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.
In the U.S, increased diagnoses of mental health issues and insufficient treatment places have resulted in many people turning to emergency departments for help. Unfortunately, this trend causes increased boarding times, ED overcrowding, and challenges for ED staff.
The increase in youth suffering from mental health issues is evident in a CDC survey. Emergency department visits for suspected suicide attempts by youth aged 12 to 17 increased by 39 percent from February through March 2021, compared with the same time in the same period in 2019.
On April 27, Sen. Shelley Moore Capito, R-W.V., introduced the Improving Mental Health Access from the Emergency Department Act (S. 1346). Supporting mental health treatment, decreasing boarding time, and addressing overcrowding are all priority issues for the Emergency Nurses Association. A similar bill is awaiting introduction in the House of Representatives.
“Many of the challenges facing emergency departments today can be directly linked to the need to improve care for behavioral health patients,” says ENA President Terry Foster, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN. “A lack of resources and treatment options often leaves individuals struggling with their mental health in the ED for extended periods, which leads to overcrowding and, frequently, acts of violence against health care workers.”
ENA President Terry Foster, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN
ENA research has shown the average ED stay for mental health patients is 18 hours compared to four hours for all other types of patients.
This proposed legislation would provide resources for EDs through a competitive grant program, allowing them to adopt more collaborative and connected care models to connect behavioral health patients with appropriate resources in their communities. It also aims to increase access to inpatient beds and alternative care settings, which will help alleviate boarding in emergency departments. Recognizing that all EDs are unique, this program would allow each ED to design solutions that will work best for them.
“The passage of this legislation could go a long way in reducing that wait time and providing a significant opportunity to establish a more collaborative approach to comprehensive mental health treatment options,” Foster says.
The VA knows that inclusion equals innovation. By ensuring that every Veteran receives care that matters to them and their whole health, VA providers and staff get to know each Veteran personally to provide better care tailored to the patient’s health and wellness goals.
All Veterans are different, and health care is not one-size-fits-all. However, diversity in VA personnel helps bridge the gap in health care disparities, an attitude adopted at the very top of their organization.
And the more diverse the VA workforce, the more tremendous success they’ll shareAnd the more diverse the VA workforce, the more tremendous success they’ll share
“To ensure a welcoming environment for Veterans, we must foster fair and inclusive VA workplaces where the experiences and perspectives of our diverse employees are valued,” says VA Secretary Denis McDonough. “The success of our mission depends on everyone being able to contribute their expertise, experience, talents, ideas, and perspectives.”
Investing in Inclusion
The Office of Academic Affiliations (OAA) plays a significant role in developing VA’s diverse workforce.
Healthcare professionals just starting in their careers can take advantage of health professions training and scholarship programs designed to increase job opportunities at VA for racial and ethnic minorities, improving healthcare experiences and outcomes for these groups.
OAA manages affiliations with more than 1,800 unique colleges and universities, including nearly 200 minority-serving institutions (MSIs). Approximately 20,000 health professions trainees from MSIs come to VA each year.
Additionally, the Veterans Healing Veterans Medical Access & Scholarship Program provides full scholarships to 12 Veteran medical students at Teague-Cranston Act and Historically Black Colleges and Universities in exchange for a four-year service obligation at VA.
Inclusion Leads to Innovation
The VA’s academic affiliations put them in a unique position to mentor and fund researchers from disadvantaged backgrounds who are motivated to make a difference in their communities, broadening career opportunities for those seeking to join the VA’s team.
Additionally, the VA recognizes that scientists and trainees from diverse backgrounds and life experiences bring different perspectives, creativity, and individual enterprise to address complex health-related problems. So the VA has developed funding opportunities in mentored research for junior VA investigators from underrepresented backgrounds. These research supplements pair early-career investigators with established VA researchers.
The supplements, supported by the VA’s Office of Research and Development (ORD), have led to research into virtual reality technology to help Veterans with mild cognitive impairment and repurposing existing drugs to treat substance use disorder, among others.
The Road Ahead
Supporting diversity, equity, and inclusion among the VA staff is an ongoing effort and a challenge that will continue in the future. As the VA celebrates its successes, they look ahead to further efforts that support and recruit a diverse workforce.
By integrating best practices into all the VA does to expand access to world-class healthcare services and to improve policies and procedures to reflect the diversity of those they serve, the VA continues to strengthen its efforts toward a safe and respectful workplace and healthcare environment.
Serving the most diverse group of Veterans in history, the VA reaffirms its commitment to hiring staff that reflects that diversity, ensuring that VA employees feel supported and providing equitable healthcare access for all.
For the second year in North America, WaterWipes has awarded a Pure Foundation Fund, which awards the department of the winning healthcare provider $9,000, as well as a 6-month supply of WaterWipes.
According to a statement from WaterWipes, the Pure Foundation Fund “recognizes the outstanding work of healthcare heroes who have made a difference in the lives of parents and babies in their pregnancy, birth, and postnatal journey.
Out of the 266 healthcare providers nominated, Alessandra Chung, a nurse for the Southcentral Foundation as a home-visiting nurse with the Nutaqusiivik program (part of the Nurse Family Partnership) in Anchorage, Alaska, won. She and the program serve Alaska Native and American Indian families living in Anchorage and the surrounding communities. In addition to an award plaque, Chung receives a $100 Visa gift card and flowers.
Chung took time to answer Daily Nurse’s questions about being this year’s award winner and how the money and wipes will help her work.
What did it feel like when you learned you won the WaterWipes Pure Foundation Award? Did you expect it?
It was a complete surprise; I had no idea my coworker, Sarah Swanland had nominated me! I was finishing my maternity leave, so it was terrific news to share with my colleagues once I returned to work. After learning more about this incredible program, I felt excited and honored to be selected.
I’m incredibly grateful and honored to be recognized by the Pure Foundation Fund. I love the team of nurses I work with and hold them in such high regard. I think any of them could have been the winner, so I am honored that Sarah thought of me.
What type of work do you do? How long have you been doing it? For what community? Why do you enjoy it?
I have been a nurse for 15 years and have been a part of Southcentral Foundation’s Nutaqsiivik Nurse Family Partnership for the last four. The Nutaqusiivik program is a voluntary nurse home-visiting program working with Alaska Native and American Indian families from pregnancy until the child is two-years-old.
The program’s overall goals are to improve pregnancy outcomes and child health and development. Still, what I love most is uncovering each mom’s heart’s desire for their children and encouraging them to become the parents they want to be. Of course, every new mom’s situation and needs are unique, so we never want them to feel pressured to approach the program in a specific way
My position is the perfect mix between maternal health nursing and psychosocial nursing. I love how holistic my role is and advocating for my patients while teaching them how to advocate for themselves and their families.
Winning $9,000 for your department, plus a six-month supply of WaterWipes, is amazing. But do you know yet how the Southcentral Foundation’s Nutaqsiivik Nurse Family Partnership will use the money?
We’re still discussing where the funds will be used to support the moms and babies in our community. This will positively impact the families we serve by allowing us to continue advocating for and empowering moms on their journeys to be the parents they want to be.
How do you make a difference in the communities you serve? What are the biggest challenges in the communities?
Every mom is different, and every situation is unique. Just being there for each mom, meeting them where they are in their journeys, and encouraging them to be the parents they want to be is how we make a difference every day in our community. When moms are supported and empowered, they are, in turn, able to support and empower their children, and that is where generational growth and change can happen. So it’s long-term change and prevention that is our goal.
What are the most significant rewards you experience by working with the people you serve?
First, serving the Alaska Native/American Indian community is an honor. I love to be able to come alongside and partner with families on their journeys. It is always a privilege to be invited into a family’s home and trusted with their stories and dreams. I’ve encountered all sorts of challenges new and expecting mothers face, and through it all, it’s always worthwhile to see them understand that they can do this.
And even when things don’t turn out as we hope, I am honored to support them through maybe that grief and loss too. At the end of the program, we host a graduation ceremony where the moms are given a chance to celebrate their growth and achievements alongside their children, and the smiles and gratitude I receive are their rewards.
What was your favorite part about this whole experience? Why are you proud of the work you do?
There were many great things about this experience, the first being that Sarah called me and told me she nominated me, and I won. I remember being in the parking lot of my PT’s office feeling torn about leaving my baby to go back to work, and it was so encouraging for her to tell me this.
My second favorite part was making the video; one of the moms I worked with was willing to participate. That was special. I’m proud of my work because it’s what holistic nursing is all about–truly meeting the patient where they are and educating and advocating for what they want for themselves and their families.
Being a nurse in Alaska, working with the Alaska Native population is the best. I wouldn’t want to be a nurse anywhere else.
As modern healthcare workers, today’s nurses have to wear many hats. However, the top priority remains the same — supporting the health and safety of their patients. There’s no question that healthcare technology has come a long way in recent years, advancing the industry and helping millions of people. However, there is still a lack of understanding when it comes to women’s health.
Nurses can help bridge that gap and improve women’s healthcare nationwide.
Nurses can provide healthcare services to women in need and help spread awareness of critical issues, educate others, and help women make more informed decisions about their bodies. It’s a fantastic way to empower today’s women and ensure they get the healthcare they deserve without worrying about any disparities in medical treatment due to gender.
Let’s look closely at how nurses can improve women’s healthcare and why it’s so important.
Offering More Services
Telehealth isn’t necessarily anything new. During and post-pandemic, though, telehealth saw a rapid rise in popularity. Now, more practitioners and patients alike are utilizing it, thanks to benefits like:
Decreased infection exposure
Improved patient scheduling
Improved collaboration
Better capacity management
It’s also an excellent option for patients who might live in underserved areas or those without the means to get to a medical office. So not only is telehealth beneficial for patients, but it also allows nurses to offer their services and expertise to those who aren’t comfortable visiting a doctor in person. That can be especially helpful for women who have had negative medical experiences or even those who struggle with medical anxiety.
Sometimes, even talking to someone via telehealth can help eliminate that medical fear and make patients comfortable enough to come in. That can be highly beneficial if they have a condition or symptoms that require an in-person visit. In addition, you never know what a caring attitude and kind tone via video call can do to change someone’s opinion about getting medical treatment.
Spreading Awareness
Nurses should be at the frontlines when fighting for health equity for women and other marginalized groups. As a nurse, your goal should be to improve global health, but you should be focused on the key medical issues affecting women in your backyard. Because so many women face societal inequities, they’re more likely to develop health issues. Some of the most prominent health issues impacting women across the world include:
Heart disease
Stroke
Diabetes
Breast cancer
Osteoporosis
Maternal health issues and sexual health problems are also largely ignored when it comes to the well-being of women.
Nurses can raise awareness on a local, national, and global scale by encouraging women to familiarize themselves with specific symptoms and helping them understand what’s considered normal. They can recommend necessary screenings, offer support, and promote healthy living.
Even if you think you need more time to spread awareness to a larger audience, you can do plenty to help each female patient you work with, starting with educating them.
Providing Education
Far too many women don’t make positive decisions about their health or bodies because they’ve either been misinformed or haven’t been given enough information about how to care for themselves or look out for signs of illness.
One of women’s most significant problems regarding health education is dealing with myths. It can be challenging to separate the truth from what they might have heard from a friend, family member, or even something online.
For example, there are many myths surrounding vaginas and how they work. Just because a woman is born with one doesn’t automatically mean she knows everything about it. Unfortunately, this lack of education can increase the risk of sexually transmitted diseases, yeast infections, and more.
Dispelling some of those women’s health myths and misinformation can help empower women regarding their bodies. Teaching women how to care for themselves and their specific body parts properly will go a long way in preventing diseases and improving their quality of life.
Nurses should be well-equipped to educate their female patients. Nurses often serve as the first point of contact in a doctor’s office or hospital. If you have the opportunity to do a patient interview, show compassion as you go through their medical history and learn about their health concerns. Part of education includes speaking with confidence and experience but not with judgment. The last thing a woman wants is to feel ashamed or embarrassed about her condition or lack of knowledge.
Many things need to change in the medical industry to improve women’s healthcare. However, don’t let that overwhelm you or lead you to believe that you can’t do your part and make a difference. Nurses can change the face of women’s healthcare for a brighter, healthier tomorrow.
Prior to finding out about Mercy Ships, Christel A. Echu, RN, admits that if you asked her if she wanted to volunteer for any organization and not get paid, she would have said, “No.”
But when a friend who was an authority in the church she attended in Cameroon, Africa, she changed her mind. “I decided to volunteer with Mercy Ships because I was interested in being a part of the great work they were doing for the people of my country, and I wanted to help in any way that I could,” Echu says.
Mercy Ships Bring Hope and Healing
Mercy Ships is a non-profit Christian organization, she says, that sails across West and Central Africa with the mission and vision to provide hope and healing to patients who are poor and/or forgotten in countries there.
When Echu began volunteering with Mercy Ships, she had just graduated from nursing school. First, she worked as a volunteer translator when the ship, the Africa Mercy, was docked in the port of Cameron. She volunteered as a translator for 10 months.
Mercy Ships bring hope and healing
By then, Echo says, she was hooked. She ended up continuing to volunteer for another two years. “I transitioned from that [working as a translator] to working as a volunteer screening nurse until the end of my commitment,” she says. “Screening nurses, we see all the patients before they are seen by the rest of the hospital. We screen, assess, and ensure patients are healthy enough for surgery.”
She says that they pre-screened more than 6,000 patients in a day when they were in Guinea Conakry. “That was the longest shift I have ever had,” she says.
One of the aspects that Echu loved about Mercy Ships is that she got to work with nurses from all over the world: including the Netherlands, Canada, Australia, the United States, and others.
“I loved working with patients and with my team. We also worked alongside our wonderful translators, which was a blessing because they helped to facilitate communication between the patients and nurses,” she recalls. “I think I enjoyed the fact that we could learn from each other to provide the best care to the patients we served. I enjoyed seeing the joy the patients felt whenever we announced to them that they were getting surgery. “The dance of joy” was a thing in the screening tent and I enjoyed seeing the patients come back to show us their “new self” without the tumor or the deformity. Moments like that, reminded me why I decided to volunteer in the first place and kept me going on difficult days.”
Biggest Challenges
There were tough days. Echu says that one of her biggest challenges while working with Mercy Ships was being away from her family, home, and community. But another difficult part was when she had to say “No” to people they couldn’t help.
“This is a part of my job that we don`t talk much about. The ship has specific surgeries they do when they sail in a nation. However, there are patients who present with conditions that are not within Mercy Ships scope of practice and that`s when we get to do ‘no’ conversations. Screening nurses initiate that conversation before the chaplaincy team on the ship takes over,” she says. “That was the most challenging thing about my job—having those ‘no’ conversations was never an easy thing to do. Most of the patients we see come with the hope of being helped, but when we have to say no to them, it almost feels like that hope crumbles before their very eyes.”
Greatest Reward
She also, though, had many rewards—the greatest of which was forming relationships with the ship’s community. “The relationships I built during that time, [ones] that become an integral part of my life. The community is really special. Now, I have friends all over the world,” says Echu, who now lives in Minnesota. “I do not have family here in the United States, but I know friends with whom I worked with on the ship, [and they] are my family while I am here.”
Echu says she will never forget “the amazing patients I got to work with and their families and the joy they always had on their faces even without having much.”
If you’re a nurse thinking about volunteering with Mercy Ships, she says, “Do it! Go and see for yourself. Have an open mind and be ready to learn and receive as well,” she says. “Most volunteers go on the ship with the mindset of giving and serving which is good, but also go with the mindset of receiving. Receiving could be anything—like being welcome in the house of a local, or being encouraged by a patient who doesn`t have much, but they still have a big smile on their faces. It’s an experience that would change your life completely for good.”
