Nurse to Patient Ratios on Labor and Delivery

Introduction

            Registered nurses represent the largest single health care profession in the United States (Steinbrook, 2002). More than 1.3 million registered nurses work in hospitals in the United States (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Nurses are vital to the everyday operations that go on in hospitals, nursing homes, and ambulatory care clinics. Needleman et al. (2002) reported that in the United States a higher proportion of nursing care hours provided by registered nurses and a greater number of registered nurse hours per day are associated with better outcomes for hospitalized patients. The outcomes included were a shorter length of stay, lower rates of urinary tract infection, less upper gastrointestinal bleeding, and lower rates of pneumonia, shock or cardiac arrest. A study of 6.2 million patients in the United States found that in hospitals with higher nurse staffing, patient stays were up to 5 percent shorter and complications up to 9 percent lower (Healy, 2002).

There is no consensus yet as to a safe and practical nurse to patient ratio on Labor and Delivery (L&D) units. In spite of this Governor Gray Davis announced proposed ratios in California in January 2002 for various hospital units. For L&D units, the minimum staffing ratio was set at one nurse to two patients (Steinbrook, 2002). Ratios were proposed in spite of the fact that patient acuity and census can change rapidly on L&D units (Loper & Hom, 2000). The role of L&D nurses has evolved over time impacting the amount of time spent with laboring patients (Gale, Forhwegill-Bourbonnais, & Chamberlain, 2001). Nursing support during labor is reported to improve labor and birth outcomes. When nurses can assist women to cope with the stress of labor using a high degree of interpersonal skills, women’s satisfaction with their birth experiences increased (Tumblin & Simkin, 2001. Inpatient maternity services have been influenced by changes in the insurance market, managed care, federal statues, advancements in technology, and most recently the growing nursing shortage (Loper & Hom, 2002). All of these influences impact the current nurse to patient ratios on L&D units. Adequate nurse staffing is crucial to the provision of quality maternity care (Loper & Horn, 2002).

Research Questions

            The purpose of this integrative literature review is to examine the effects of nurse-patient staffing ratios on perinatal outcomes. The integrative review of the literature will ask two research questions:

1. What are the effects of varying nurse-patient staffing ratios in L&D units on perinatal outcomes?
2. What are the managerial impacts of varying nurse-patient staffing ratios in L&D units?

Background

            There were 4.1 million births recorded in the United States (US) in 2004. The birth of a baby is the most common reason for admission into US hospitals. A laboring woman today has many choices concerning her pain management during labor. Labor pain and methods to relieve it are major concerns of childbearing women and their families. The experience of labor pain is a complex, subjective, multidimensional response. Labor pain is not associated with pathology but with the most basic fundamental of life’s experiences; the bringing forth of new life (Lowe, 2002).

The laboring woman may elect to have an unmedicated childbirth, a continuous lumbar epidural (CLE), narcotic administration, or hydrotherapy to manage her pain in labor. Labor and Delivery (L&D) nurses need to be familiar and competent in all the above methods for relieving pain during labor. Patients who elect to attempt an unmedicated childbirth require continuous labor support. They need additional guidance on how to utilize the various breathing patterns or styles, relaxation techniques, guided imagery, acupressure, massage therapy, and positioning exercises. Support during childbirth involves the provision of physical comfort measures such as touch, as well as emotional support such as reassurance and praise, instruction/information giving, and advocacy (Miltner, 2000).

Randomized controlled trials (RCTs) have shown that women with a lay supportive companion during labor have better labor and birth outcomes than those who labor alone. Outcomes included: lower cesarean section birth rates, decreased use of oxytocin, decreased use of epidural anesthesia, decreased use of any analgesia or anesthesia, improved Apgar scores, fewer operative vaginal births, fewer admissions to neonatal intensive care  units, and longer breastfeeding durations (Gagnon & Wagohorn, 1996). In most hospital L&D rooms, the L&D nurse is the support person who assists the mother through labor. The L&D nurse, however, also starts intravenous lines, checks vital signs, administers medications, performs pelvic exams, documents labor progress regularly, and usually is responsible for other laboring patients. Such responsibilities often prevent the L&D nurse from providing continuous laboring support, and consequently, the benefits resulting from this support (Winslow, 1998).

            The role of the labor and delivery nurse has changed over the past 20 years in North America. In the 1980s the standard of care was “one-on-one” nursing care, and hospitals advertised that they provided “family-centered” maternity care with attractively decorated birthing rooms. At the same time new technologies were being introduced which became a standard component of maternity care (Tumblin & Simkin, 2001). In the 1990s the increase in inductions, epidural analgesia, and cesarean births gave nurses more equipment to monitor and took more time. The increasing emphasis on documentation for medico legal reasons often require that nurses use computers  out of the  mother’s room or positioned so that the nurse faces away from the woman (Tumblin & Simkin, 2001).

Currently it is common to encounter laboring women, connected to an electronic fetal monitor, receiving an infusion of oxytocin to induce labor as well as an epidural infusion for pain relief. Although nurses’ competence with technology is crucial in caring for laboring women, providing continuous labor support is also an important aspect of care in the birth experience (Miltner, 2000). Nurses in an intrapartum unit are thus required to possess two sets of skills, technical and supportive. However, many studies have shown that intrapartum unit nurses spend only a small amount of their time providing supportive care to women in labor. One study showed the percentage of time spent in supportive care was 6.1 percent (Gagnon & Waghorn, 1996). The Association of Women’s Health Obstetrical and Neonatal Nursing (AWOHN) identified some barriers that can influence the nurse’s ability to provide bedside nursing care. These factors include: limited numbers of available experienced registered nurses, limited financial resources, rigid organizational processes and structures, cumbersome documentation requirements, and decreasing reimbursement by their party payers in the United States (Tumblin & Simkin, 2001).

During the past century, the practices surrounding childbirth have changed dramatically from woman-supported birth in the home to a highly medicalized process in a hospital setting. The needs of maternity patients, however, have not changed. They still require a sense of safety, acceptance, freedom from fear, and the presence of a supportive companion throughout labor and birth (Kayne, Greulich, & Albers, 2001). The L&D nurse, midwife, and physician are often unable to be that support person. Fathers/partners or family members may not be equipped to provide this essential support. The doula has been introduced as an answer to this need. Doula is a Greek word that has come to mean a woman experienced in childbirth who provides continuous physical and emotional support to a laboring woman and her partner (Young, 1998). Doulas are trained to provide a pregnant woman with continuous one-to-one support during childbirth.

The doula is concerned with only one patient for the entire labor and delivery. She focuses on the emotional needs of women, not medical issues like the intrapartum L&D nurse. Doula training helps them remain calm and objective unlike some family members or friends. Continuous labor support by a doula has been demonstrated in RCTs to have a positive effect on perinatal outcomes, including reductions in cesarean deliveries and the need for analgesia during labor (McGrath, Kennell, Suresh, Moise, & Hinkley, 1999). “Continuous labor support, provided under widely varying circumstances by women with varying levels of training, results in lower rates of analgesia and anesthesia use, lower operative delivery rates, lower episiotomy rates, shorter labors, and decreased numbers of infants with five-minute Apgar scores less than seven” (Hodnett, pg. 80, 1997).

Many maternity patients are aware that L&D nurses are not consistently available for providing continuous laboring support. As a result, maternity patients are employing professional doulas to provide continuous laboring support in increasing numbers. They have become aware of the improved clinical outcomes for both mother and baby when utilizing doula services. The number of DONA certified doulas has risen from 31 in 1994 to over 2,400 in 2002 (Stein, Kennell, & Fulcher, 2004). If staffing ratios were set at one nurse to one patient during L&D nurses could then be the sole providers, providing both the technical and supportive care that a registered nurse (RN) can provide. This more intensive care by RNs during L&D might improve birth outcomes as well as satisfaction with care.

In recent decades, the importance of measuring satisfaction within the health care system has been recognized. Since childbearing is the most common reason for accessing health services, assessments of women’s satisfaction with their care during labor and delivery are relevant to healthcare providers, administrators, and policy makers (Hodnett, 2002). Satisfaction involves both a positive attitude and an affective response to an experience. Satisfaction is multidimensional; one can be satisfied with some aspects of an experience and dissatisfied with others (Hodnett, 2002).

Hodnett found that in every instance studied, caregiver support had a major influence on satisfaction. The quality of a laboring woman’s relationships with and support from her caregivers during labor are consistent strong predictors of childbirth satisfaction (Hodnett, 2002). Caregivers frequently assume that optimum pain relief during labor and delivery is very important to most laboring women. Hodnett found that pain and pain relief do not generally play major roles in satisfaction with the childbirth experience, unless expectations regarding either are unmet. Hodnett states that continuous support was consistently associated with more positive views and less likelihood of intrapartum analgesia/anesthesia. Today nulliparous couples still expect to have more direct, individualized attention from their doctors and nurses than they actually receive (Tumblin & Simkin, 2001). It is important for caregivers as well as managers to consider the laboring woman’s expectations about childbirth because fulfilling these expectations can increase her satisfaction with the birth experience (Tumblin & Simkin, 2001). To maximize patient satisfaction managers need to assess, assign, and support appropriate nurse to patient ratios on L&D units so that maternity patients receive continuous laboring support as needed.

A high patient-to-nurse ratio may actually raise expenditures, rather than reducing costs, by increasing the need for unnecessary medical interventions (Scott, Berkowitz, & Klaus, 1999). As hospitals decrease the ratio of L&D nurses to patients they decrease the amount of direct contact and support of women in labor by those nurses. Over the years, technology has replaced the human aspect of patient care without any improvement of outcomes; this might be an appropriate time for managers to reassess the effects of nurses on the labor and delivery process (Gordon, Walton, McAdam, Derman, Gallitero, & Garrett, 1999).

Definitions of Key Terms and Variables

L&D nurse: The registered nurse (RN) caring for a pregnant patient during labor and delivery.

Continuous labor support: The continuous presence of lay women or RNs from hospital admission to birth, during which time touch and speech are used for comfort, reassurance, and praise.

Nulliparous: A woman pregnant for the first time.

Perinatal outcomes: Include but are not limited to the following; live born, stillborn or perinatal death, assistive or cesarean delivery, continuous lumbar epidural or analgesia during labor, apgar scores.

Managerial impacts: Financial aspects, staff retention, and patient rate of return.

Nurse-patient staffing ratio: The number of patients per RN per shift.

Methods   

            An integrative review was chosen as the research design because it allows for generalizations about a topic from a group of studies (Jackson, 1980). The integrative review creates and organizes a body of literature for the examination of the current knowledge base of a particular topic. This allows the reader/investigator to contribute to the development of future research. Strengths of an integrative review include: the generation of new information, answers to questions, the possible creation of new hypotheses, and the subjects are the articles being investigated. Ethical issues related to human rights do not need to be weighed as heavily when compared to studies using human and or animals as subjects. A weakness of the integrative review is that the author in interpreting the works of someone else and these biases may impact the researcher’s results.

This integrative review of the literature used the following search engines: Medline Ovid, CINAHL, Pub Med, Google, and librarians. The key words used for the search include: nurse-patient staffing ratios, labor and delivery (L&D) units, labor support, doulas, perinatal/childbirth outcomes, and L&D management impacts. Three inclusion criteria will be used to assist in the data collection. The inclusion criteria are:

• Research articles published from 1996-present to support the analysis of the most current information;
• Research articles written in English or translated into English;
• Research articles utilize key terms and variables which describe the association between nurse-patient staffing ratios on L&D units and perinatal outcomes or managerial issues.

One exclusion criteria will be utilized: The research articles will be excluded if they do not specifically address the impact of staffing ratios on perinatal outcomes or managerial impacts of varying staffing ratios.

A collective findings table (Table I) will be developed and the data abstracted based on the following elements:

1. Author/Year
2. Purpose
3. Setting/Sample Size
4. Data Collection and Measures
5. Strengths and Limitations

The data will be organized in a literature review summary table to try and facilitate its analysis and interpretation. Ganong (1987), states that one of the simplest ways to show characteristics of the primary research is by making tables. This allows the researcher an opportunity to present large amounts of information without overwhelming the reader.

Conceptual Framework

            The Omaha System will be part of the conceptual framework utilized in this review in the analysis of patient impact. The Omaha System is a widely used research-based comprehensive taxonomy of the Problem Classification Scheme, the Intervention Scheme, and the Problem Rating Scale for Outcomes (Monsen & Martin, 2002). In order to determine the effects of varying nurse-patient staffing ratios on perinatal outcomes the three outcome measures, client knowledge, behavior, and clinical status will be utilized and arranged in a table (Table II) for analysis. Table II will list all the research articles used in this integrative review that fall within the inclusion criteria, analyze patient outcomes from varying nurse-patient staffing ratios using the three outcomes measures, and state the implications on nursing practice. The Omaha System is a model that can assist clinicians and administrators with practice, documentation, and information management.

The Balanced Scorecard will be included in the conceptual framework utilized in this review in the analysis of management impact. The Balanced Scorecard includes financial measures that tell the results of actions already taken. It complements the financial measures with operational measures on four other perspectives: customer, systems and processes, and learning and growth (Kaplan & Norton, 1992). In order to determine the managerial impacts of varying nurse-patient staffing ratios the four perspectives: financial, customer, systems and processes, and learning and growth will be utilized and arranged in a table (Table III) for analysis.  Table III will list all the research articles used in this integrative review that fall within the inclusion criteria, analyze managerial impacts from varying nurse-patient staffing ratios using the four operational measures, and state the implications on nursing practice. The Balanced Scorecard captures both the financial and the non-financial elements of a company’s strategy, and discusses the cause and effect relationships that drive business results.

Results

Data Collection and Analysis

At the first stage of the data collection process, an effort was made to incorporate different perspectives on the phenomenon of labor and delivery (as conducted by registered nurses, doulas, hospital administration, etc.) in order to collect the valid and generalizable body of information. Twenty-seven articles met the qualifications for this integrative review. They closely examined the issues of labor support and perinatal/childbirth outcomes in the context of labor and delivery (L&D) units. However, after reviewing the inclusion criteria for this piece of research, 16 articles were excluded. The reasons for their exclusion were they did not specify the impact of nurse-patient ratios on obstetric outcomes.

To be specific, the studies by Ballen and Fulcher (2006), Gordon et al. (1999), Kayne, Greulich, and Albers (2001), Scott, Berkowitz, and Klaus (1999), Scott, Klaus, and Klaus (1999), Stein, Kennell, and Fulcher (2004), Young (1998), and Zhang et al. (1996) described the activities of doulas as providers of continuous support for women in childbearing and breastfeeding conditions. Although this type of care providers deserves attention as the one contributing significantly to the well-being of a mother and a child, the present literature review focuses on nurses. Therefore the aforementioned articles were found irrelevant to the scope of the study.

The studies by Lowe (2002) and Caton et al. (2002) specified nursing activity as part of labor pain management. The former article avoided mentioning nurses at all, whereas the latter summarized the research papers which have been prepared for the symposium held collaboratively by the Maternity Center Association and the New York Academy of Medicine in 2002. Overall, these two articles were excluded from the research framework as being irrelevant to labor support performed by nurses specifically.

The articles by Hodnett (2002), Marmor and Krol (2002), Pearson (2006), Rosen (2004), and Steinbrook (2002) were identified as literature reviews and were therefore excluded from this summative literature review. Finally, the research framework of Yang’s article (2003) was found too general since it examined the effect of nurse staffing variables on patient outcomes overall without an emphasis on obstetric issues. It should be noted, nevertheless, that these 16 writings mentioned above will be included in the reference list to allow readers and future researchers the opportunity to thoroughly examine and critique these articles.

Eleven articles met the inclusion criteria. Data from these articles were organized in a table format (Table I) to facilitate the analysis of information. The designs varied from descriptive studies (Gagnon and Waghorn, 1996; Gale, Fothergill-Bourbonnais, and Chamberlain, 2001) and prospective studies (Hodnett et al., 2002) to applied research projects (Capuano, Bokovoy, Hitchings, and Houser, 2005; Stenske and Ferguson, 1996), randomized control trials (Carabin, Cowan, Beebe, Skaggs, Thompson, & Agbangla, 2005), and surveys (Miltner, 2000; Chen, Wang, and Chang, 2001; Tumblin and Simkin, 2001; Burke, 2003; Sleutel, 2000).

Four studies (Gale et al., 2001; Chen et al., 2001; Sleutel, 2000; Tumblin & Simkin, 2001) analyzed respondents’ reactions qualitatively. The rest of the studies employed quantitative methods of data analysis, including one-way analysis of variance (ANOVA), Pearson’s correlation, contingency table (chi) analysis for categorical and binary variations, Wilcoxon rank sum test, and negative binomial regression analysis.

The data gathered from this integrative review on the issue of nurse-patient ratios will be categorized into the two multi-factor clusters. The first cluster will include the three categories of clients’ knowledge, clients’ behavior, and clients’ clinical status as affected by nurse-patient ratios. The second cluster will comprise the four categories of outcomes that match the following perspectives of the Balanced Scorecard model: financial, customer-oriented, systems and processes, and learning and growth (Kaplan & Norton, 1992).

Characteristics of Sample

 The sample consisted of a total of 252 obstetric nurses (Burke, 2003; Gagnon & Waghorn, 1996; Gale et al., 2001; Miltner, 2000; Sleutel, 2000), over 15,600 women in labor, and 20 hospitals located in the United States, Canada (Burke, 2003; Gagnon & Waghorn, 1996; Gale et al., 2001 ; Hodnett et al., 2002), and Taiwan (Chen et al., 2001). Data were collected through questionnaires, interviews and observations, as well as from national/professional databases, and hospital patient and staff census records.

The majority of nurses were married (living together) females of 46 to 55 years old with children, holding college or university diplomas as registered nurses (RN), employed full time, with 5 to more than 20 years of experience. The age of women in labor ranged from 15 to 48 years. The largest pool of hospitals (n = 13 across the United States and Canada) was observed in the study by Hodnett et al. (2002). The annual birth census in the L&D units across the sample of the current review ranged from slightly above 2000 to 8500 births.

The studies under review demonstrated consistency in regard to nurse-patient ratios. Stenske and Ferguson (1996) recommended matching actual nurses’ staffing with patient volume and acuity within the standard framework proposed by American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) in 1992. Those standards suggested employing the 1:1 ratio in complicated cases of antepartum testing, during the second stage of labors, when initiating epidural anesthesia, dealing with III patients with complications, and when managing circulation for cesarean delivery. The ratio of 1:2 was recommended for uncomplicated cases of antepartum testing, for laboring patients, for oxytocin induction or augmentation of labor, and for postoperative recovery.

The ratios mentioned in the seven articles under research (Burke, 2003; Chen et al., 2001; Gagnon & Waghorn, 1996; Gale et al., 2001 Hodnett et al., 2002; Sleutel, 2000; Stenske & Ferguson, 1996) fitted the suggested framework, although the three of them (Gagnon & Waghorn, 1996; Gale et al., 2001; Chen et al., 2001) tackled upon medical care outside the United States. The articles by Capuano et al. (2005), Miltner (2000), Tumblin and Simkin (2001) and Carabin et al. (2005) did not specify nurse-patient ratios.

The studies with the most representative samples concentrated on organizational issues, whereas the articles covering smaller number of hospitals/units investigated clients’ perceptions as well as physical and psychological status as affected by nursing actions. The variety of managerial and nursing inputs related to patient outcomes will be discussed below.

Patient Outcomes as Affected by Nursing Actions

After reviewing the 11 articles which met the inclusion criteria, three categories of factors were found to be consistent in contributing to patient outcomes of women in labor as affected by varying nurse-patient staffing ratios. The three categories are: 1) patients’ knowledge, 2) patients’ behavior, and 3) patients’ clinical status.

The taxonomy of nurses’ actions that facilitated the exchange of information between L&D units’ staff and patients, enhanced clients’ behavioral patterns, and prevented negative clinical outcomes for women in labor was described in the six articles (Chen et al., 2001; Gagnon & Waghorn, 1996; Gale et al., 2001; Miltner, 2000; Sleutel, 2000; Tumblin & Simkin, 2001). The studies by Chen et al. (2001) and Tumblin and Simkin (2001) examined the elements of supportive and direct care as they were conceptualized by patients, whereas the other four studies analyzed those elements as perceived by nurses.

Research demonstrated that patients and nurses had similar ideas of what constituted the quality care. Nurses’ actions which contributed to increasing the level of knowledge in laboring women were categorized as follows: 1) instructing or coaching; 2) explaining or providing information/advice; and 3) negotiating women’s needs with other stakeholders or providing advocacy. Nurses could encounter certain ethical dilemmas during provision of information to clients (Sleutel, 2000). Sleutel’s case study demonstrated that nurses were likely to balance their efforts of informing clients about the labor course against the professional ethic.

Nurses’ actions that reduced the likehood of negative behavioral outcomes in patients were labeled as psychological support (Chen et al., 2001) or emotional support (Gagnon & Waghorn, 1996; Gale et al., 2001). This type of care could be manifested through: 1) invigorating attitude (reassurance, encouragement, praise); 2) providing companionship; 3) conducting social conversation with woman; and 4) encouraging verbalization of women’s fears, concerns, and needs, as well as soothing and consoling women. Judging by Miltner’s (2000) report, the nursing actions that were normally categorized as informational support (coaching) affected also clients’ behaviors at the active stages of labor. For example, a nurse informed a patient how to alternate relaxation and pushing efforts; consequently, a woman controlled her behavior and felt more comfortable and safe during the process. Sleutel (2000) stressed that nursing activities aimed at improving clients’ behaviors were more likely to be effective when labors were not induced.

Nursing actions that might contribute to clients’ clinical status fitted the five following sub-categories: 1) providing physical comfort; 2) providing direct care in a woman’s room; 3) providing indirect care in a woman’s room; and 4) providing postpartum care. It is worth mentioning that the sub-category of physical comfort (i.e. massaging, bathing, giving fluids, and etc.) was viewed either as a part of supportive care (Gagnon & Waghorn, 1996) or a type of direct care (Gale et al., 2001). Sleutel’s study (2000) expanded the categorization of clinically important nursing actions by reporting about a case of induced labors that were geared by a nurse on the command from a physician. The nurse had to create a cascade of interventions (pitocin, epidural, urinary catheterization) which limited a patient’s mobility and increased risk of operative delivery as well as fetal intolerance of labor. The example demonstrates that nursing actions as related to patients’ clinical status could be either positive or negative.

One and the same action might affect simultaneously clients’ knowledge, behavior, and clinical status. For example, Chen et al. (2001) evidenced that clients displayed fewer negative behaviors such as “high levels of anxiety and tension” (p. 183) when nurses informed clients about the labor course and provided appropriate instruction at the right time. In other words, appropriate nursing care resulted in the improvement of both clients’ behavior and knowledge.

To proceed, Gale et al. (2001) emphasized that, “The presence of a support person providing encouragement and comforting touch had been shown to significantly reduce the likehood of operative delivery and the use of analgesia, and increases mothers’ satisfaction with the birth” (under “Clinical Implications, para. 1, lines 3-5 p. ??? ). Thus a positive relationship was found between nurses’ actions, patient’s behavior and clinical status. The same hypothesis was proven to be true in the study by Miltner (2000). The researcher argued that continuity of nursing care (e.g., when nurses followed patients to OR to check if cesarean was necessary) stabilized both women’s emotional and physical well-being. To summarize, the borderlines between the categories and sub-categories of nursing inputs as related to different client outcomes were reported to be rather flexible.

The comparison of data from the studies under review resulted in a few important findings regarding the relationship between nurse-patient ratios and patients’ knowledge, behavior, and clinical status. Judging from the empirical evidence gathered by three research groups (Gagnon & Waghorn, 1996; Gale et al., 2001; Hodnett et al., 2002), the variable of patients’ clinical status seemed to be the least affected by the variable of nurse-patient ratio. Both a nurse who was in charge for two women at once (Gagnon & Waghorn, 1996) and a nurse who had to look after only one patient (Gale et al., 2001) spent approximately equal portions of time, 10.6% and 8.7%, accordingly, on direct care in the client’s ward. In other words, nurses scheduled their responsibilities that might affect the client’s clinical status (e.g., were busy taking temperature and blood pressure, inserting catheter, and so on) in a similar fashion regardless of how many patients were assigned to each of them.

It is interesting that both nurses working in the L&D units with the 1:2 ratio (Gagnon & Waghorn, 1996) and those working in the units with the 1:1 ratio (Gale et al., 2001) maintained a close contact with patients for hardly the one-forth part of their time (25.2% and 27.8%, accordingly). Hodnett et al. (2002) also proved that clients’ clinical status was not significantly affected by the proportion of nurses’ presence nearby. In that study (the 1:1 nurse-patient ratio) there were control and experimental groups. In the latter type of groups nurses were expected to spend the minimum of 80% of their time with patients. Surprisingly, the rates of clinically important patient outcomes (e.g., cesarean delivery, operative vaginal delivery, perineal traumas, and health problems during postpartum stay) varied insignificantly across the groups.

Those findings demonstrated that nurse-patient ratios were likely to influence clients’ knowledge and behavior. A nurse being assigned to one patient (Gagnon & Waghorn, 1996) was able to dedicate 12.4% of her time to providing supportive care in the form of advocacy, physical comfort measures, companionship, instruction, and so on, whereas a nurse in charge for two patients (Gale et al., 2001) spent only 6.1% of time on analogous activities. It speaks to the fact that nurses were often unable to provide adequate psychological help for their clients. Meanwhile, in women’s conceptualization, such type of care was as significant as clinical interventions.

As Tumblin and Simkin (2001) stated,

When nurses can assist women to cope with the stress of labor using a high realistically prepare pregnant women for the likelihood that the nurse may provide less support than women degree of interpersonal skills, women’s satisfaction with their birth experiences increased. (p. 55)

Women’s reactions registered by Chen et al. (2001) and Sleutel (2000) also supported the assumption that patients highly valued those nursing actions that provided them with information and empathy. Carabin et al. (2005) observed that nursing emotional and informational support mattered also outside hospitals when nurses were enrolled in home visitations of their patients.

As Capuano et al. (2005) proved, nursing activities affecting clients’ knowledge, behavior, and clinical status were influenced not only by nurses’ interpersonal skills but by organizational variables. The following section will summarize findings concerning managerial impacts on nursing practices.

Managerial Impacts on Nursing Activities and Patient Outcomes

The analysis of the articles under review showed that there were four types of managerial impacts on nursing practices and, subsequently, patient outcomes. The categories of impacts are: 1) financial issues, 2) customer-oriented issues, 3) systems and processes issues, 4) learning and growth issues.

Seven articles (Capuano et al., 2005; Carabin et al., 2005; Gagnon & Waghorn, 1996; Hodnett et al., 2002; Sleutel, 2000; Stenske & Ferguson, 1996; Tumblin & Simkin, 2001) provided an account of financial issues affecting hospitals overall and L&D units specifically. For example, Stenske and Ferguson (1996) observed that, since the late 1980s, both actual personnel cost per delivery and staff nurse salaries had been constantly increasing. As Gagnon and Waghorn (1996) acknowledged, the trend was accompanied by reduction of hospital budgets. Among all stakeholders of medical system patients appeared to be the least defended in terms of availability and quality of medical care.

Three articles (Capuano et al., 2005; Hodnett et al., 2002; Sleutel, 2000) directly stated that a substantial share in hospital budgets was spent on nursing service costs. The latter looked as follows (Capuano et al., 2005): 1) RN dollars or salary for regularly scheduled registered nurses; 2) overtime dollars or salary for regularly scheduled RNs working overtime; and 3) agency dollars or salary for nurses who were not employed in the given hospital. The articles under review showed how hospital administration attempted to reduce expenditures on nursing staff.

For example, Capuano et al. (2005) evidenced that hospitals struggling to receive the prestigious “Magnet Status” declined the services of agency nurses and recruited additional personnel in order not to rely so heavily on overtime shifts. Sleutel (2000) hypothesized that labor inductions would also result in cheaper costs of nursing services. The logic was as follows: the periods of patients staying in L&D units would be shorter; subsequently, patient volume would increase; but there would be no need to hire extra nursing staff because nurses’ workload during labor inductions would be lower than in a normal labor process.

To proceed with the theme, social programs sponsored by state budgets (Carabin et al., 2005) were also cited as financially efficient cases of obstetric care. The research by Carabin et al. provided a link between the variables of medical expenditures and of patient outcomes as existing outside the hospital infrastructure. The researchers observed that women of disadvantaged socioeconomic backgrounds followed recommendations in prenatal care more eagerly if their travel fees to the clinic were reimbursed by the state government.

It is clear that the quality of medical and obstetric care was challenged not only by small hospital budgets and expensive staffing costs. The idea was supported by Tumblin and Simkin (2001) who cited the position statement published by the Association of Women’s Health, Obstetrical and Neonatal Nursing (AWHONN). Those organizations stated that the quality of nursing services was undermined by several factors, including “limited numbers of available experienced registered nurses, limited financial resources, rigid organizational processes and structures, cumbersome documentation requirements, and decreasing reimbursement by third party payers in the United States’’ (qtd. p. 55). Thus, financial implications of obstetrics were directly related to the quality of organizational systemic processes and of nurses’ retention and training.

Many scholars emphasized that the transparency and efficiency of system processes and the impetus for professional learning and growth played an important role in providing the quality obstetric care. For example, Hodnett et al. (2002) argued that a commitment to 1:1 nurse-patient ratio should be accompanied by such organizational factors as “regular audits of [organizations’] practices, shared decision-making by multidisciplinary teams, active consumer involvement in policy setting, and a belief system based on labor and birth as healthy life events” (page 17 of 19 in the faxed text, para. 3, lines 8-10). In order to get a clearer conceptualization of systemic and educational processes relevant for obstetric care, the articles under review were compared in a qualitative fashion.

Regarding the factors related to the systems and processes perspective, Capuano et al. (2005) predicted that patient outcomes were affected by nurses’ work environment. The latter was influenced in its turn by the factors of leadership, teamwork, staff competence, resources and stability. It is hypothesized here that the elements of 1) teambuilding (teamwork), 2) system maintenance (resources), and 3) workload (stability) in the abovementioned model could be placed within the category of “systems and processes” of the Balanced Scorecard model.

In Capuano et al.’s research (2005) the quality of teambuilding processes was assessed through 1) coworker cohesion or the presence of supportive relationships in a team, 2) supervisor support or the link between senior and subordinate personnel, and 3) involvement or the opportunities for decision-making. It is worth mentioning that the former two of the three above cited factors were also mentioned by Burke (2003), who researched the dynamics of organizational processes as affected by changes in nurse-patient ratios, under the names of staff coordination and quality service culture. Burke (2003) observed that nurses were more able to coordinate their professional efforts in a team in the hospitals with stable nurse-patient ratios. It was argued that restructuring (either increase in or reduction of the number of patients assigned to one nurse) would negatively affect organizational systems and, subsequently, patient outcomes.

Furthermore, Capuano et al. (2005) viewed system maintenance as integrity of 1) clearly stated goals; 2) managerial control; 3) innovation; and 4) nurses’ physical comfort. Whereas Capuano et al. viewed those processes as positive, Burke (2003) acknowledged that some innovations could produce a negative impact on nurses’ perceptions of their work environment. Specifically, increased nurse-patient ratios could make nurses more fearful of future threats and less satisfied with their jobs.

The variable of workload was researched in-depth by Capuano et al. (2005) and Stenske and Ferguson (1996). The former research group employed nurses’ perceptions of workload as one of the measures to assess the quality of work environment. They found that higher levels of workload could complicate organizational processes through weakening teambuilding skills. Workload was reported as negatively affecting not only nurses who felt themselves overtired and depressed but patients as well. Capuano et al. (2005) evidenced that the greatest number of adverse patient outcomes happened in the last quartile of overtime hours. Stenske and Ferguson (1996) also mentioned workload as a potential stressor for nurses and patients and as an obstacle for building an efficient organizational system.

The negative effect of work pressure was partly mediated by the factors related to learning and growth. As Capuano et al. (2005) witnessed, educational opportunities and leadership culture produced a positive effect on team members. They perceived their work pressure less tragically in the presence of experienced nurses. The variable of nurses’ expertise was highly appraised by Gagnon and Waghorn (1996) who observed that nurses with more than seven years of working experience were able to provide support of higher quality to their patients.

To summarize, researching the routine of L&D units through the lens of the Balanced Scorecard model lent a valuable insight on nursing support as related to patient outcomes. Implications for obstetric practices and future research will be overviewed in the section below.

Future Research

It seems that there should be a clearer conceptualization of factors affecting patient outcomes in obstetric settings. This is regrettable that most of the studies researching the diversity of client-oriented nursing actions abstain from analyzing the same issues at the organizational macrolevel. More research is needed to trace managerial impacts on both nurses and women in labor. Case studies and applied research projects would ensure that specific guidelines are worked out regarding nurses’ activities in the challenging settings of modern L&D units with their reduced budgets, staff shortages, little opportunities for personnel training, and inefficient system processes.

Nursing Implications

The eleven articles under review demonstrated that none of the factors forming any of research perspectives (be it The Omaha System model, the Balanced Scorecard model, or any other models) should be valued by itself. The formative elements should be taken rather in their integrity as interacting and enriching each other. For example, decision-making is highly welcome in organizational settings as the evidence of mature systemic culture and the catalyst of system processes. In the L&D settings, however, the necessity to participate in discussions of unit policy may turn out to be a waste of time. As Gale et al. (2001) indicated, such discussions were not manifestations of democratic decision-making but rather an exuse for nirses to spend a substantial portion of their time outside the patient’s ward. System processes should be run in a maximal proximity to the clients but obstetricians should balance this recommendation against professional ethics in order not to make clients uncomfortable or nervous. Nurses should be trained not only in technical but also in interpersonal skills to provide emotional as well as informational support and advocacy. The needs of patients should be taken as a cornerstone of obstetrics. The 1 :1 nurse-patient ratio would not repair all problems when introduced mechanically without improving the overall organizational culture and motivating nurses to perform their duties at best.

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Table I: Collective findings

Table II

Table III