Nursing Notes newsletter delivers a look at the Perinatal Nursing specialty. I brought together a panel of perinatal nurses to discuss this nursing specialty and some of the exciting changes on the horizon for patient care and nurses in this field. On the panel were current AWHONN board member and Labor and Delivery Nurse Manager Kelly Walker, Anne Robinson, public health nurse for Eagle County, Colorado and previously a labor and delivery nurse and patient care quality manager, and Cyndy Krening, a perinatal nurse specialist at Littleton Adventist Hospital in Littleton, Colorado and our featured Get To Know Nurse this month
MP3 Audio Podcast
Transcript of Discussion:
Jamie: I want to start off the discussion with Kelly Walker. Kelly, you were awarded as one of the Emerging Leaders Grantees and participated in this unique mentoring program that AWHONN has supported – the Association of Women’s Health Obstetrical and Neonatal Nurses – and I wonder if you would share with us some of the things that you gained from being part of this groundbreaking program.
Kelly: Part of the leadership program, which I encourage everyone to apply for, it took my perspective of my little work area in OB and just giving it a more global perspective – how things work altogether hand in hand from prenatal care to antepartum care to labor and delivery to the newborn stage. It’s just all those little aspects to affect the whole big picture. I think working through the Emerging Leader program, you met other mentors throughout AWHONN and other nurses like yourself working in the trenches trying to figure out what can we do to improve our patient outcomes.
Jamie: I think that mentoring is such a vital part of the nursing process as nurses share and pass on their knowledge and collaborate and creating new ways to improve patient outcome. It’s really exciting to hear about this program. Cyndy, we talked in our other episode this month about your specific path through the nursing career as our Get-to-Know Nurse but I wonder if you would share some of your thoughts about being a member of this organization for perinatal nurses. AWHONN has so many programs and projects like this Emerging Leaders program that improve patient outcomes, what do you look forward to on the future in this organization?
Cyndy: Well, I do think that AWHONN, for many years, has strived to enhance perinatal nursing as a profession from many fronts. There’s quality education coming out of the organization. The Emerging Leaders program like Kelly just mentioned. There’s written resources that are educational material as well as educational offerings and our national convention and just resources within the organization at many levels. Nursing is an amazing profession because there are so many ways to diversify yourself and specialize as a nurse. I think our specialty is no different than others.
Jamie: Anne, go ahead.
Anne: Yes. Cyndy, I agree. I was an OB nurse and went to neonatal nurse for eight years and moved in to quality patient safety and then I’ve been working in the last four years within public health. More on the prenatal end of things of the maternal child health and what can we do to get those women to access care, to prevent problems and complications later on. It’s amazing to see how that organization helps with educating in those opportunities but then once you’re involved in that organization, how then your experience can change and evolve as your career evolves.
Jamie: It’s interesting. Anne, you talked about prenatal care. It really is a continuum of care surrounding the birth of a child and women’s health leading up to that point. Because, of course, the healthier the mother is when she becomes pregnant, the healthier both the mom and the newborn are at the end of the process. I wonder some of the things, Anne, that you’ve seen as, far as serving underserved population because I know that’s something that’s very important in your role in a public health setting.
Anne: Well, and I think it’s also important to know that for every dollar spent on prenatal care, $3.00 is saved in healthcare dollars in the long run. The more we can get the women into prenatal care, the better off we will be. We do. We really do. We even target the high-risk population because they are more at risk for more complications – pre-term babies, other medical conditions, gestational diabetes – our population seems to have a higher risk for. Yes, really pushing that prevention and prenatal care is kind of, in some way, is looked at as prevention in the maternal child health field.
Jamie: Anne, I liked how you touched on the data associated with long-term healthcare costs and some of the evidence-based and research-based programs that are supporting some of the initiatives that are going on perinatal care. I wonder, Kelly, if you utilize the [needed] resources on the frontlines in your care for your patients and how you find those resources and what you make of them.
Kelly: Looking at more perinatal nursing, we use a lot of the evidence-based practice resources. AWHONN has many evidence-based practice resources. The latest one was on the late preterm infant that came out a few weeks ago. In my role as a clinical nurse specialist, is taking that piece, that monograph, and bringing it to the staff and kind of see how we can affect care based on the latest evidence. I think a lot of what we do we’re trying to improve outcomes based on evidence. Getting it to the bedside to the patients doesn’t happen overnight. It does take a few months, weeks, time to get that going in the right direction. In my role, that’s what I see happening in trying to get nurses excited about feeling that they can make a difference. I know, as a nurse, that something we feel is that – yes, we can make a difference whether it’s in baby steps or, in the long run, we will see a positive outcome.
Cyndy: I also wanted to tag on to that by mentioning also the new Perinatal Nursing Staffing Standards that our national organization has published recently. It’s really a time where our specialty area is getting recognized as a critical care area and that, in order to promote best outcomes for both our moms and their babies – unborn as well born – we need to have staffing within our inpatient units that’s much more like the critical care area. So many more patient-nurse ratios that are 1:1, which I think is exciting because that’s another example where the evidence has shown that we’re dealing with high acuity patients. We’re giving high alert medications and to promote best outcomes we need to make our staffing more of a 1:1 ratio.
Kelly: I have to agree. The staffing guidelines are pretty exciting. Trying to get the staff to figure out ways to implement those, not just from a management perspective, but what can we do as a whole to make sure we have the right patient-to-nurse ratio and have faith in better quality care.
Jamie: It’s interesting you mentioned the nurse staffing ratio. It’s such a hot button issue. I’ve seen that discussed in so many other areas of hospital care facility management. It’s something that’s one of the most hotly contentious issues. I wonder what the response is from hospital management on trying to change the staff ratios in labor and deliver, in maternal care, to increase that to more of an intensive care status that just seems like will it be such an uphill fight compared to even some of the other areas where we’re trying to improve nurse staffing ratios in med-surg to just slightly better staffing ratios.
Cyndy: It’s interesting. The CFOs I think are probably not excited about it within our organizations. Yet, AWHONN is a nationally-recognized organization and the standards were put out with a fabulous review of the evidence and showing that ratios that are appropriate definitely enhance outcomes, the patient outcomes. We’ve approached the financial and administrative people in my organization just saying, “This is not an option. We need to look at ways to meet these standards in a timely fashion.” But what we’re doing just try to meet them in the middle is to look at ways to – sort of like Kelly and Anne alluded to – we need to look at ways we change our systems of care to try to maximize meeting staffing standards within our current environment before we ask for additional staffing manpower. It’s probably going to also involve training new nurses to our area as well.
Anne: Kelly and Cyndy, I have a question since I haven’t been in OB in the clinical setting in a while, what are you seeing some of the standards and how they’re going to impact rural agencies and rural hospital settings?
Cyndy: I think it’s a challenge because even for me in an urban area – I’m from the Denver area – there are lots of hospitals with OB services and so everyone potentially is looking for more nursing staff to provide inpatient care. I think there is going to be a huge role for education of nurses and training nurses to do labor and delivery, which is exciting for all those nurses and the graduate nurses who are very excited, and wanting an opportunity to get into our specialty area. In my world, we actually run twice a year a didactic course where we’re doing training for nurses coming in to the specialty area. We have lots of rural facilities around Colorado and neighboring states to us that send their nurses for training to our course. They can also stay and do some clinical time in our busier unit because it’s a huge challenge in a small rural facility with limited opportunity to get the experience. It’s very hard to really become competent. I think for rural areas, partnering with the tertiary facilities that they transfer patients to or that they use for collaboration and consultation in terms of education, it’s probably going to be imperative.
Kelly: I’m part of a three-hospital system with OB services in community settings. Our volumes vary from hospital to hospital. When we have new nurses, like Cyndy mentioned, we will send the new nurse to spend some time at a busier hospital to just get that experience in volume and then come back to her home base and learn learn her home base basically. It’s trying to get that experience and making sure people get that training and education right off from the start.
Jamie: What about resources for those nurses that are in those small rural facilities? Maybe most likely they have a very tiny labor and delivery unit, perhaps one or two nurses working on a unit with one obstetrician that is working in an entire region and has to maintain their knowledge base while they’re floating from unit to unit when they’re not that busy in the L & D unit that day. How do we maintain our skills in that setting? I know that’s very difficult when you don’t see a lot of patients in a high-volume and a high acuity level of patient.
Kelly: I’ve heard this before. One of the emerging leaders that I was on as part of that team, she works in a rural community in California and she said it’s sometimes hard to – as a nurse I think we do what we have to do at the time to take care of that patient. It sounded like, from her perspective, that you’re just a multi-skilled nurse learning so many different things taking care of that patient and whether you have to float to a different area that day, at least you will learn something probably a valuable skill that you can take back to your OB unit. Because if you‘re floating, you need to have the skills and keep your competencies up because you might not have those resources available to you.
Jamie: I also wonder if there is an opportunity to find ways to integrate an advance practice nurse – nurse-midwife or other advanced practice nurse into those settings to provide some more guidance and leadership for these nurses. An on-site nurse mentor, nurse leader to kind of engage those nurses and give them an opportunity as a way to provide that leadership on-site and maybe it’s very effective to associate that with the clinic program. Cyndy, what does AWHONN do to support the advance practice setting for nurses? Is there a program that they have in place to do that?
Cyndy: I think AWHONN is very supportive of the advance practice nurse as far as certification and advanced skills. I know they’re very involved with their College of Nurse-Midwives and other healthcare organizations, the practice organizations. Their position statements do support that advance practice role.
Jamie: I’m curious, Anne, as you look at it from a different perspective because we talked a lot about labor and delivery in OB, but the prenatal care and the health of this whole community has such an effect and impact on the health of the babies, what are some of the things you’d like to see change in just providing that prenatal care even something that I saw on the AWHONN site talking about the preconception care?
Anne: Well, that’s even going towards family planning and what can we do to make sure those services are available to decrease the unintended pregnancy rate in your area, your county, your state, region, whatever it may be. Again I would like to see better resources for access to care. We struggle with our women being able to receive the services that they need and the funds to be able to support it. With our diverse population and people that don’t qualify for Medicaid, how do we assure that they actually are being seen? The improvements that I would like to see as we move forward with healthcare are assuring that these women are getting access to care whether it’s for prevention of pregnancy or it is prenatal care or in postpartum. Making sure that their children are following up after the baby is born and their immunizations and their well-child checks. That is my biggest challenge that I see that we’re up against: making sure that they are getting the care that they need and that it’s high quality. It sounds like the standards are there to make the services high quality but if people can’t access it then that’s the bigger issue from my public health point of view.
Jamie: Accessibility to care is such a big deal and when you don’t those available care resources it’s difficult to provide good care for the community but it comes around to something I’m just – I feel very strongly about the fact that I’m not just a nurse on a job. I’m a nurse 24/7. It’s something that I am not necessarily something that I do. Being a nurse, for me, also includes being involved in outreach and looking at other ways to improve the health of my community not just waiting for patients to come to me but being involved in things like CPR education, community outreach for things like poison control resources and education. I wonder what your thoughts are about the labor and delivery nurses, the perinatal nurses really reaching out beyond their facilities and becoming more involved in community outreach and education of the population that may not be getting in to see them until the very last minute.
Cyndy: Well, it’s true and it still amazes me how many old wives’ tales there are related to childbearing, pregnancy and childbirth, and how many people actually seek advice from their sister or their neighbor. I think it is, as you say Jamie, a full time job. I think a combination of being well-linked be in the community, to be involved in a health fair, to teach a class at a local community center, something where local community folks are actually hearing from those of us who have expertise in the area. Then I also think, since we live in such an electronic age, there are obviously many ways to promote education of consumers through hospital websites, through electronic media or written media out there. I think we all know that people definitely go to the internet as well for health education. For us to be very proactive in terms of reaching out to those venues – for instance, I just was speaking with somebody in my local area last week some time, who puts out a local news magazine for expectant families. I really want to reach out more to families about the issue of not choosing induction of labor prior to 39 weeks gestation. My providers say that their patients really push for that. That’s an example of an area where we really need to re-educate our consumers, our patients and families about the risks of elective birth that’s not indicated prior to 39 weeks. There are a lot of opportunities.
Jamie: Yes. How often do you have that question from someone and you have to explain to them – it’s not like a cake in the oven that when a timer goes off it’s done, you have to wait until the time is ripe. Often I think that’s part of the problem. People are so used to having life be just convenient and on their schedule and people’s busy lives working everything around to make things work. I have so many people that come and go, “Yes, we’re going to plan to have the baby born on such and such day.” I say, “Are you late? Is this something that you’ve gone past term?” “No, we just want to make sure the baby doesn’t get too big.” I have to sit there and bite my lip and then say, “Hey, you might want to just think about and talk to your doctor and talk to the nurses in your facilities to find out maybe if that’s not necessarily the best option for you or your child.”
Cyndy: Right. I think it has to do with education because most patients want the best for their child. I feel like if we can re-educate them about the ongoing growth and development of their fetus in the latter days and weeks of pregnancy that that can only help. As you said, Jamie, just to remind them that although it might seem convenient to deliver on a certain day parenting isn’t always about convenience, there are a lot of inconvenient things that happen to parents.
Jamie: I think anybody that’s a parent – myself, I know Anne is a parent, I don’t know about Kelly – but I think we all can agree with that.
Anne: Yes, very much so. The pregnancy is just the start.
Jamie: Yes. They should really start on the right foot and make sure that they understand that it’s not going to always be convenient getting the right start is often so important. Kelly, what do you see as your job moving forward as a leader in AWHONN and in perinatal nursing, in general, and in your facility and community. What do you see your role down the road as a perinatal nurse?
Kelly: A lot of our healthcare initiatives within my organization and what I see happening in AWHONN, it’s becoming more evidence-based and quality-driven. As a clinical nurse specialist, looking at the data, looking at the trends, looking at patient outcomes, what can we do to improve them, what could we be doing better. There’s always room for improvement. Using the evidence, guidelines, like the staffing guidelines from AWHONN, it affects outcomes. That’s what I see happening more and more often as healthcare economics, our healthcare environment continues to change. Not knowing what’s going to be out there on the horizon kind of makes people uneasy but if we can just pay attention to our quality, everything should be okay for our patients and for our nursing profession.
Jamie: Anne, what about you? Do you have anything – advice you might offer to another nurse thinking about becoming a labor and delivery nurse getting into this field or perhaps a nursing student because, of course, they’re a lot more nursing students coming right out of school and going in to this specialty and that didn’t use to always be the case?
Anne: Right. I was privileged to be able to go right in to OB out of nursing school which it was my heart and my love and I think it always will be. I think embrace these opportunities of these education and training programs such that Cyndy spoke to and the new grad programs that are out there. The more you can go with those agencies that have those new graduate programs together and that their quality standards are where they need to be. Their customer satisfaction results are high. Those would be those agencies that I’d really want to be more attracted to as a new grad but then maybe look at where you did some of your clinical rotation and spending time with your nursing school, with those OB nurses, talking to them and seeing if that’s really the area that you want to be in. Those preceptors in clinicals are amazing. So the more you can tap in to their knowledge and expertise will really help guide you in your professional path that you want to go as a new graduate nurse in the future.
Jamie: Cyndy, final thoughts?
Cyndy: Final thoughts.
Jamie: The big final-thoughts question.
Cyndy: Well, I do think the sky is the limit. I think the exciting thing for us is general we deal with patients and families that are healthy and well and motivated to be good parents. If we provide them the right start and the right foundation, those who suffer complications of childbearing usually start into their pregnancy fairly healthy so usually they can recover from even significant complications. As always within nursing there are so many opportunities for part-time and full-time and inpatient and outpatient. All levels of education – nurse practitioners – there are just so many opportunities I think to be involved with the childbearing family across the continuum. I’m sure that I speak for all of us in saying that it’s a very exciting specialty of healthcare to be in.
– End of Discussion –
Don’t forget to check out the entire April, 2011 issue of Nursing Notes, looking at perinatal nursing specialties. This month’s Nursing Notes newsletter includes articles on the long term health impact of preconception care dialogue discussion between patient and nurse, specific roles within prenatal nursing, and a recap of the 2011 NSNA National Convention. .You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month, an interview with this month’s “Get to Know” nurse, Perinatal Nurse Specialist Cyndy Krening. You’ll find this and our other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.