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Nurse-midwifery prototypes: Clinical practice and education featuring … Nurse-midwifery in a private obstetrical practice
Nu:rsc-Midwifery Prototypes: Clinical Practice and Education featuring ...
Nurs&Mid~iferyin
a Private Obstetrical Practice By Lois C. Olsen, CNM, MS.N.
Ms. Olsen rece ived her B.S. Degree from the University of Wisconsin and a M.S.N. from Marquette University. She is certified by both the Central Midwives Board of London and the American Coll ege of Nurse-Mid wives. She has practiced as a nursem idwife for 12 years in Sierra Leone, West Africa and for 4 years in Milwaukee. She is currently employed as an Assistant Professor in Maternity Nursing at the University of Wisconsin. n 1973 when I was considering a position as a nurse-midwife in private practice with two obste. tricians, I called the American Col lege of Nurse -Midwives to ask if any nurse-midwives were similarly em ployed. The College was able to give me the names of only two persons so employed, one in Connecticut and one in Kentucky. I talked to both of them regarding salaries, case load, methods of payment and division of responsibilities. Since that time, an incre asing number of nurse-midwives have found employment with private obstetricians. There are several reasons for the incre ase of this type of partnership.
I
6
One is the popularity of nurse-midwifery management among private patients. They enjoy the amount of time the nurse-midwife can spend with them and usually agree with her phllosphy of practice. The use of a nurse -midwife can keep down the cost of obstetric service. Another reason is that wh ile the nurse-midwife concentrates on the normal, both in the office and in the hospital delivery suite, the physician is able to devote more of his time and greater obstetric skills to the complicated and/or high risk patient. Prior to 1973, I spent one year as a staff nurse-midwife in a large hospital in Milwaukee. Subsequent to my inquiry to the ACNM , I spent three years working with two private obstetricians. During these four years, with a short exception, I was the only nu rse-midwife practicing in Wisconsin. Early in my employment I developed a written policy statement as well as a job description. Both of these were mutually agreed to by myself and the physicians. They were also shared with the hospital nursing . staff. Among my responsibilities were the opportunities to see all maternity patients on the first visit to the office . I d id the initial history and physical e xam ination. This also gave me an opportunity to explain my role within the office structure as well as the policies and procedures we followed . I spent much time in teaching and
answering questions. If there were no problems during this initial visit, the patient was then scheduled to see one of the physicians on the subsequent visit. After that, an effort was made to schedule her visits alternately with the physician and the nursemidwife, but there was a great deal of var iation in this due to our uncertain schedules. We made every effort to make sure that all three of us met the patient at least once during her pregnancy in case circumstances provided that the person, who the patient was expecting to deliver her, was unavailable at that time. At any one visit, including the introductory one, if I felt that I needed consultation or that the patient needed to be seen by the physician. I made that referral. At the time of the patient's admission to the hospital, if she had indicated that she wanted the nurse-midwife, both the physician and I were notified. I attempted to spend as much time as possible with the patient in labor. Often this was the entire period of labor. However. I soon found out that periods of twen ty or twenty-four hours of constant attendance were neither possible physically nor wise emotionally. Once the patient was in active labor, I did try to stay with her. For example, if a primigravida was admitted at one a.m. with a cervix dilated one centi meter and having contractions every twenty minutes, I we nt back to bed and to sleep, assured that once the
JOURNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
labor became more active, the labor room staff would call me again . On some occasions, I came to the hos pital and slept there so that I was more readily available. Following the delivery, I made daily visits to all postpartum patients. I also saw patients at six weeks and conducted that visit. In addition to office and hospital responsibilities, I had some freedom to do home visiting, both prenatally and postpartally. Usually the prenatal visits were to patients who. were on limited activity and needed some nursing supervision . Postpartum visits were to assist mothers with things like breast feeding. f one is considering the role of the nurse-midwife in private practice, the following observations might be given consideration:
I
1_ Experience is necessary,
This is not a role for a beginning practitioner. One should be fairly
sure of one's skills before attempting to practice in what may be an isolated situation without other nurse-midwives. Even more important, it is necessary to be very secure about your own philosophy of obstetrics and midwifery. If one believes in minimal analgesia and anesthesia, for example, and the current practice in the community is to use heavy medi cation and mandatory inhalation anesthesia, it takes a determined and well founded ph ilosophy to maintain one's principles . 2. Role definition.
A basic problem is role definition, both for the nurse-midwife and the people with whom she is working. While a written job description is essential, it is only on paper until it is implemented. The role will probably be perceived differently by physicians, by patients, and by staff nurses; and all of these may be at variance with the way in which the nurse-midwife understands her role . The role
will probably change with the passage of time and circumstances. Some physicians may view the nurse-midwife as a physician's assistant. Management is the key word in the official definition of a nurse-midwife and it is this word that most clearly differentiates what the nurse midwife does from that which the physician's assistant does. Both work under medical supervision; but as long as the patient "meets the criteria of normal", ' the nurse-midwife is responsible for management. I felt that, in three years, this problem of role definition was one of major pro · portions th~t was not resolved s~tis factorily. We made continuing efforts to resolve the differences; but basically, it was a matter of the differences in our philosophy of what was ex pected of the nurse-midwife. Record keeping and clerical tasks are an essential responsibility of any care giver. However, they are not the primary responsibility of the profes(continued on page 8)
" Management.is what most clearly differentiates the nurse-midwife's role from that of the physician's assistant
----------" JOURNAL OF NURSE·MIDWIFERY • "01. X_XII, No.3, Fall 1977
7
(continued /rom page 7) sional person and a basic decision needs to be made in any office as to what needs to be done by professional personnel and those things that can be done by the clerical staff. Do nurse-midwives scrub and assist in surgery, particularly for Cesarean Sections? Is this the best use of her time and skills? This question must be answered individually . The answer will be dependent on the skills of the nurse-midwife, other demands on her time , and the availabilityof other personnel. A basic tenet in the philosophy of nurse-midwifery practice is that the nurse-midwife attempts to stay with the laboring patient. During this time, one not only does the management and the nursing care, but she has the opportunity to support the patient, physically and emotionally. Admittedly, this is time and energy consuming; but it is essential to the concept of nurse-midwifery and without it, the practice is empty. To the physician who is accustomed to delegating this function to the labor room nurses and who usually arrives in the delivery room just prior to the delivery, sitting with the laboring patient is wasteful in terms of energy and time and as such is unnecessary. Role exploration with the patients was easier, probably because their expectations were close to mine when we started. We both expected continuity of care. The patients anticipated that I would stay with them in labor; indeed. many of them sought a midwife because of this aspect of the care. They quickly became accustomed to a free exchange of inforrna tion prenatally which was extended to labor, delivery and postpartum. The ' patients quickly came to an understanding that managing the normal was within my province, but that complications and problems would need consultation and sometimes management by the physician. o le definition with the nursing staff was a constantly evolving process. The office staff quickly defined my role and would often
R 8
determine whether the patient had a problem that I could manage, either from the statements the patient made as she came into the office or from the information she gave over the phone. The hospital staff had a little more difficulty. I was a nurse but at times I was more than a nurse and in their eyes I functioned in the role of a physician. In labor I gave nursing care but then I did the delivery. Gradually we established our expectations and our interdependent roles.
3. How many nurse-midwives? I am not convinced that this is something that should be attempted singly. I did try to do it alone most of the time. One of the practical reasons for having more than one nurse-midwife is scheduling. Two, or better. four people can share the responsibilities by being on regular schedules. If a patient has been supported by one person for ten or twelve hours, a second person can then take over the responsibilities. Or if two patients need attention at one time, it cannot be managed if you are alone. Only three times in three years did I have two patients delivering sirnultaneously; but it did happen. When a patient delivers during office hours, it would be helpful to have another nurse-midwife to take over the care of one of the pat ients. A more compelling reason for not attempting practice alone is the need for collegial consultation and support. Two nurse- midwives have an input in an institution that is greater than twice as much as one. Two or more voices will have a greater impact on changing practice or altering the pattern of care given at an institution. Innovations by one person may be regarded as an individual idiosyn crasy but when advocated by several . people will have greater validity. An' additional reason for having more than one nurse-midwife is the need for free time . In retrospect, one of the most difficult problems was the lack of time that was totally free from responsibility. Although I had one afternoon a week and weekends free from assignments, I was still on call. I never felt free about leaving the city
for more than a few hours and certainly not overnight. The problem is not that someone else cannot do the delivery. The problem is the sense of commitment that one feels to the patient. Very often they had defied their family, friends and physician to seek out a midwife. Over a period of several months, a relationship has been established and an expectation has been developed. It was this cornmitment that made me hes itate to make plans that would take me out of town overnight. I guess I found it particularly difficult since my life has offered me a gr_eat deal of freedom and I enjoy traveling . I found this kind of confinement and discipline difficult as well as tiring. I think if I had it to do over, and I did it without another nurse-midwife, I would insist that at least one weekend a month I would be free of all responsibility and would ask that someone would insist that I do this for my own physical and emotional well being. I did take a vacat ion every year, and left town for a period of refreshment.
4. Reimbursement. At the time of my employment it was mutually agreed that I would be paid a salary. This seemed satisfactory to me at the time, and I still think it can be an adequate means of pay' ment. Two methods of reimbursement seem inappropriate: an hourly rate and payment by patient load . This first is impractical since the number of hours worked in any given day or week is unequal. The second presents problems because the nurse-midwife may support a patient in labor and give much care, only to hi ve the patient delivered by forceps or Cesarean Section. Is the nurse-midwife not paid because she did not do the delivery? Would the nurse-midwife be tempted to manage patients with problems either in the office or during the delivery because she was receiving her income from the number of patients she man aged? It does not seem a practical answer. There are several alternate plans. One would be for the nursemidwife to receive a percentage of the income of the practice. An incor -
JOURNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
porated partnership is another answer. In either case, while the income might be irregular, it would make her feel that she was more directly involved and responsible for helping to assume the overall expenses of the practice. 5. Development of a case load .
This problem, like the one of defining the nurse-midwife role, was never really solved. The mechanics were stated in the initial policies and procedures but the implementation was periodically revised. Some patients indicated on their initial visit that they wanted the nurse-midwife to deliver them; others would indicate later in their pregnancy that they
"
patient an expectation of who would be with her. 6. Support of the practitioner.
If there is more than one nursemidwife practicing, there will be a certain amount of support from each other. If this is a single venture, and even with more than one person, there must be at least one person somewhere who will give you un qual ified support. The more there are the better; but at least one is essential. It is good, but not necessary, that this be a professional person and it is helpful if this person is functioning somewhere within the system. I had days of doubt, discouragement, and frustration. Somewhere there has to
There must be at least onepe~onsomewhe~
who will give you unqualified support.
------------"
wanted me to take care of them. At first, an indication of this was made on the chart. If this was done early in the pregnancy and the patient developed complications, I would no longer be responsible for management although I would give support and nursing care in labor. Eventually, we developed a system where I submitted to the phys icians "a list of names of patients that I expected to manage. This was done about the eighth month of pregnancy. I also included the names of patients that I intended to support during labor but did not intend to manage. The patient was given a card wh ich indicated that I was to be not ified when the patient was admitted. This helped to solve the problem of who the nurses were to notify when the pa tient was admitted and also gave the
be a person who will listen to you without being convinced that you are as bad as you think you are at that point. One has to be able to fail in a certain area of a project without admitting that the total idea is a failture . And one has to be able to pick up the pieces of that broken project and use them for building a new project.
uring one period, my source of support was the director of nursing. She was not a nursemidwife, but she wanted me to come on her staff and she wanted nursemidwifery to succeed. She listened unendingly to my discouragement, my frustration. and my triumphs. After she resigned, some of my support within the institution disappeared and I felt the loss deeply, both professionally and as a person.
D
J0I!RNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
7. Possible sources of conflict.
There is no doubt in my mind that some of the continuing sources of problems between physicians and nurse-midwives in the United States is the fact that most physicians are men and nurse-midwives are usually women. In our society, but more particularly in the health care system, men control and women serve. The auxiliary status of the woman still persists and when women attempt to change that status, problems arise . Independent nurse practitioners are very new on the American health care scene and the ir appearance can and does produce conflict and problems. A second source of difficulty can arise with the use of publicity. To break the ice can cause a lot of ripples in the pond beneath. To be the "first" something, whether it is the new giraffe at the local zoo or the first nurse-midwife on the scene is to ereate a lot of curiousily and frequently to generate publicity. This has both its good and bad points. Publicity can tell waiting patients that one is present and ready to practice, but it can also create hostility among those who are already practicing. It is very pleasing to appear on a local television station or to have one's picture in the paper with a lengthy accorn panying article. However. statements made facetiously on the air can come back to haunt one. In my experience, newspaper reporters did not quote me inaccurately. On the contrary, they were all too accurate in repeating my unwise remarks, word for word. III feeling engendered by publicity is hard to heal. Saying no to a request for a television interview may damage one's ego ; but the damage may not be as ser ious as that which results from those people who are affronted by one's appearance and words. Finally if I had to do it all over again, I would, But I would do some things differently. I don't regret my experience. I had a great deal of satisfaction and I learned much. I hope my learning experiences will help someone else. 9
Nurs&Mid~iferyin
a Private Obstetrical Practice By Lois C. Olsen, CNM, MS.N.
Ms. Olsen rece ived her B.S. Degree from the University of Wisconsin and a M.S.N. from Marquette University. She is certified by both the Central Midwives Board of London and the American Coll ege of Nurse-Mid wives. She has practiced as a nursem idwife for 12 years in Sierra Leone, West Africa and for 4 years in Milwaukee. She is currently employed as an Assistant Professor in Maternity Nursing at the University of Wisconsin. n 1973 when I was considering a position as a nurse-midwife in private practice with two obste. tricians, I called the American Col lege of Nurse -Midwives to ask if any nurse-midwives were similarly em ployed. The College was able to give me the names of only two persons so employed, one in Connecticut and one in Kentucky. I talked to both of them regarding salaries, case load, methods of payment and division of responsibilities. Since that time, an incre asing number of nurse-midwives have found employment with private obstetricians. There are several reasons for the incre ase of this type of partnership.
I
6
One is the popularity of nurse-midwifery management among private patients. They enjoy the amount of time the nurse-midwife can spend with them and usually agree with her phllosphy of practice. The use of a nurse -midwife can keep down the cost of obstetric service. Another reason is that wh ile the nurse-midwife concentrates on the normal, both in the office and in the hospital delivery suite, the physician is able to devote more of his time and greater obstetric skills to the complicated and/or high risk patient. Prior to 1973, I spent one year as a staff nurse-midwife in a large hospital in Milwaukee. Subsequent to my inquiry to the ACNM , I spent three years working with two private obstetricians. During these four years, with a short exception, I was the only nu rse-midwife practicing in Wisconsin. Early in my employment I developed a written policy statement as well as a job description. Both of these were mutually agreed to by myself and the physicians. They were also shared with the hospital nursing . staff. Among my responsibilities were the opportunities to see all maternity patients on the first visit to the office . I d id the initial history and physical e xam ination. This also gave me an opportunity to explain my role within the office structure as well as the policies and procedures we followed . I spent much time in teaching and
answering questions. If there were no problems during this initial visit, the patient was then scheduled to see one of the physicians on the subsequent visit. After that, an effort was made to schedule her visits alternately with the physician and the nursemidwife, but there was a great deal of var iation in this due to our uncertain schedules. We made every effort to make sure that all three of us met the patient at least once during her pregnancy in case circumstances provided that the person, who the patient was expecting to deliver her, was unavailable at that time. At any one visit, including the introductory one, if I felt that I needed consultation or that the patient needed to be seen by the physician. I made that referral. At the time of the patient's admission to the hospital, if she had indicated that she wanted the nurse-midwife, both the physician and I were notified. I attempted to spend as much time as possible with the patient in labor. Often this was the entire period of labor. However. I soon found out that periods of twen ty or twenty-four hours of constant attendance were neither possible physically nor wise emotionally. Once the patient was in active labor, I did try to stay with her. For example, if a primigravida was admitted at one a.m. with a cervix dilated one centi meter and having contractions every twenty minutes, I we nt back to bed and to sleep, assured that once the
JOURNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
labor became more active, the labor room staff would call me again . On some occasions, I came to the hos pital and slept there so that I was more readily available. Following the delivery, I made daily visits to all postpartum patients. I also saw patients at six weeks and conducted that visit. In addition to office and hospital responsibilities, I had some freedom to do home visiting, both prenatally and postpartally. Usually the prenatal visits were to patients who. were on limited activity and needed some nursing supervision . Postpartum visits were to assist mothers with things like breast feeding. f one is considering the role of the nurse-midwife in private practice, the following observations might be given consideration:
I
1_ Experience is necessary,
This is not a role for a beginning practitioner. One should be fairly
sure of one's skills before attempting to practice in what may be an isolated situation without other nurse-midwives. Even more important, it is necessary to be very secure about your own philosophy of obstetrics and midwifery. If one believes in minimal analgesia and anesthesia, for example, and the current practice in the community is to use heavy medi cation and mandatory inhalation anesthesia, it takes a determined and well founded ph ilosophy to maintain one's principles . 2. Role definition.
A basic problem is role definition, both for the nurse-midwife and the people with whom she is working. While a written job description is essential, it is only on paper until it is implemented. The role will probably be perceived differently by physicians, by patients, and by staff nurses; and all of these may be at variance with the way in which the nurse-midwife understands her role . The role
will probably change with the passage of time and circumstances. Some physicians may view the nurse-midwife as a physician's assistant. Management is the key word in the official definition of a nurse-midwife and it is this word that most clearly differentiates what the nurse midwife does from that which the physician's assistant does. Both work under medical supervision; but as long as the patient "meets the criteria of normal", ' the nurse-midwife is responsible for management. I felt that, in three years, this problem of role definition was one of major pro · portions th~t was not resolved s~tis factorily. We made continuing efforts to resolve the differences; but basically, it was a matter of the differences in our philosophy of what was ex pected of the nurse-midwife. Record keeping and clerical tasks are an essential responsibility of any care giver. However, they are not the primary responsibility of the profes(continued on page 8)
" Management.is what most clearly differentiates the nurse-midwife's role from that of the physician's assistant
----------" JOURNAL OF NURSE·MIDWIFERY • "01. X_XII, No.3, Fall 1977
7
(continued /rom page 7) sional person and a basic decision needs to be made in any office as to what needs to be done by professional personnel and those things that can be done by the clerical staff. Do nurse-midwives scrub and assist in surgery, particularly for Cesarean Sections? Is this the best use of her time and skills? This question must be answered individually . The answer will be dependent on the skills of the nurse-midwife, other demands on her time , and the availabilityof other personnel. A basic tenet in the philosophy of nurse-midwifery practice is that the nurse-midwife attempts to stay with the laboring patient. During this time, one not only does the management and the nursing care, but she has the opportunity to support the patient, physically and emotionally. Admittedly, this is time and energy consuming; but it is essential to the concept of nurse-midwifery and without it, the practice is empty. To the physician who is accustomed to delegating this function to the labor room nurses and who usually arrives in the delivery room just prior to the delivery, sitting with the laboring patient is wasteful in terms of energy and time and as such is unnecessary. Role exploration with the patients was easier, probably because their expectations were close to mine when we started. We both expected continuity of care. The patients anticipated that I would stay with them in labor; indeed. many of them sought a midwife because of this aspect of the care. They quickly became accustomed to a free exchange of inforrna tion prenatally which was extended to labor, delivery and postpartum. The ' patients quickly came to an understanding that managing the normal was within my province, but that complications and problems would need consultation and sometimes management by the physician. o le definition with the nursing staff was a constantly evolving process. The office staff quickly defined my role and would often
R 8
determine whether the patient had a problem that I could manage, either from the statements the patient made as she came into the office or from the information she gave over the phone. The hospital staff had a little more difficulty. I was a nurse but at times I was more than a nurse and in their eyes I functioned in the role of a physician. In labor I gave nursing care but then I did the delivery. Gradually we established our expectations and our interdependent roles.
3. How many nurse-midwives? I am not convinced that this is something that should be attempted singly. I did try to do it alone most of the time. One of the practical reasons for having more than one nurse-midwife is scheduling. Two, or better. four people can share the responsibilities by being on regular schedules. If a patient has been supported by one person for ten or twelve hours, a second person can then take over the responsibilities. Or if two patients need attention at one time, it cannot be managed if you are alone. Only three times in three years did I have two patients delivering sirnultaneously; but it did happen. When a patient delivers during office hours, it would be helpful to have another nurse-midwife to take over the care of one of the pat ients. A more compelling reason for not attempting practice alone is the need for collegial consultation and support. Two nurse- midwives have an input in an institution that is greater than twice as much as one. Two or more voices will have a greater impact on changing practice or altering the pattern of care given at an institution. Innovations by one person may be regarded as an individual idiosyn crasy but when advocated by several . people will have greater validity. An' additional reason for having more than one nurse-midwife is the need for free time . In retrospect, one of the most difficult problems was the lack of time that was totally free from responsibility. Although I had one afternoon a week and weekends free from assignments, I was still on call. I never felt free about leaving the city
for more than a few hours and certainly not overnight. The problem is not that someone else cannot do the delivery. The problem is the sense of commitment that one feels to the patient. Very often they had defied their family, friends and physician to seek out a midwife. Over a period of several months, a relationship has been established and an expectation has been developed. It was this cornmitment that made me hes itate to make plans that would take me out of town overnight. I guess I found it particularly difficult since my life has offered me a gr_eat deal of freedom and I enjoy traveling . I found this kind of confinement and discipline difficult as well as tiring. I think if I had it to do over, and I did it without another nurse-midwife, I would insist that at least one weekend a month I would be free of all responsibility and would ask that someone would insist that I do this for my own physical and emotional well being. I did take a vacat ion every year, and left town for a period of refreshment.
4. Reimbursement. At the time of my employment it was mutually agreed that I would be paid a salary. This seemed satisfactory to me at the time, and I still think it can be an adequate means of pay' ment. Two methods of reimbursement seem inappropriate: an hourly rate and payment by patient load . This first is impractical since the number of hours worked in any given day or week is unequal. The second presents problems because the nurse-midwife may support a patient in labor and give much care, only to hi ve the patient delivered by forceps or Cesarean Section. Is the nurse-midwife not paid because she did not do the delivery? Would the nurse-midwife be tempted to manage patients with problems either in the office or during the delivery because she was receiving her income from the number of patients she man aged? It does not seem a practical answer. There are several alternate plans. One would be for the nursemidwife to receive a percentage of the income of the practice. An incor -
JOURNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
porated partnership is another answer. In either case, while the income might be irregular, it would make her feel that she was more directly involved and responsible for helping to assume the overall expenses of the practice. 5. Development of a case load .
This problem, like the one of defining the nurse-midwife role, was never really solved. The mechanics were stated in the initial policies and procedures but the implementation was periodically revised. Some patients indicated on their initial visit that they wanted the nurse-midwife to deliver them; others would indicate later in their pregnancy that they
"
patient an expectation of who would be with her. 6. Support of the practitioner.
If there is more than one nursemidwife practicing, there will be a certain amount of support from each other. If this is a single venture, and even with more than one person, there must be at least one person somewhere who will give you un qual ified support. The more there are the better; but at least one is essential. It is good, but not necessary, that this be a professional person and it is helpful if this person is functioning somewhere within the system. I had days of doubt, discouragement, and frustration. Somewhere there has to
There must be at least onepe~onsomewhe~
who will give you unqualified support.
------------"
wanted me to take care of them. At first, an indication of this was made on the chart. If this was done early in the pregnancy and the patient developed complications, I would no longer be responsible for management although I would give support and nursing care in labor. Eventually, we developed a system where I submitted to the phys icians "a list of names of patients that I expected to manage. This was done about the eighth month of pregnancy. I also included the names of patients that I intended to support during labor but did not intend to manage. The patient was given a card wh ich indicated that I was to be not ified when the patient was admitted. This helped to solve the problem of who the nurses were to notify when the pa tient was admitted and also gave the
be a person who will listen to you without being convinced that you are as bad as you think you are at that point. One has to be able to fail in a certain area of a project without admitting that the total idea is a failture . And one has to be able to pick up the pieces of that broken project and use them for building a new project.
uring one period, my source of support was the director of nursing. She was not a nursemidwife, but she wanted me to come on her staff and she wanted nursemidwifery to succeed. She listened unendingly to my discouragement, my frustration. and my triumphs. After she resigned, some of my support within the institution disappeared and I felt the loss deeply, both professionally and as a person.
D
J0I!RNAL OF NURSE-MIDWIFERY. Vol. XXII, No.3, Fall 1977
7. Possible sources of conflict.
There is no doubt in my mind that some of the continuing sources of problems between physicians and nurse-midwives in the United States is the fact that most physicians are men and nurse-midwives are usually women. In our society, but more particularly in the health care system, men control and women serve. The auxiliary status of the woman still persists and when women attempt to change that status, problems arise . Independent nurse practitioners are very new on the American health care scene and the ir appearance can and does produce conflict and problems. A second source of difficulty can arise with the use of publicity. To break the ice can cause a lot of ripples in the pond beneath. To be the "first" something, whether it is the new giraffe at the local zoo or the first nurse-midwife on the scene is to ereate a lot of curiousily and frequently to generate publicity. This has both its good and bad points. Publicity can tell waiting patients that one is present and ready to practice, but it can also create hostility among those who are already practicing. It is very pleasing to appear on a local television station or to have one's picture in the paper with a lengthy accorn panying article. However. statements made facetiously on the air can come back to haunt one. In my experience, newspaper reporters did not quote me inaccurately. On the contrary, they were all too accurate in repeating my unwise remarks, word for word. III feeling engendered by publicity is hard to heal. Saying no to a request for a television interview may damage one's ego ; but the damage may not be as ser ious as that which results from those people who are affronted by one's appearance and words. Finally if I had to do it all over again, I would, But I would do some things differently. I don't regret my experience. I had a great deal of satisfaction and I learned much. I hope my learning experiences will help someone else. 9