Katherine Camacho Carr

Professional Liability Issues and Practice Patterns of Obstetric Providers in Washington State

OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician–gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician–gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician–gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician–gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers’ most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician–gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington’s obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study’s results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III

Innovations in Midwifery Education

Midwifery educators and the American College of Nurse-Midwives (ACNM) have created educational pathways for Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) based on sound principles and creativity. A review of these educational innovations portrays the strong foundation that exists and provides direction for the future. Accreditation of educational programs, the development of core competencies, and the certification process for graduates of midwifery education programs form the foundation for excellence in midwifery education, while the early development of the modular mastery learning curriculum provided a transition to later use of telecommunications and the incorporation of various instructional technologies into midwifery education. Midwifery educators have continued to innovate with distance-learning, Web-enhanced curricula and community-based clinical preceptorships, and a masters degree in midwifery option to increase access to midwifery education and degree programs. Continued innovation and creativity will be required to prepare midwives for the 21st century.

Creating off-campus/distance learning courses for midwifery education. A brief introduction.

Midwifery education is undergoing a curriculum revolution that is reflective of current trends in other fields. Distance learning programs have developed in response to these changes. This article provides an overview of a student-centered transactional educational model, discusses the role of faculty as midwife-teachers, and reviews the factors influencing technology decisions for distance education. Curricular structure is discussed and ideas for learning activities are presented to assist faculty considering the development of off-campus, distance learning courses.

New directions in midwifery education: the master’s of science in midwifery degree

Midwifery is reclaiming its perspective as a discipline separate from, yet integrally related to nursing and medicine. Emerging trends in health care place increased demands on the knowledge base and clinical practice of midwifery, stimulating a need for new directions in midwifery education. The masters of science with a major in midwifery is a new degree option available to midwifery students in the United States. This article presents the argument that midwifery is a distinct discipline and describes the importance of a masters of science in midwifery degree toward furthering the work of the discipline of midwifery. Descriptions of the current masters of science in midwifery degree programs are included.

The importance of non-master's degree options in nurse-midwifery education

A crisis in our country’s ability to provide maternity care to poor women and to women who live in rural areas has created a unique opportunity for nurse-midwifery. Twelve percent of practicing obsti nearly 30% of OB/GYNs do no more deliveries after they reach the age of 45.’ In adlitton, family practitioners have stopped delivering babies in some rural areas.2 National political, foundation, and corporate leaders have finally awakened to the magnitude and importance of maternal and child health problems in this country and are making increasing efforts to find cost-effective ways to improve the well-being of mothers and babies. For more than 60 years, nurse-midwives have demonstrated a willingness to work in rural areas and inner-city communities and the ability to improve pregnancy outcomes for women whose lives are compiicated by social and economic problems. After decades in which we struggled to sutvive, there is now an

Using the unfolding case study in midwifery education.

One of the challenges in teaching clinicians is helping health care provider students, including midwives, develop the critical thinking and clinical decision-making skills needed for various situations encountered in practice. Health care provider students need to master the required core knowledge and skills but also need to assess, analyze, judge, decide on action, act, and evaluate their actions. Lecture-heavy classroom teaching, which is usually delivered separately from clinical experiences in health care education, focuses on knowledge acquisition, often leaving knowledge application to trial and error. Case studies are commonly used by faculty with a problem-based learning approach, which is more analytic but sometimes static. The unfolding case study presents students with a patient scenario that changes over time and allows for discussion; lecture points as needed; and decision making as the situation or condition changes, reflecting what happens in real-life clinical practice. The use of the unfolding case study moves health care provider education from fact-based lecturing to situation-based discussion and decision making as a persons condition or situation changes. Use of the unfolding case facilitates collaborative learning, covers necessary content, and assists students to think beyond the facts and use their clinical imagination. Unfolding case studies require students to begin to grasp the nature of a clinical situation and adjust interventions as the clinical situation unfolds. Steps in developing and using an unfolding case study for midwifery students are presented, including 2 examples. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Developing an evidence-based practice protocol: implications for midwifery practice.

Evidence-based practice is defined and its importance to midwifery practice is presented. Guidelines are provided for the development of an evidence-based practice protocol. These include: identifying the clinical question, obtaining the evidence, evaluating the validity and importance of the evidence, synthesizing the evidence and applying it to the development of a protocol or clinical algorithm, and, finally, developing an evaluation plan or measurement strategy to see if the new protocol is effective.

Community-Based Nurse-Midwifery Education Program: Distance learning in nurse-midwifery education

Distance-learning has greatly expanded the number of students admitted to a nurse-midwifery education program. This article describes the Community-Based Nurse-Midwifery Education Program (CNEP) of the Frontier School of Midwifery and Family Nursing. The organizational structure and curriculum of the CNEP combines apprenticeship learning with academic rigor, permitting students who cannot relocate to the university to pursue graduate education. New technology, such as an interactive electronic bulletin board, networks students and faculty. The program emphasizes theories of independent, adult learning. There is a masters completion option available through the affiliation with Case Western Reserve University.Distance-learning has greatly expanded the number of students admitted to a nurse-midwifery education program. This article describes the Community-Based Nurse-Midwifery Education Program (CNEP) of the Frontier School of Midwifery and Family Nursing. The organizational structure and curriculum of the CNEP combines apprenticeship learning with academic rigor, permitting students who cannot relocate to the university to pursue graduate education. New technology, such as an interactive electronic bulletin board, networks students and faculty. The program emphasizes theories of independent, adult learning. There is a masters completion option available through the affiliation with Case Western Reserve University.

FROM COACH TO COLLEAGUE: ADJUSTING PEDAGOGICAL APPROACHES AND ATTITUDES IN ACCELERATED NURSING PROGRAMS

Accelerated nursing programs are an innovative approach to training nurses and advanced practice nurses that are growing steadily in number and popularity. Although there is ample evidence to show that these programs have good outcomes, acceptance by both faculty and nurses in the community remains low. This article gives a description of the accelerated nursing student, which provides some insight as to why this student is both a challenge and a joy to mentor. In addition, an overview of pedagogical approaches that may be helpful in teaching this bright group of accelerated nursing students is provided. Accelerated nursing students enrich the nursing profession with the myriad of skills and varied backgrounds they bring to nursing. As professionals, mentors, and educators, we need to not only embrace accelerated students but also be advocates and mentors for them as they assimilate into our profession.

The United States midwifery education, regulation, and association work group: what is it and what does it hope to accomplish?

During the triennium 2008 to 2011, the International Confederation of Midwives (ICM) developed a group of essential documents that described the Three Pillars of midwifery: education, regulation, and association. The pillars of midwifery were built upon the ICM Essential Competencies for Basic Midwifery and the ICM Definition of a Midwife.1,2 The core documents,3–5 which together comprise the global standards for midwifery education, practice, and regulation, are meant to strengthen midwifery worldwide and to provide high-quality evidence-based care for women, newborns, and families in order to decrease maternal and infant mortality and morbidity.3–5 In response to this global midwifery initiative, 7 US midwifery organizations convened the United States Midwifery Education, Regulation, and Association (US MERA) Steering Committee and a larger work group to develop a collaborative response to the ICM global vision, strengthen the midwifery profession in the United States, and expand delivery of high-quality care.6 These organizations include 3 professional associations as well as the 4 organizations responsible for education, certification, and regulation related to the 3 professional US midwifery credentials: the certified professional midwife (CPM), certified nurse-midwife (CNM), and certified midwife (CM). This article provides an overview of the history, current activities, and future directions of US MERA.