5

Workforce Issues

Workforce issues extend beyond “who does what” questions to questions about who is allowed to do what, who gets to do what with whom, who makes it on to the team, and who takes responsibility (or has responsibility “shoved” on them) when something goes wrong. Although workforce issues emerged as topics of discussion in various contexts throughout the course of the workshop, Panel 4 was designed to focus exclusively on these and related questions and to identify future research needs. This chapter describes the information presented and discussions that occurred during the workforce issues panel. See Box 5-1 for a summary of key points made by individual speakers. The panel was moderated by Thomas C. Ricketts, Ph.D., M.P.H., University of North Carolina at Chapel Hill.

EDUCATION, REGULATION, AND MANAGEMENT OF HEALTH CARE PROFESSIONALS IN BIRTH SETTINGS1

Catherine Dower provided an overview of the U.S. birth setting workforce, including its changing supply and demand, varying educational backgrounds of different types of care providers, varying regulations for different types of providers, the role of care teams, and future research needs.

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1This section summarizes information presented by Catherine Dower, J.D., University of California, San Francisco.



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5 Workforce Issues W orkforce issues extend beyond “who does what” questions to questions about who is allowed to do what, who gets to do what with whom, who makes it on to the team, and who takes responsibility (or has responsibility “shoved” on them) when something goes wrong. Although workforce issues emerged as topics of discussion in various contexts throughout the course of the workshop, Panel 4 was designed to focus exclusively on these and related questions and to identify future research needs. This chapter describes the information presented and discussions that occurred during the workforce issues panel. See Box 5-1 for a summary of key points made by individual speakers. The panel was moderated by Thomas C. Ricketts, Ph.D., M.P.H., University of North Carolina at Chapel Hill. EDUCATION, REGULATION, AND MANAGEMENT OF HEALTH CARE PROFESSIONALS IN BIRTH SETTINGS1 Catherine Dower provided an overview of the U.S. birth setting work- force, including its changing supply and demand, varying educational back- grounds of different types of care providers, varying regulations for different types of providers, the role of care teams, and future research needs. 1  his T section summarizes information presented by Catherine Dower, J.D., University of California, San Francisco. 77

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78 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS BOX 5-1 Workforce Issues Key Points Made by Individual Speakers •  atherine Dower noted that many different types of health care professionals C are involved in the care of birthing mothers and their babies, with obstetricians comprising the largest sector of the workforce and midwives the second largest sector. •  ccording to Dower, the impact of teams of birth setting professionals work- A ing together is unknown, and researchers still do not know how to define or measure teams. •  hile education and training among obstetricians and the different types of W midwives varies, all professions are challenged by insufficient interprofessional education and a lack of awareness about what people in other professions can do. In Dower’s opinion, much of the mistrust, or distrust, that exists among dif- ferent types of perinatal care professionals stems from the lack of interprofes- sional education. •  ccording to Debra Bingham, registered nurses (RNs) have played an in- A creasingly important role in birth settings because of the many intervention and outcome changes that have occurred over the past few decades, most notably dramatic increases in Cesarean deliveries, severe maternal morbidity, and women receiving blood transfusions during hospital birth admissions. •  ingham stated that there has been significant recent growth in the number B of births attended by midwives. It is unclear whether and how demand for midwives or other professionals would change if women were fully informed about all of their birth setting options. •  hile nurse staffing and nurse education have been shown to affect patient W outcomes, Bingham stressed that little is known about perinatal RN staffing patterns, the qualifications of perinatal nurses who provide care to women and newborns, and how those patterns and qualification impact outcomes. •  usan Stapleton observed that the list of what is unknown about the maternity S care workforce is much longer than the list of what is known. Workforce Supply and Demand Physicians comprise the largest segment of U.S. health care profes- sionals working in birth settings, with an estimated 50,000 obstetricians nationwide. Dower warned, however, that the numbers she was presenting were “squishy,” saying that every time she reports a number, there are many ways to qualify that information. For example, not all obstetricians work in labor and delivery. Nonetheless, they do comprise the largest sector of birth setting professionals. Second to physicians are midwives, which are composed primarily of four groups: (1) CNMs, with an estimated 13,000 to 18,500 nationwide (Dower suspected that the number was closer to 13,000, with many of the 18,500 estimated by the Health Resources and Services

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WORKFORCE ISSUES 79 Administration inactive); (2) CPMs, with an estimated 2,000 nationwide; (3) licensed midwives (LMs), with an estimated 750 to 2,000 nationwide; and (4) CMs, with fewer than 100 nationwide. Additional health care pro- fessionals working in birth settings include doctors of osteopathy (DOs), family practice medical doctors (MDs), anesthesiologists, nurses, doulas, hospital staff, paramedics, and interpreters. Dower said, “There are a lot of people who are peripherally and directly involved in the care of birthing moms and their babies.” All of the different professions involved with the care of birthing moms and their babies have increased in size in recent years, although to vary- ing degrees. For example, the number of obstetricians has increased nearly 20 percent over the past 15 years, outpacing population growth. Dower emphasized that, although not all obstetricians are involved with labor and delivery, the fact that growth of the obstetrician supply is outpacing population growth is an important trend to recognize. The CPM supply is also growing at a very quick rate, at about 10 percent per year over the past 3 years, again outpacing population growth. However, with CPMs, the “N” is very small (again, only about 2,000 nationwide), so a 10 percent growth rate does not translate into a significantly larger number of CPMs practicing. Dower noted that there has also been significant growth in the number of births attended by midwives, from about 6 percent 10 years ago to 8 to 10 percent in 2009 (8 percent for total births, 12 percent for vaginal births). With respect to diversity, the birth setting workforce tends to be very heavily female dominated, particularly among the CNMs and CPMs, with neither race nor ethnicity reflecting the general population. Collecting workforce supply numbers is a challenging task. The data are difficult to find. Dower had to contact colleagues from multiple orga- nizations and, as she said, “pull all those pieces together.” Not only are the data difficult to collect, but they are not standardized, making it very difficult to compare estimates across the various health professions. In terms of workforce demand, there has been a fairly steady and predictable need for birth setting professionals. The predictability stems from the predictability of the number of babies born per year. However, according to Dower, there is unknown demand with respect to choices that women would make if they were fully informed about all their birth setting options. It is also not clear how demand will change in response to changes resulting from the Affordable Care Act, changes in the economy (i.e., cost is an issue not just for consumers, but also for health care pro- viders), changes in delivery technology, shifts in consumer choice (e.g., when consumers are provided with additional information), and changing public health concerns. An example of a changing public health concern is the growth of antibiotic resistance (or superbugs) in hospitals. Currently,

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80 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS Dower said labor and delivery is the highest revenue source for hospitals. She suggested that even just a couple of high-profile antibiotic-resistant bac- terial outbreaks could create a significant reduction in consumer demand for hospital-based labor and delivery. Education Education, training, model of care, and practice location vary among the different birth setting professions. MDs are trained via a very academic program (i.e., a bachelor’s program and then medical school), followed by residency and board certification; their training and practice are based on a medicine model of care; and they train and practice primarily in hospi- tals. CNMs are initially trained via a bachelor’s or registered nurse (RN) program, followed by master’s or doctoral degrees; their advanced training and practice are based on a midwifery model of care; and they practice primarily in hospitals. CPMs are trained via either an apprenticeship or an accredited educational program, with CPM apprenticeships (the most popular track) not requiring any formal education and the education track including anything from certificates to doctoral degrees; their training and practice are based on a midwifery model of care; and they work primarily in homes and birth centers. CMs are educated and trained much like CNMs in a midwifery model, but without having a prior nursing background; CMs must complete at least a bachelor’s degree plus master’s to receive certification. Dower emphasized that all four professions—MDs, CNMs, CPMs, and CMs—share some of the same challenges. These include finding sites for clinical training, particularly sites outside of hospital settings; provid- ing interprofessional education; providing evidence-based preparation (i.e., entering evidence into the curricula and training professionals based on that evidence); and training professionals to work in a changing health care environment (i.e., the environment that most people work in today looks little like it did when people were trained 15, 20, or 30 years ago). Dower emphasized the challenge of interprofessional education, an issue where much of her current work is focused. Because they do not train together, many people do not know what people in other professions can do. Much of the mistrust, or distrust, that exists among different types of perinatal care professionals is rooted in the lack of interprofessional education. Workforce Regulation As with education and training, regulation too varies among the vari- ous birth setting professionals. MDs and DOs have the same full scope of

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WORKFORCE ISSUES 81 practice; they can provide any care to anyone in any health care setting. Moreover, their scope of practice is standardized among all 50 states, which is not the case for midwives (or any of the other professions involved with labor and delivery). While CNMs are recognized and can practice legally in all 50 states, they can practice independently in only 20 states. State variation in CNM scope of practice stems, in part, from different defini- tions and compromises over terms like “collaboration” and “supervision” in legislation. With respect to the other types of midwives, only about half of the states recognize CPMs, only half recognize LMs (and they are not necessarily the same states that recognize CPMs), and only five states au- thorize CMs to practice. Scope-of-practice laws for all health professions involved with labor and delivery are state based and politically driven, according to Dower, re- sulting in significant state variability and some disconnects between compe- tence and authority. In some places, people are authorized to provide more care than they can competently provide, while in other places people are not allowed to provide care that they can competently provide. In Dower’s opinion, scope-of-practice “turf battles” exacerbate the problem. Not only do people from different professions not know how to communicate with each other or work together, but they are taught from a very early stage of their professional development to think of people in other professions as competitors or opponents. Management: The Challenge of Defining “The Team” A team of birth setting professionals can include obstetricians, nurse midwives, midwives, doulas, and any of the many other professionals in- volved with labor and delivery. But it is still not clear how to put a team together in any given setting in the most effective way. Again, part of the challenge is that people from different professions are not trained to work together as teams. Thus, the impact of real teamwork is unknown. It is not clear how many of each type of provider are needed in each care setting; how real team care impacts provision of care and patient outcomes; how real teamwork impacts educational programs; and how real teamwork im- pacts cost. “We don’t know how to define or measure teams yet,” Dower said. Still to Learn There is still much to learn about the birth setting workforce. Dower identified several key needs. First are accurate, comparable supply numbers so that researchers can compare the different professions. Second, it is not clear how to measure demand. People do not have a fully informed range

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82 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS of choices available to them; thus, it is not clear how many people would choose different providers in different settings. Third, the costs of various workforce and staffing models are unknown. Dower remarked that such costs have been only barely touched on in some of the research featured at the workshop, which in her opinion is the best research in the field con- ducted thus far. Finally, there is much more still to learn about the impact of technology, policy changes, consumer choice, and innovative financing on workforce needs, education, regulation, or management. For example, many systems are joining together to work collaboratively (e.g., birthing centers and hospitals). What will the impacts of that collaboration be on care? PERINATAL RN STAFFING IN BIRTH SETTINGS2 Representing the Association of Women’s Health, Obstetric and Neo- natal Nurses (AWHONN), Debra Bingham spoke about the importance of measuring and tracking perinatal RN staffing, what is known about trends in perinatal RN staffing, and the need for more research on perina- tal RN staffing. AWHONN is the standard-bearer organization for more than 350,000 women’s health, obstetric, and neonatal nurses in the United States. The organization advocates for key health care and nursing profes- sional issues, develops and disseminates evidence-based nursing practice resources, and serves as an international nursing leader. Trends in Perinatal RN Staffing There is considerable variation in the volume of births and the type of registered nurse staffing present in hospital settings where women give birth. In 2008, 79 percent of the 3,265 U.S. hospitals with obstetric services reported fewer than 2,000 annual births despite the fact that nearly half of all births occur in only 15 percent of U.S. hospitals (Simpson, 2011). Not every hospital in the United States has an in-house physician or midwife. Bingham herself has worked in hospital units where there are no physicians or midwives in house, only nurses. AWHONN issued updated guidelines for perinatal RN nurse staffing (AWHONN, 2010), but not without controversy. The guidelines, which represent an update from 1983 guidelines, were issued because of the many intervention and outcome changes that have occurred since 1983 and the need for more intensive nursing care as a result of those changes. Most notably, between 1983 and 2008, there was a 100 percent increase 2  his T section summarizes information presented by Debra Bingham, Dr.P.H., RN, LCCE, Asso­ iation of Women’s Health, Obstetric and Neonatal Nurses, Washington, DC. c

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WORKFORCE ISSUES 83 in Cesarean deliveries, from 16.5 percent to 33 percent. From 1998-1999 to 2008-2009, severe maternal morbidity increased by 75 percent and the number of women receiving a blood transfusion during a hospital birth admission increased by 184 percent (Callaghan et al., 2012). Technol- ogy is also changing. A comparison of the electronic health record for a nonpregnant patient and the electronic health record of a pregnant patient illustrates the much more complicated flow of records associated with preg- nancy. In theory, integration of electronic health records should save nurses time. Bingham observed that this is not the case. The flow of outpatient and inpatient records is especially slow, with the necessary records not always available to clinical teams. The AWHONN staffing guidelines are applicable to all settings. They are based on the type of patient and care needed, not where care is being provided. While RN maternity nurses are essential frontline clinicians in hospital-based perinatal units, where multiple types of care are provided (from emergency triage and evaluation to psychiatric care), birthing centers have various types of staffing models which can include RNs, licensed prac- tical nurses (LPNs), or nurses’ aides. Home births do not usually employ RN care. Bingham noted that it is not clear whether women giving birth in nonhospital birth settings by non-RNs are missing important nursing interventions. Research on Perinatal RN Staffing and Outcomes “Unfortunately,” Bingham said, “there has been very limited curiosity in the effect of nursing staff on birth settings and birth outcomes.” There have been only a few studies, including one on the impact of nursing staff ratios on survival and outcomes for low-birth-weight and preterm infants (Hamilton et al., 2007) and one on oxygen-related outcomes in prema- ture newborns (Sink et al., 2011). However, more than two decades of studies linking RN staffing and RN competencies to improved outcomes in intensive care and medical surgical settings suggest that similar types of outcomes could be expected in a perinatal population. For example, Needleman et al. (2002) linked greater hours of RN staffing to decreased length of stay and lower rates of urinary tract infections, upper gastroin- testinal bleeding, shock or cardiac arrest, pneumonia, and failure to rescue. Of these, Bingham pointed to urinary tract infections, length of stay, and failure to rescue as being most relevant to a perinatal population. As an- other example, Kane et al. (2007) linked RN staffing to hospital-acquired pneumonia, unplanned extubation, respiratory failure, cardiac arrest in intensive care units, and failure to rescue after a postsurgical complication. Of these, Bingham pointed to the last as being most relevant to a perinatal population.

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84 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS Another study of relevance to birth settings, in Bingham’s opinion, is Needleman and colleagues’ 2011 study on care transitions, with higher- than-typical rates of patient admissions, discharges, and transfers during a shift being associated with increased mortality. The association is an indica- tion of the important time and attention needed by RNs to ensure effective coordination of care for patients at critical transition periods. Bingham has witnessed transitions involving women transferring into the hospital setting from a home birth not going as smoothly as they should. She said, “I think there’s a very important role for understanding those transitions and mak- ing them more effective.” Based on the premise that the core, or essence, of nursing work is caring relationships, AWHONN is currently conducting a study on the effect of nurse staffing on a range of nurse-sensitive processes and outcomes and is developing nursing care quality measures (AWHONN, 2013). Bingham commented briefly on community-based models of care and how randomized controlled trials have shown that Nurse-Family Partner- ship3 programs have improved the “maternal life course.” More specifically, they have demonstrated improved choices in health and education, such as decreased perinatal cigarette smoking and improved spacing of children. Finally, she noted that other countries have found that improving perinatal outcomes requires increased surveillance and response to early warning signs (Singh et al., 2012). She urged paying more attention not just to sur- veillance but also to team mobilization. Maternity nurses play a key role in team mobilization, given that other care team members are not in the hospital 24 hours per day, 7 days per week, as nurses are. AWHONN Data Collaborative To fill gaps in data and to help better understand perinatal RN staff- ing patterns in the United States, AWHONN formed a data collaborative covering more than 170 hospitals, with approximately 23,000 nurses who work at those hospitals, and about 413,000 births, based on 2010 and 2011 annual birth volumes. The data are not generalizable (hospitals pay to participate), but it is the largest database to date on RN perinatal staff- ing patterns. Participating hospitals are divided into five groupings based on birth volume: <1,000; 1,000 to 1,999; 2,000 to 2,999; 3,000 to 3,999; and 4,000+ births. For every participating hospital, AWHONN researchers have examined 32 different care situations to determine whether the AWHONN guidelines for perinatal RN staffing are being met. Bingham commented only on 3  or F information on the Nurse-Family Partnership, visit http://www.nursefamilypartnership. org.

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WORKFORCE ISSUES 85 situations related to intrapartum care. These data indicate that situations involving oxytocin or women who choose no pharmacologic or anesthetic pain management are most likely to not meet AWHONN RN staffing guidelines. As expected, these data also showed that more experienced RNs receive fewer orientation hours. Among new hires, hours of orientation range from 216 (first quartile) to 1,872 (maximum), with a mean of 388. Similarly, there is considerable variation among the number of RNs per 1,000 births among the five groupings of hospitals, ranging from 6.6 to 82, with a mean of 29.79. While there are some outliers, most of the hospitals within a single grouping fall within a fairly narrow range, although there is considerable variation among groupings. Finally, these data show con- siderable variation in how many nurses hold bachelor’s degrees, with some hospitals reporting 0 percent and others as much as 92 percent, with an average of 52 percent. More research is needed on how level of education impacts perinatal outcomes. Summary of Key Points In summary, nurse staffing and nurses’ education have been shown to affect patient outcomes, and the number of interventions performed and patient population characteristics have been shown to affect nurse staffing. However, there are limited data on perinatal staffing patterns and on the qualifications of perinatal nurses who provide care to women and newborns in the United States. Based on these summary points, Bingham highlighted four recommen- dations made in a previous Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health (2011). First, nurses should practice to the full extent of their education and training. Second, nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Third, nurses should be full partners with physicians and other health profession- als in redesigning health care in the United States. Bingham remarked that nurses “didn’t even really make it” into the 1982 birth setting assessment report (IOM and NRC, 1982). Although there are more nurses than physi- cians in the United States, their participation on health care redesign com- mittees is usually only token representation; rarely are nurses in leadership positions on those committees. Fourth, effective workforce planning and policy making require better data collection and an improved information infrastructure. Bingham pointed to several specific outcomes where better data are needed on the effect of RN staffing levels and RN competence: failure to rescue, severe maternal morbidity, labor support, breastfeeding support, transitions of care and transports, and outpatient and community care.

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86 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS In conclusion, Bingham emphasized two key points: the importance of measuring and tracking perinatal RN staffing patterns and the need for more perinatal nurse staffing research for all types of birth settings. RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS: WORKFORCE ISSUES4 Based on data presented during this panel, as well as some evidence pre- sented during earlier presentations, Susan Stapleton offered some thoughts on “what we know” versus “what we need to know.” She observed, “One of the things I’m learning as I’m sitting in the room today is that the list of what we don’t know is growing significantly longer than the list of what we know.” Workforce Issues: What We Know Stapleton observed the following: • The level of acuity of hospital-based intrapartum care has increased partly as a result of higher rates of labor induction and Cesarean delivery. • Some perinatal outcomes are worsening and have worsened over the past couple of decades. • Competent and educated nurses improve patient outcomes. Stapleton wondered what the impact would be on perinatal out- comes if all obstetrical nurses in the United States were midwives. • Midwife-attended out-of-hospital births have increased. (It is un- clear whether and how this trend is being driven by access to such services.) • Transitions from one setting to another or from one provider to another are associated with increased adverse outcomes; hand-offs require a high level of care and coordination. • The need to expand and fully utilize the women’s health provider workforce is becoming more urgent as the age of the current pro- vider workforce increases. • Evidence suggests that collaborative teams of maternity care pro- viders improve outcomes and may lower costs. • The current education system for maternity care providers tends to reinforce barriers to working collaboratively and is disparate in terms of resources devoted to different groups of providers. 4  his T section summarizes information presented by Susan R. Stapleton, D.N.P., CNM, FACNM, Commission for the Accreditation of Birth Centers, Miami, Florida.

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WORKFORCE ISSUES 87 Workforce Issues: What We Need to Know Based on evidence presented during this panel and earlier in the work- shop, Stapleton identified several key gaps in knowledge regarding the maternity care workforce: • How does nurse staffing affect quality, safety, and cost of hospital- based perinatal care? Most studies on nurse staffing have been conducted in nonperinatal settings; are the patterns observed in those settings the same as those in perinatal settings? • What is the impact of “missed nursing care” on perinatal out- comes, including breastfeeding measures (breastfeeding success and duration)? That is, what is the impact on breastfeeding when peri- natal nurses do not have time to provide support and teach women what they need to know to ensure breastfeeding success? • How will changes in electronic health record technology impact workforce training needs and demands? Will such changes demand more or fewer providers? • What will be the impact of patient engagement and shared d ­ ecision-making models on workforce training and staffing needs? How can the mother and childbearing family be included as an integral part of the perinatal team? • How does care being provided in the various birth settings dif- fer? How do those differences contribute to the outcomes being observed? • What are the cost and outcome implications for new models of care that rely on perinatal teams providing collaborative care (e.g., the types of models mentioned by Catherine Dower)? For example, how will providers be trained? What will the costs be? • What provider ratios are optimal for full utilization of the work- force and for high-value care? For example, are more doctors needed? Are more midwives needed? Are more doulas needed? Stapleton remarked that very little is known about optimal ratios for these different types of providers. • Is the current workforce being utilized to the full extent of its education, training, and scope of practice? Data presented by Catherine Dower indicate that the answer to this question is “no.” What are the barriers and incentives? • What new team members can be added to the perinatal team (be- sides the mother and childbearing family) to improve outcomes and decrease cost? There may be other providers who are less expensive to educate and train and whose contributions can significantly im- prove outcomes in ways not well understood right now.

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88 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS • What professional education model(s) will best prepare perinatal care providers to function as part of collaborative teams? Stapleton reiterated Dower’s remarks about training providers to work col- laboratively before patterns of communication are established. What changes in graduate education funding are needed to develop these models? • What are the “best practices” to develop and maintain competency of perinatal teams in responding to the need for transfer from one setting to another? What do we know about these hand-offs? How can hand-offs be conducted smoothly and seamlessly? What characteristics of transfer make for the best outcomes? What com- munication patterns among providers make for the best outcomes, and what role does the childbearing family play in those patterns? • What are the best collaborative-based models, both within the United States and elsewhere, and how can they be replicated? • What institutional support and incentives are needed (i.e., in terms of regulation, liability reform, payment reform, and professional education) to support collaborative practice models at the health care system level? DISCUSSION WITH THE AUDIENCE5 Following the panel discussion on workforce research issues, the floor was opened to comments and questions from the audience. Workshop attendees touched on a range of research topics: collaborative care and teamwork, single-room maternity care, home births and nursing, pain relief and nurse staffing, rural maternity care, workforce diversity, and national trends. Collaborative Care and Teamwork Much of the discussion during the question-and-answer period focused on collaborative care and teamwork. A member of the audience suggested that the state of California might be a good place to test various models of collaborative care, given its history of research on health professions and the large number of different types of professionals providing maternity care (e.g., physicians, CNMs, and CPMs). Moreover, the state has a diverse geography, with dense urban areas and sparsely populated areas. A variety of conditions could be examined (e.g., different ratios of providers) and their impact on care assessed. 5  his T section summarizes the discussion that occurred at the end of Panel 4, immediately following Stapleton’s presentation.

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WORKFORCE ISSUES 89 Another member of the audience commented on the difficulty that many certified professional midwives face when seeking physicians to sign collaborative agreements so that the midwives can provide care to Medicaid patients. Many of these midwives are midwives of color, serving women of color. The implication was that if collaborative relationships could be fostered, outcomes among women of color might improve. There was some discussion around the cost of collaboration. One par- ticipant expressed concern that having multiple providers present during every birth is not economically sustainable. He noted that collaborative models being applied in countries where midwife-driven births are more prevalent (e.g., England, France) than in the United States are very different than the U.S. model. Catherine Dower clarified that her earlier comments about teamwork did not imply that all team members would be present at all times, rather that each would contribute at a different time during preg- nancy. She agreed that there are some good alternative collaborative models out there that should be examined (i.e., alternatives to the physician-centric team leader model), including models with midwives as team leaders and other professionals being called upon as necessary during labor and de- livery. Different groups are examining these alternative models, including physicians, for various reasons. Some are trying to improve quality of care, while others are trying to save money. Still others are trying to improve staffing satisfaction. In addition to encouraging the consideration of non-physician-centric team leader models, Dower also encouraged thinking of teams “more ex- pansively.” She envisioned teams composed of a variety of professionals, from midwives and doulas to mental health professionals and commu- nity health workers, each being called on at a different point during the pregnancy—teamwork that involves “many more touches with the health care system, but much shorter touches.” Single-Room Maternity Care There was a suggestion that more research be done on single-room maternity care and its impact on safety, cost, patient satisfaction, and other outcomes. Not unlike the merged step-down units mentioned earlier in the workshop by Esther Sternberg, single-room maternity units staffed by cross- trained nurses (i.e., with staff not divided between labor and delivery) might be a way to ensure that all women have one-on-one continuous support while avoiding problems caused by the “peaks and valleys of workload” (e.g., high cost because of the large number of nurses on staff even during times when demand is low).

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90 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS Home Births and Nursing There was a question about what the potential role of RNs in home birth settings and what RNs would do that midwives attending home births are not already doing. Debra Bingham replied that it is a difficult question to answer because so little is known about how RNs spend their time in hospital settings and, thus, whether there is care that they are providing that is not being provided in home birth settings. Likewise, it is unclear whether there are things being done in hospital settings that should not be replicated in a home birth setting. Another audience member asserted that evidence-based nursing care is already being provided in the home birth setting and that, in fact, nursing students would become much better nurses if they were to spend some time in those settings during their training. She predicted that the role of the RN in a home setting would be “doing the old- fashioned nursing many of us were brought up on—being there for women, getting to know women well, providing the kind of continuous emotional and physical support that nurses taking care of IV drips and post-op Cesar- ean mothers don’t have time to do.” Yet another audience member agreed that much can be learned by attending a home birth and suggested that the type of birth that happens more often at home, that is, a birth facilitated by a woman’s own capacity, can also occur in a hospital setting; the challenge is in preparing all providers to facilitate that type of experience. Pain Relief and Nursing An audience member expressed concern about the impact of overuse of oxytocin on nursing staff, that is, the “heavy burden of oxytocin.” The recommended patient-staffing ratio for pharmaceutically induced pain re- lief administration is one-to-one. Another audience member asked whether obstetric nurses are trained to treat pain differently than other types of nurses. Specifically, is the threshold of no pain a goal for all nurses, not just obstetric nurses? Bingham stated that more data are needed to assess whether nurses are being adequately trained in nonpharmacological meth- ods of labor support. Rural Maternity Care A question was asked about rural maternity care and whether any of the panelists had any thoughts on maternity care in settings where care is typically provided by generalists (e.g., many Indian Health Service sites do not have dedicated obstetrical nurses). Bingham replied that AWHONN’s data collaborative includes hospitals with fewer than 500 births per year and that AWHONN RN staffing guidelines apply to all settings, not just

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WORKFORCE ISSUES 91 high-volume hospital settings. She added that models are available for con- ducting staff orientations in sites without in-house expertise. Maternity Care Workforce Diversity There was a comment about the lack of diversity in the maternity care workforce and a question about whether any initiatives were under way to add diversity. Dower agreed that, while gender representation in medicine and, to a lesser extent, nursing, is improving, racial and ethnic diversity is still very poorly represented in the maternity care workforce. While the issue is on several organizations’ “radar screens,” she was unaware of any research being conducted to determine why or initiatives under way to change the situation for maternity care workforce specifically. A Need for National Trend Data It was mentioned that the seven midwifery organizations in the United States responsible for accreditation and certification are currently working together to resolve confusion around the numbers of the various profession- als who provide maternal care and the need to gain a better understanding of those trends at a national level.

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