s anti-tuberculosis (TB) campaign on the island. She was the only Board of Health nurse on the island and served approximately 5,000 people. Often on foot or horseback, she did case investigations, collected sputum samples, educated the community about the disease, and provided follow-up care to those diagnosed with TB. Wilcox quickly saw the need for a TB Hospital on Kauai. She convinced service clubs and business organizations on the island to support her idea and solicited most of the funds needed from her aunt and uncle, Emma and Albert Wilcox. After a year of construction, the Samuel Mahelona Memorial Hospital opened in 1917.
Although Wilcox was hired to reduce the number of tuberculosis cases on Kauai, in 1920, Hawaii reported a 25% infant mortality rate, double that of the mainland. In addition, there were no maternal/infant health nursing programs on Kauai, so Wilcox added education on nutrition, sanitation, and healthy birthing practices to her rounds when she encountered pregnant women and young children. As a result, she earned the moniker “Kauku Wilikoki” or Doctor Wilcox for her work.
As soon as the U.S entered WWI in April 1917, Wilcox was anxious to do her part. She wrote the American Red Cross nursing service requesting an overseas assignment. Her work with maternal/child health in Hawaii gave her knowledge and experiences she would draw on during her war years.
Nurse Behind the Lines During WWI
Beginning in the winter of 1918, Wilcox was the Head Nurse of a hospital and outpatient clinic for women and children in Le Havre, France. The facility was relatively safe miles from the battlefront lines when Wilcox arrived. After that, however, the fighting grew closer. In September of 1918, Wilcox was sent into nearby Belgium, directly behind the advancing Allied troops, to inspect maternal and child health conditions and conduct clinics. While there during the final Allied campaign, she wrote to her family: “One night we were bombed, crawled under the bed, two of us trying to get into one helmet. Scared.” After the war ended, Wilcox spent another year in France helping mothers and children, many of whom were orphaned or refugees. Once the French government was stable enough to take over her work, she returned to Hawaii. She was awarded medals from the Queen of Belgium and the mayor of Le Havre for her service.
Kauai’s First Territorial Maternity and Child Health Hygiene Nurse
In 1921 Congress passed the Sheppard-Towner Act providing funds for maternal-child health programs. With these new monies, Wilcox was hired as Kauai’s first Territorial Maternity and Child Health Hygiene Nurse to focus full-time on improving the health of women and children. As they began hiring more nurses, she became the Supervising Nurse, a position she held until her retirement in 1935. In the first year, public health nurses made nearly 1,000 home visits, and newly organized “demonstration clinics” recorded an attendance of 4,403 mothers. Infant mortality dropped by 14% in the first year of the program. The program successfully provided care to 8,398 mothers and infants in 1927.
Congress discontinued funding the Sheppard-Towner programs in 1929. Then in 1930, Wilcox became the supervisor of the new generalized public health nursing program on Kauai. She oversaw tuberculosis, maternal-child health, and school and home health nursing programs on the island. During this time, Wilcox was a leader in many professional associations. She launched the Kauai Nurses Association, served as its first president from 1932-1946, served as the first executive director of the Kauai TB Association, and was on the Board of the Mahelona Hospital.
G.N. Wilcox Memorial Hospital
On Kauai, many sugar plantations maintained small, often inadequate, hospitals for their workers and families. After Wilcox’s father and mother died (1929 and 1934, respectively), she and her siblings decided to build a new, modern general hospital in their memory. She retired in 1935 and spent her time and energy making the G.N. Wilcox Memorial Hospital a reality for the next few years. It was dedicated on November 1, 1938, with 96 beds in wards and semi-private private rooms, 17 physicians and 50 employees, and 14 graduate nurses. The hospital provided more than 10,000 days of care in the first year of operation.
Upon Wilcox’s retirement, Mabel Smyth, RN, the Head Nurse of the Territorial Board of Health, wrote a tribute to her in The Pacific Coast Journal of Nursing.
It read in part: “With clarity of purpose and wisdom in leadership Miss Wilcox has developed an unusual spirit of loyalty and devotion among her corps of nurses and superiors … every nurse … on the island turns to her for inspiration and leadership in matters pertaining to individual and community well-being.” (Smyth, M, “Public Health Nursing in Hawaii: A Tribute to Mabel I. Wilcox,” (1935) The Pacific Coast Journal of Nursing, 297-98).
Mabel Wilcox circa 1911 and 1951
Influence of Wilcox Lives On
In her late 50s and 60s, Wilcox stayed active with the Wilcox Hospital in an unpaid capacity. She served on the hospital board, raised money for expansions, and recruited nurses. During this time, Wilcox also became very interested in historic preservation. Because both sides of her family tree had been missionaries and plantation owners in Hawaii for over 125 years, she and her living siblings began restoration efforts to preserve their ancestral homes and papers. Today the Waiolo Mission House, the Lyman House Memorial, and Grove Farm all stand as testimonies to their efforts, as do many manuscripts, records, and correspondence housed at the Grove Farm library.
After years of declining health, Wilcox died on December 27, 1978, at age 96. Before her death, the Kauai Tuberculosis Society honored her with these words: Through the years, there has been little in the health and welfare fields on this island that does not owe its beginnings to Miss Wilcox’s vision and active support. Her scope has been not only island-wide but territorial and even national.
Wilcox is is buried on her beloved Kauai Island.
Check back next week for part 2 of the Three Trailblazing Hawaiian Nurses blog series – Mabel Leilani Smyth, First Hawaiian Registered Nurse with Hawaiian Ancestry.
Hospitals serving more patients at risk for complications during childbirth are less likely to have enough nurses to care for patients during labor, delivery, and recovery, according to a new study in Nursing Outlook.
The findings reveal one of many factors that may contribute to poor maternal health outcomes in the U.S. for the most vulnerable childbearing populations, including Black mothers and those insured by Medicaid.
Nurses play a central role in the 3.6 million births in U.S. hospitals each year. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) issues guidelines on nurse staffing levels for maternity units; its 2010 guidelines call for one nurse to one birthing person during many parts of labor, two nurses at birth, one nurse for each mother-newborn pair during the first few hours after birth, and one nurse for every three pairs of mothers and babies after that period. These same nurse-to-patient ratios were included in the AWHONN nurse staffing standards published in 2022.
Recent data show that patients at high risk for severe maternal complications are more likely to give birth in teaching hospitals and have Medicaid as their insurer. In addition, teaching hospitals—often safety-net hospitals providing a significant amount of care to low-income and uninsured patients—are also more likely to have high volumes of births. In this study, the researchers aimed to determine nurse staffing levels at hospitals with vulnerable maternity patients, using high-birth volume and teaching status as proxies for high-risk patients.
The researchers surveyed 3,471 registered nurses from 271 hospitals across the country. Nurses were asked about staffing levels on their maternity units during labor, delivery, and recovery using AWHONN guidelines. The researchers compared nurses’ responses on staffing with hospital characteristics from the American Hospital Association Annual Survey.
Overall, nurses reported strong adherence to AWHONN staffing guidelines in their hospitals, with more than 80% of respondents saying that their unit frequently or always met the staffing guidelines. Adherence to guidelines was particularly high for specific stages of labor, including a nurse being continuously present at the bedside during second-stage labor (93.3%) and one-on-one care during epidural initiation (84.1%). However, adherence was lower for having a dedicated nurse for postpartum recovery in the two hours right after delivery (71.8%), one-on-one care for mothers with high-risk conditions (72.6%), a nurse dedicated to fetal heart rate monitoring (61.3-77.2%), and one-on-one care during oxytocin administration in labor (54.6%).
Analyzing hospital characteristics, the researchers found that teaching hospitals and hospitals with higher birth volumes, neonatal intensive care units, and higher percentages of births paid by Medicaid were associated with lower staffing guideline adherence—all of which have been shown to serve high-risk maternity patients.
“These gaps in staffing are particularly troubling for our most at-risk patients,” added Lyndon. “Many maternal complications can be prevented or quickly addressed through timely recognition of risk factors and clinical warning signs, and, when issues are identified, the escalation of care and coordination with the care team—but this is only possible when there are enough nurses monitoring patients.”
The researchers note that one possible cause of nurses in these types of hospitals having more patients than recommended may be poor reimbursement from Medicaid for childbirth services.
“Studies show that Medicaid pays hospitals less than half of what commercial insurers pay for a birth. This inequity in reimbursement creates a fiscal challenge in hospitals with a high percentage of maternity patients insured by Medicaid,” says Kathleen Rice Simpson, PhD, RNC, FAAN, a perinatal clinical nurse specialist in St. Louis, MO, and the study’s lead author. “Better funding for teaching and safety-net hospitals caring for high-risk maternity patients could support better nurse staffing.”
In addition, the researchers encourage the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission to consider safe staffing requirements for inpatient maternity care, similar to CMS working to establish minimum staffing regulations for nursing homes to promote patient safety.
Remember when you’d run home with your report card to show your parents how you did in school? Or were you the kid who hid it at the bottom of your bag so they wouldn’t see it? Well, your nursing career deserves a report card, too. So how’ve you been doing, and what grade do you think you deserve?
Report cards can measure performance, communication, talent, intelligence, diligence, attention to detail, time management, relationships, and many other categories. In some schools, letter grades are the norm, while in some alternative schools, there are no grades. Sometimes, our report cards are pass\fail, and we either make the cut or don’t. And sometimes, those grades don’t seem fair.
The Nurse’s Report Card
The nurse’s career report card can look different for everyone, and there are various classifications we can use to measure a nurse’s success. What do you think you excel in, and what could use a boost?
If we look at clinical performance, we can examine and assign a grade to different assessment skills (neuro, psych, cardiac, respiratory, etc.). Clinically, nurses also need to do well in collaboration, communication, documentation, and patient relationships. And those nurses who work in non-clinical roles (like yours truly) need an entirely different measure of their skill sets and responsibilities.
While I don’t use any clinical skills in my current career manifestation (except with friends, family, neighbors, and the occasional stranger on the street), I still think of myself as a nurse and have judgments about where my greatest and weakest skills manifest.
Do you play well with others? Do you readily share your toys? Do you hand in your homework on time? What would your nursing report card say?
What’s on Your Nursing Career Report Card?
Aside from evaluating and assigning value to your clinical skills, let’s examine your career. For those of you familiar with my blog or podcast, some of these will be familiar since I talk about them ad nauseam. Nevertheless, taking a few moments to assess yourself in a new way is important. Shall we?
Your career toolbox:
Let’s review what this means. Inside your nursing career toolbox is your basic resume, skeleton cover letter, and thank you note; your LinkedIn profile and LinkedIn strategy; your business card (yes, you need one); apps and tools that make your life easier; your professional network; and whatever else moves the needle for you.
If you were to give yourself a grade on the state of your career toolbox, would you get an A? Where could you lean in a little bit more?
Time management:
Time management can be a bear for anyone living in the 21st century. However, since nurses are more apt to care for their neighbors, friends, family, and even strangers, we can be hard-pressed to find time for some aspects of our lives that should receive at least a little attention.
What kind of a grade would you get for your time management skills? How often are you late for appointments? How often do you get home from work much later than you’d like? How badly are you challenged in managing your time professionally, and how does that impact your family and personal life?
Self-care and wellness:
Self-care and personal wellness can be inextricably connected to time management since we can easily let go of our self-care when time slips through our fingers. Get to the gym? “Impossible!” Take a leisurely bath? “Are you kidding me?” Go to a movie? “How indulgent!”
How badly are you falling down on the job of self-care, nurses? What would it take to reprioritize it again and get it back on the calendar? Is it solely a time management issue, or do we need to give you a D for prioritizing your health and well-being?
Collaboration, teamwork, and relationships:
Teamwork and collaboration are about getting along with others in the sandbox. Collaboration is key in most nursing and healthcare sectors; some of us are better at it than others. Is working on a team hard for you? Do you chafe at sitting through committee meetings? (I know, I know; meetings are usually deadly boring.)
If you work in home health, you must collaborate with the therapists, case managers, schedulers, and aides. In med/surg, you talk with doctors, surgeons, RTs, interventional radiologists, and other nurses. It’s a circus of personalities and ways of being.
Teamwork, collaboration, and professional development are so important; how are you doing? Is there something that needs to change so that you develop yourself in this career area?
Networking:
Many nurses wait to do assiduous networking until they’ve lost a job and are in the job market, desperate to find work. You’ll likely get a D or F in this category if you’re not consistently and actively building your network and nurturing professional relationships.
Happiness and satisfaction:
Being happy in your personal and professional lives should be measured on your career report card. Maybe you do all the “right” things, but you’re still miserable; in that case, something has to give.
Your resume may be awesome, and your nursing skills could be through the roof, but if you’re in the dumps every day about the direction your career is heading, it’s time for a change.
What is it that makes you tick? Where do you find satisfaction? How do you manifest joy in your life?
How would you grade your personal and professional happiness and satisfaction? Be honest!
Career/professional development:
It’s easy to fall into stagnation in your nursing career. We’ve likely all done it at times, and this type of complacency can lead to burnout, compassion fatigue, and downright unhappiness and misery.
Career development means different things to different nurses, depending on where you are in your nursing career.
For you, it might mean earning a BSN, MSN, PhD, or DNP. For someone else, it’s volunteering and meeting new people. For yet another nurse, it might entail becoming an EHR super-user or joining a QA committee at work. Finally, you might join your state nursing association and learn how to lobby your legislators about important public health bills under consideration. Career development is a personal journey, and how you develop your nursing career is as idiosyncratic as it is important.
Meanwhile, we acknowledge that there are times when doing anything about our careers is the furthest thing from our minds. When a baby has been born, a parent is ill, or a spouse is disabled or out of work, the personal understandably takes precedence over the professional. But when the dust clears and life is more or less on an even keel, it’s time to lean in again.
Make the Grade
Nurses, no one but you issues your career report card unless you engage with a career coach or other professional to help you raise your grades. Sure, I can tutor you in resume writing, LinkedIn, interview skills, and networking, but the final grade is up to you.
Would you like to change that calculation if you’re playing well with others but aren’t getting enough recess?
If you stay current on evidence-based nursing research but haven’t upgraded your resume in a while, is that an area worthy of focus and attention?
Have you made your well-being so low on the priority list that your health has suffered? Are you OK with that?
Making the grade is about you, what you want, and where you’re going in your nursing career. It’s not about the pressure from others about what they think you should do. It’s all about what will bring you the most joy, health, satisfaction, and professional success you desire to create for yourself.
Your Career Homework
Review the seven categories listed above and grade yourself between A+ and F. To review, they are:
Your career toolbox
Time management
Self-care and wellness
Collaboration, teamwork, and relationships
Networking
Happiness and satisfaction
Career/professional development
Once you’ve done that, decide which areas you’ll tackle, a timeline for doing so, and a set of actionable, measurable, and achievable steps to bring that grade up next “semester.” If you need a tutor and a cheerleader in that process, email me, and we can work together on bringing your report card up to speed.
Manifesting the nursing career you want isn’t always easy. Measuring your relative success and taking inspired action can also be a challenge. But in the interest of your career and calling as a nurse, you couldn’t choose a better way to focus your energy to create the life and career you want and deserve.
Minority Nurse is thrilled to feature Keith Carlson, “Nurse Keith,” a well-known nurse career coach and podcaster of The Nurse Keith Show as a guest columnist. Check back every other Thursday for Keith’s column.
