Academic journal article Nursing and Health Care Perspectives

A Model for the Future: Certified Nurse-Midwives Replace Residents and House Staff in Hospitals

Academic journal article Nursing and Health Care Perspectives

A Model for the Future: Certified Nurse-Midwives Replace Residents and House Staff in Hospitals

Article excerpt

In one model of the future, certified nurse-midwives (CNMs) replace most obstetric residents and house staff in hospitals. This model offers numerous benefits, such as cost containment and quality outcomes. Furthermore, its application could open opportunities for educating CNMs and residents in a truly collaborative model in an educational setting and begin to balance the ration of physicians to CNMs in the care of low-risk populations. This model was used with some success in the late 1980s to early 1990s at an inner-city Midwestern medical center. * By definition, CNMs are educated in the two disciplines of nursing and midwifery and possess evidence of certification according to the requirements of the American College of Nurse Midwives (ACNM, 1978). Nurse-midwifery practice is the independent management of care of normal newborns and women, antepartally, intrapartally, postpartally, and/or gynecologically. Certified Nurse Midwifery practice occurs within a health care system that provides for medical consultation, collaborative management, and referral (ACNM, 1978). Physician and CNM roles differ. Certified nurse-midwives focus on supporting the process of normal birth, whereas physicians focus more on the management of complications. There are data that suggest that CNM outcomes are equivalent to those of physicians (American Nurses Association, 1992; Thompson, 1986; Wilson, 1989); that CNM costs are less than those of physicians (Bell & Mills, 1989; Cherry & Foster, 1982; Gravely & Littlefield, 1992; Rooks, 1986); and that the cost of educating CNMs is much less than the cost of educating physicians (Safriet, 1992). Within an environment of health care reform and cost containment, CNMs can replace residents and house staff in hospitals in the care of low-risk clients and work in consultation with physicians for the care of high-risk clients. This article compares medical education and nurse-midwifery education, reviews nurse-midwifery outcome data, and discusses the pros and cons of a practice model for the future.

Education, Outcomes, and Practice Models Medical Education Between the years 1750 and 1825, women in the United States had four choices for childbirth: physicians, Indian doctors, herbalists, and midwives. A review of deliveries during the colonial period (Cash, Christianson, & Estes, 1980) showed that 2 percent of urban physicians had obstetrical cases and rural physicians had none. Between 1850 and 1900, childbirth was still uncommon in hospitals. Many obstetric departments were closed periodically and sometimes permanently due to puerperal fever. Medical education at this time consisted of three-year apprenticeships required for medical school graduation, which were associated with a physician rather than an institution. Concurrently, there was a proliferation of private schools in which only didactic material was taught.

In 1837, a unique event occurred: the Obstetrical Institute was organized in Philadelphia. The Institute was the first organized educational program for the training of obstetricians. It was a private school that taught obstetrics to groups of twelve second-year medical students. Later, the Institute admitted nursing students. These nursing students were trained side by side with the medical students (Rothstein, 1987). This model existed over 150 years ago but did not survive.

The Flexner Report of 1910 revolutionized medical education. Abraham Flexner, the author, blasted the way medical education was administered, describing it as a system based solely on profit, with no controls on educational standards. The report resulted in the establishment of accredited medical schools that employed full-time clinical faculty devoted to education, service, and research (Vevier, 1987).

In the 1970s, a shortage of physicians forced hospitals to rely on residents for more patient care, leading to criticism of the resident model for care. Rothstein (1987) stated that residents were relatively unskilled providers who were becoming more expensive and attributed the increase in gynecologic surgical complications in certain settings to the use of residents. …

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