Philosophy of care

PHILOSOPHY OF CARE A Pilot Study Comparing Certified Nurse-Midwives and Physicians

Dawn Yankou,

RN, MHS~, Barbara

A. Petersen,

CNM,

EdD,

Deborah

Oakley,

Pm,

and Fran Mayes, RN, MS ~-

ABSTRACT CerSfied nurse-m,dtives (CNMs, and physicians (MD9 are thought to dilier in phdosq,hy of pregnancy care and childbirth tlowever. these differences have not been dcamented quantitatiuely This article describes and compares the b&Is and cafe philosophies of CNME and MDs toward aspectsof antepartum --d intmpxtum care at kwrlsk women The sample included seven CNMs and 10 obstemcians at a large teti~ry-care hospital. “sing rdngent statisttcatcriteria for tesiing d,tierencer between the .wo groups. alrmificantly more teaching was done by the CNMs than by the MD5. Otbdr differences were all in expected directions. Comparisons of certified nurse-midwife (CNM) and physician (MD) maten..iy care for low-risk women have sho in that the two provider groups diH,q in the way they deliver that care (l-3). It is not known whether these differences are due to different orofessionalstandards different norms or different practice environments. Models of professional socialization (10, 11) suggest that these three factoIs may interact in producing patterns of behavior that differ among groups. In order to avoid the complexity of three interacting factors, the current study was designed to examine only professional norms, expressed as the provider’s philosophy of care. The study was conducted in a has-

pita1where the practiceenvironment was the samefor both CNMs and MDs. The overall charqefor vrenatal. labor, and delivey ca& w& the same, resardless of the tvoe of orovider. Their iacuIty offices .A &uped together on the same corridor, and they share clinical facilities. Their practiceis collabaative: referrals and consultations occur in both directions. Thus, differences in the practice environment have been minimized or eliminated as an explanatoy factor for differences in delivery of care in this case. We examined official statements from the American College of NurseMidwives (ACNM) (12) and the AmericanCo@ of Obstetriciansand Gynecologists (ACOGI (13) to discover whether there were differences in standards. Both organizational statements emphasize the importance of the individual woman and her family; both say that clinicians should provide for safe physical care, emotional and social support. and the

involvement of family and significant others: and both mention consideration of swcial needs and the importanceof patientidient education. In addition, ACOG also mentions some technical aspects of care such as assessment of medical records. diagn& accuracy,and Lebaatoy use In contrast, ACNM mentions tight to dignity, cultural diversify, and seli-determination. In order to keep the standards constant, removing them as an explanation for different pratice patterns we concentrated on testing phiphies about managementand teaching based on those standards that were similar: safe physical care, emotional end social supporL par;ner involvement, special needs. and education. The current study is part of a larger comparison of processes of care and outcomes for women of comparable dsk cared for by CNMs and obstetricians at a large tertiary

care hospital. Because the number of individual providers in that one s.etBngk small. the resulk of thk part of the larger study must be considered only a pilot study for multisite i”“estigatio”s.

METHODS Sample In the study setting. the CNM sewice k a private sewice. Therefore, the approptiate comparison group of MD5 k composed of all obstetricians (also specialists) in their pfivate care. Clinic care service was not included because CNMs are not part of the clinic service and. in addition, most clinic careis provided by residents. who are not fully trained maternity care spe dalkk. In this setting, there were five CNM and 13 MD positions at the beginning of the larger study. All providers were asked to complete questiannaireeat the beginnIngof the study or. in the caseof staff turnover, when they first started working in their re-

Dawn Yankou, RN,MI.&, is (I dwtoml candidatein nuning ot the Unniuersityof Michigan.She has been o research a&&lntfor over two years on the lower sardy comparingcore by CNMs and MDs fmm which this pilot was genemted.

DebomhOokkv. phi. b e om,-r

160

o,

sp=dve services. seven different CNMs and 15 MDs have provided care in their respective setices since the stan of the larger study. Of those, seven CNMs and 10 MDs returned qu&;onnaires that provided the data for thts report. Although the study staff were unable to identify the reasons for nonresponse with certainty, shot+term contrackandstaff turnovermay have played a role. Some providers whose positions lasted onty a short time may not have considered their partidpation to be relevant. given the longitudinal natore of the larger study. Additionally. some of the MDS were placedat satellite services where they had little involvement with either the obstetric service or the larger study. It k believedthat the praiders in both groups who did partkipate in this part of the study have shown commitment to their respective eewiceefor a substantial length of time. Inetrument The four and one-half page wvey consisted of demographic information pertaining to the practice group, gender, e&al security number, and yewofpra&eoftbepwidemAko included were 11 questions rqrding the usual time scheduled for maternity @sits and the respondent’s opinions about the importance of various information and practices in prenatal and intrap&um care. These opinions were their expressions of norms, oxpressed as their philosophy of care. Respondents were also asked lo report the percentageof prenatal teaching on 15 topics they addressed person&y as comparedwith the teaching the respondenk believed other he& care providere, such as a registered nurse or a medical assktant in their practice, offered. The questionnaire was constructed by clinical experts familiar with the national organizetional etater”enk for both nurse-midwives and obstetridan~ecologisk. Topic areas considered important to prectice and ini-

tial Items were senerated bv selected members of the research t&en (i.e., CNMs. obstetricians, and nursing research faculty) based on their clinical expertise. familiarity with the literature. and understanding of the goals of ACCG and ACNM. Individuals representing both types of providers contibuted to the developmentof the specific items to eneure that areas of care con$dered important to the two groups were included and that wording was appropriate for both professional groups. This preliminary version was then distributed to both CNMs and obstetricians for feedback. Thus. aueetionnaire ~reoaration bv expert s’tidy staff in c%&ation witi CNM and obstehic facultv contributed to content validity. There are no other published measures that have been developed to examine philosophy of care issues among maternal care professtonals. The present self-report questionnaire was developed to be specifically reevent to clinical practice. The questionnaire itself appears to be quick and easy to we, es well as clinically relevant Test-retest measures were not done and would be unrealistic. In the study eetttng, neither provider group has the time to complete the cane questionnatre Woe within aperiod of time that would adequately measure test-retest reliability. Also, internal reliability k not relevant to this instrument Predictive valldtty k the most impatant psychometric property, and this twe of validity till be &s&d when i&a about clinical procedures are wallable for the much larger sample of paltenk/clienk. Procedure The chief of each service was a coprincipal investigator on the study; thus, both the department of obstetrics and gynecology and the hospital had agreed to Partkipate in the study before the proposal was submitted to the funding agency. When funded, the sbldy was presented to an obet&ics-gynecology staff meeting and

approved and verbally supported by the department chair and chiefs of service. A” informational letter was sent to each eligible provider, giving them a” opportu”:ty to ~artxipaate. All agreed to take part in the stJdv. The chief of the appropriate set&e then distributed blank questionnaires to each eligible potential respondent. To maintain confidentiality while retaining the ability to link the provider with her or his own clients/patients. providers were asked to fill in their &al secuity numbers. They then returned the questionnaire in a blank envelope. After approximately one month, a list of social security “umhers received was sent to the depatiental eecretay. She placed a second questionnaire and second request for participation in the faculty mailbox of “onrespondenk. Reminders were also made at depatmental staff meetings. In order to avoid inferring Identity from some of the demographic data, all completed questionnaires were see” only by the first author, who did not know any of the praiders. All analyses used the media” test because the date were ordinal and there were significant differences in the variances of the two grows. In this case there was more v&k&e in the lamer MD mou”. thus lnflatlns chance: (if a t-t&t hab’bee” used) to; believing there was a difference behwen groups when, in reality, there was no difference in the underlying population. Outlier problems also made the media” test a more conservative test, given the small sample size (14). Further, because multiple tests were computed simultaneously, the Bonfemmi procedure (15) was used to select a” appropriate alpha level to evaluate significance so that tbe overall level of significance for the f.&ly of tesk was .05. When multiple bivariate tests are done, there k a chance of finding five out of 100 stgnificant ferroneously) simply by chance. The Bonferroni procedure corrects for this artifact of multiple simultaneous tests by dividing the de-

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t

the “une-mid&es said t!xy achedukd appmximately 20 minuta more for new “kits than the obst&tck”s and twtce the length of time for return obstehic “kits. These self-reports of scheduled tit times were approximately the same as those tit times RESULTS found by a research team member I” order 10 protect co”fide”ti&j, data who checkedclinic Visit schedules. were gathered on only two demoIn anaiyzingthe data, issues of pregraphic identifiers: gender and age. natal care were distinguished from All CNMs were women. as were four thmp of intmpartum care. The pro(40%) of the MDs. The CNMs were viders were asked to r&e the imporolder. with a” average age of 47.0 tance of knowing about six items that years as compared with 36.9 years are relevant infomtion for safe, effor MDs. But this difference was not fective ~eenatalcare and the imporstatistically significant using the metance of five ekrnenk of care mandian test with Bonferroni’s correction. agement for I~-risk women. As Data were also gathered on three shovm in Table 1, although the CNMs characteristics associated with pmfesrated five of the information items as sional practice: years in practice, the more important, the differences genpercentage of work time spent in clinerally were not large, and “one was ical practice, teaching, research, and significant using the median test Isother activities, and the usual time sues such as whether or not the pregscheduled for new and return prenancywas planned and working co”natal visits. Despite their older averdttions in early pregnancy were not age age, CNMs had been in nurse believed to be as important as other midtifey practices&hUy fewer years issues by either group. As for manthan had been in ;bstehic ~racprenatal care,rating3 for the imtice: 8.3 for CNMs, compared with portance of chtdbii classes and in9.9 years for h4Ds. This d&rence was cluding the father for prenaal visik not statistically significant Further, were simikr for both groups. AlCNMs spent more time in clinical though “ubitim~ screening was @ve” practiceand lesstime in teaching and a much higher rating by the CNMs research as commred with MDs. aland routine uhrasounds and alphafetoprotei” awasment were given though these d&e”ces were ¬ significant Even the apparent differrnuchbtqherratkgstytheMEs,thez ence may have been a” artifact of the differences were not stattsticauy sigtimes. When data were colfected, there “i6cant using the Bcmferroni comawas a medical school but no nursetion. The importance of personally pm midwtfey teaching program at the unfw&, thus r&Wing teachf”gand prenatal lnfomtion on 15 different totics is shown in Taresearch oowtinities for CNMs. Since the”,. a new ruse-midwifery bk 2. CerLZted“&-mtdwivez tended master’s degree program has been to rate these items as more important, established at the untverstty. but agatnthe differe”ces were “otstgnifxant when the median test was Certified nurse-midwives reported that their usual schedule for a first used. It is important to note that bath pre~tal tit was 49.3 minutes. siggroups rated all items at or abwe the nftkantly mae than the average of midpoint. 5.0, on the 10.point scales. Despite the general tiikritizs in 29.8 minutes scheduledby MD5 (P = .M!4). For return visits, the average the importanceof teachingabout these 15 topics, as see” in Table 3 eve” whedukd dme reportedby CNMs was 29.3 minute& compared with 14.6 when the smngent Bonfenonl clitelion is used, there were signifka”t difminutes by MDs W’= .OOW. Thus,

sired level of significance 05) by the “umbad tee performed I” thk we, the resulting value of .WO8 k required for any single test to be reported as statktically significant

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vk3ing

towomen

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TABLE 1 Importance for Prenatal Care of Low-Risk and rnh

Women as Rated by

cams

MeanRiryrrtonce *

Topic

CNM I” = 7)

(n “240,

Median Test P

9.1

8.4

1.00

z.7

8.9 7.8

1.w .34

8.7 7.7

8.5 5.5

.35 .16

t”fOIlll~tiO” Feeling mother expreses

about fetus Socialsuppo* Partner suppa* Working conditionsin late P”wancY

Plannedor unplannedpregnancy Workingconditionsin early P=gnancY Management Nutddonxreentng Childbirthclasses Fatherat prenatalvisit Routineulhasound Maternalalpha-fetoprotein asse%rne”t

7.0

6.3

l.w

9.3 8.1

6.8 7.7

.02 1.00

6.7 3

6.4 5.0

:E

4.7

7.1

.I3

TABLE 2 hnptance of Topics for Prenatal Teaching as Rated by cornsand mh

staff members (mostlikely staff nurses or specialists such as genetic counselonj. As shown in Table 3, the five areas in which the CNMs did the majority of teaching reflect more nonmedical or psychosocial aspects of care compared with medical issues such as genetic counseling These foci mirror the emohasis on issues such as cultural di&rsiiy and self-determination in the omanimtional coals of the CNMs. and the emphasis-on processes such as assessment of use of services and accuracyof diagnosis in the stated goals of the MDs (12, 13). For ihe managementof careof lowrisk women dudng childbirth, providers were asked to rate the importance of 12 items, shown in Table 4. The CNM group considered ambulation in labor signiticantly mcxe important. Although there were noticeable differences in the two groups’ ratings for the remaining items, using the Bonferroni cfiterion showed that the differences were not statistically significant. DISCUSSION

M.2dV.l”

CNM

Topics Physicalrisks Dangersigns Preterm labor signs Avoid tem@ens Geneticcounseling Sian5 of labor Other Sm&ng while pregnant Nutrition Infantfeeding Exercise Weight gain Genera,health Diwomfo* of pregnancy

(n = 7)

Test P

9.6 9.3 9.1 9.0 8.9

9.1 8.9 8.5 9.2 9.2

NA 1.00 1.M) NA 1.00

9.9 9.6 8.6 8.6 8.7 7.6 7.7

9.1 8.1 6.3 7.9 7.2 7.6 7.6

NA .16 .15 .15 .I6 .64 .35

7.9 7.6 fi.6

6.8 6.5 6.1

E 64

Parenting Stress reduction Minor illnesses

ferences, all in the same direction, indicating that CNMs were more likely to do the teaching in five of these areas. These areas were “ubitto”, illfan: feeding, exercise, parenting, and

162

(” ‘240,

minor maternal illnesses. It is also iaportant to note that CNMs reported that they did almost all of the teaching on the vast majority of the topics, whereasphysiciansdependedon other

In this tidy, self-rep&s obtainedfrom the providers indicatedthat there were consistent differences between the CNM and MC groups in their b&k about appropriate apprwches to prenatal and intrapartum care. Although the official organizatkmal statements of the Iwo groups are similar in s.xne respects, this study supports the view Ulat CNMs and MDs differ fn sonw predictableways about expressed beliefs regarding exe practices. Given the &all &ple and the use of the statktltlcallVstdnqentBonfenoni procedure with the median test (a nonparametric test for statlstlcal significance), many of these differences in expressed beliefs did not reach statistical significance. With larger sarnpies, more of the apparent differences may well become sta!isttcally significant. The small sample size is a recognized limitation of this study. and the findings must be considered pre-

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T*gLE 3 Percentage of Total Teaching Done by Provider

tify whether there were any differences between those MLk choosing to participate and those who chw “ot to participateor whether any differences could have significzmtiq affected findings Also, the gene&&abilitv moblems inherent in usina vol&& subjects mustbe acknowi: 92 9 51 5 964 650 edged. 76.4 545 These findings are based on self66.4 650 reports of caregiversregardingbeliefs 929 580 aboutpregnancycare. How care@ver philosophy is actualiied in pmc6ce 445 82.1 33.5 943 cannot be answered ful’, by this sur25 0 90.7 vey and was not the purpose of this 420 964 study. This project was designed to 502 92.9 describe and compare philosophy of 305 89.3 CNMs and MDs regarding care, not 46.5 893 42 0 97 9 care practices. However. one aspect 31.5 964 of labor and delivery care (i.e., com365 95.0 fort measures initiated by caregive~) was observed by a member of the research team. Observations of care by CNMr and MDs during labor and TABLE 4 delivey support the differences in Importance for Management of lntrapartum Care of Low-.&k Women practicereported by the practitioners as Rated by CNMs and MDs themselves Ipe2sonal conespondew. S. Hamiltcn. 1992). The !aqer Meon lmportonce Rohng* five-year tidy from which this pilot M&l” CNM was generated has as part o! its pdTODie ,” = 71 In TlJ, T&P may aim a comparison of anteparturn, intrapahu”. and p&p&urn care 5.9 .Ambukdon in labor 9.6 .m 80 .fl4 UkXi” 2.4 processes by CNMs and MDs. 7.2 .Ol lntmvenws flufds As Parsons (16) noted, groups .cJl NPOlice chips during labor i.: shape expected behaviors by defin2.: Labor analgesiiaianesthesia .lO 3.0 ing roles. C&f&I nurse-midwivesand Co”tin”ous ekctronic fetal MDs fill their own. profofessionally dis2.1 monitorfng Father at birth 8.1 ttnct roles. Addttionally. in practice. Motherchoiceof birth an apprenticeship or t&&form of 6.1 .I5 position 8.0 teaching. adapted and used in both 4.8 .fll Lithotomy position 1.0 medicine and nurse-midwifery, is de4.3 Delivew in delivey mom 1.3 .Ol signed to hansmiitboth the beliefs and 5.4 2.3 .23 EpWotomy 3.9 41 4.3 Dischargeunder24 hours the practices of preceding genemtions. Thus, the teaching reinforces and perpetuates separate role de& “itions for the two goups of pmctttioners in way3 that have more trends continue. more of the apparinfluence than do organizational liminary in nature. It is interesting that statements. In addition, it may be difcnt differences between groups may given the small sample and the shinAcult for MDs to differentiate their weUbecomestatisticallysignificantwith gent statistical criteria that some St?practice solely according to the risk a larger sample. tistically significant differences bestatus of the woman for whom they A further issue relative to both semtween caregiver groups were found. are providing care. It is also often suS_ pie size and results is the nonpalticiAdditionally, differences that did not pation of five out of 15 (33%) of the wed that MDs may feel compelled reach stattsiical significance were all to f&w certain practices primarily MDs. The study staff could not idenin the expected directions. If these

2

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because of malpractice threats, which are considerebly higher for obstebiclans than for CNMs (17, 18). Does the future hold increasing divergence in the philosophies and patterns of care as practiced by CNMs and MDs, or will there be convergence? If there is convergence, will it be based on professional philosophies or on external forces? Philosophies are likely to be affected by increasing professional interaction as CNMS become more numerous and more influential. Cat&d nurse-midwives seek more wllaboration (19) and regard suitable MD mllataatio” and a productive professional relationship as the most important contributor to succezsful nurse-midwifery practice (201. In practice, MDs seek CNMs as collaborators in their practices. seeWng to observe CNM biis in labor-deltvpmtpiutum (LDRF’) units ely-raowy and birthing centers. Additionally. many medical students and residents are taught normal spanteneous “aginal delivery in classrooms and are supenrised in hospitals by CNMs. Parson’s (16) view of intern&e eyeterns suggests that increased interactton might lead to increasing etmila@ through changesin both groups. But gtve” the importance of understending these interactive systems within iheir surrounding “culture,” es Parsons (16) also poink out, the external changes in the health care syetern may also be important factors. For instance. as one example, if ultrasound, intravenous fluid% electronic fetal moni!ore, and delivery roonw cannot be charged for sewrately, but are subsumed in flat-rate reimbuwmenk (DRGs). there will he pressure to avoid the&more expensive ~ntenrentions. Given externally supported changes in actual practice. providers may find it more comfortable to adjust their philosophy and reduce their lmp~rence rattngsfor the more expensive interventions.If these external forces do occur, and If they lead to reduced emphasis on expen-

164

sive technology, MD and CNM philosophies could become more similar, with more change to be expected among MDs.

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10. Bynum JE. Medical schoolso&lizatio” and the “ew physician: role. stetw adjushnents,personal problems, and social identity. Psycho1 Rep 1985;57:182. 11. D&ties RG. Care &en in oreanancyand chlldbirtb.I”: Chalmersi, EnIdn M. K&se MING, editors Effectivecare in pregnancyand childbirth.Oxford: Oxford Universiiy Press,1989. 12. American College of Nurse Midwives. Statement of philosophy. Washington, DC ACNM. 1989. 13. AmeticanCollege of Obstetricians and Gu”ecolc&ts Standards for obstetrical-gy”ec&,ical services.6th ed. WashIngto”.DC ACOG. 1986. REFERENCES 1. Aaronso”L. Nurse midwivesand obstebtcians:alternativemodels of care and client “fit.” Rs Nurs Health 1987;10:217-26. 2. Baluffi G. DeltingerW, Strobino D, RudolphA, et al Patternsof obstebic praceduresused~matemitycare.Obstet Gy”ecol1984$4:493-8. 3. Dillon TF. BrennanBA, Dwyer JF. Risk 4 et al. Midwifery, 1977. Am J ObstetGynecol 1978;130:917-26. 4. Feldman E. Hurst M. Outcomes and moceduresin low risk birth: a comp=.&” of hospitaland birth fenter settings.Birth 1987;14:18-24.

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6. Mayes F, Oakley D, WraneshB, et al. A retrospectivecomparisonof certified nunemidtife and physician managementof low risk birth% a piloi study.J Nurse Midwifery 1987;32:21& 21. 7. Rooks JP. The contextof “urw

14. kr JH. Btostatistical analysis.2nd ed. Engkwood Cliffs (NJ): Prentice-Hall, 1984. 15. By&it DR. Sutstiu today: a comprehetive inhodtio”. Menlo Park IN)): &“taml”/Cumrmngs. 1987:613. 16. ParsonsT.The satal system.New York, Free Pr,, 1951. 17. Lubic RW. Nurse midwivesand liabtlitvi”s”ra”ce. Nurs Outlook 1987~35: 17c7. 18. Gordon f&J. The effectsof ma,practiceinsuranceon c&ed “uw-midtiws: the caseof rural Arizona.J Nurse Midwifery 1990;35:99-105. 19. Baldwin LM, HutchinsonHL. Rosenblatt RA. Professional relationrhips between midwives and physicians:collaborationor mnflict? Am J PublicHealth 1992;82:262-4. 20. Haas JE, Rooks JP. National survey of factors contributing to and hindering the successful practice of nurse-midwifery:summay of the American College of Nurse-Midwives Fwndatio” Study. J Nulre Midtifey 1986;31:212-5.

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