By Samantha Bernstein, PhD, RN
Hospital labor and delivery units are unique venues because they are the only units where healthy people are hospitalized for normal physiologic events.
Despite this generally healthy population, rates of maternal mortality in the United States have doubled in the past generation with the greatest burden on Black and Indigenous communities. An estimated 60% of maternal deaths are preventable. Maternal morbidity, while harder to define, is also rising rapidly and contributing to high healthcare costs, as well as harm to individuals in labor and their families.
Evidence suggests that maternal morbidity develops gradually and that “failure to rescue” is a contributor to maternal deaths. Nurses are at the bedside more than any other healthcare professional and are poised to intervene and protect.
In our study from upcoming the June/July issue of The Joint Commission Journal on Quality and Patient Safety, “Systems-Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration,” we asked nurses, physicians and certified nurse-midwives at a tertiary care center to tell us stories about times when laboring patients experienced deterioration, as well as times when events went well. By comparing and contrasting these stories, we gained an understanding of the barriers that nurses face during care of laboring people.
Environment
We found that the labor and delivery environment can be misunderstood and policies across the hospital often excluded or did not consider the dynamic aspects of this unit. Furthermore, the labor and delivery unit was not optimally designed for the work being done. Nurses frequently had issues with broken or insufficient equipment and sometimes spent considerable time chasing down the correct equipment.
Charting
Tremendous time was reported on charting in the electronic medical record (EMR). While we lack current research describing exactly how long labor nurses spend on charting, it’s clear that nurses feel it’s too much time.
Nurses in our study felt tied to a desk when they preferred to have been at the bedside. This has many effects, including an increased risk for burnout. The cognitive load of the charting burden takes attention away from the patient without evidence that patient outcomes are improved.
Staffing and “Swamping”
Nurses were frequently expected to fulfill other roles to fill staffing gaps. This has two important effects:
- diminishes nurses’ autonomy and sense of professionalism
- contributes to burnout and unhappiness in nursing roles
Nurses become swamped due to high patient load or acuity, or due to overall staffing issues on a hospital unit. Being swamped may be the result of an excessive cognitive load, making nurses less able to discern the most important tasks from less important tasks. Thus, nurses may miss early signs of patient deterioration, such as subtle changes in vital signs. Missing early signs may lead to failure-to-rescue events. Frequently, when an individual nurse feels swamped, other nurses were also swamped. This diminished the ability of the nursing staff as a whole to respond to emergencies.
Being swamped also made nurses in our study feel inadequate. Nurses knew the care they were giving was less than ideal and felt deeply that they were failing their patients, even when outcomes did not suffer. When there were bad outcomes during a swamped shift, nurses wondered if they could have done things differently and felt helpless. These negative feelings are well-documented pre-cursors to burnout.
Potential Solutions and Future Research
It is somewhat counter-intuitive to suggest that nurses need more work, but in fact that is one solution. Specifically, nurses need more tasks that are at the top of their license, and fewer tasks that can be done by non-nurses. Nurses should not be assigned custodial or secretarial tasks; nurses’ time should be spent on direct patient care. When nurses are assigned non-nursing tasks in addition to their patient assignments, they are at increased risk of being “swamped.”
Working at the top of the nursing license may also be a key to improving patient safety. Future research should study not only the numbers of tasks nurses are assigned, but specifically examine how different types of tasks are performed on labor and delivery units. If nurses are given the cognitive space to focus on their patients, they may be able to fully realize their patient safety role and intervene to prevent failure-to-rescue events.
Samantha Bernstein, PhD, RN, is an Assistant Professor in the School of Nursing at the MGH Institute of Health Professions in Boston. Dr. Bernstein is an obstetric nurse and researches maternal morbidity and mortality through the lens of human factors and patient safety.