Advancing Nursing

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Advancing Nursing Midwifery Practice in the
Community

• Leda M. McKenry, PhD, MBA, FNP-C, FAAN
• Associate Professor
• Director of Academic Outreach
• School of Nursing
• University of Massachusetts, Amherst

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ROLES WITHIN ADVANCED PRACTICE NURSING

• Clinical Nurse Specialist (CNS)
• Primary Care Nurse Practitioner
• Acute Care Nurse Practitioner
• Blended roles of CNS NP
• Certified Nurse-Midwife
• Certified Nurse Anesthetist

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Number of Advanced Practice Nurses in the U.S. as
of March 96

• Title Number_______
• CRNAs 30,386
• CNMs 6,534
• CNSs 53,799
• NPs 63,191
• CNS/NPs 7,802

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Primary Critieria of Advanced Practice Nurses
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The Central Competency of Advanced Nursing
Practice
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Core Competencies of Advanced Nursing Practice

• Expert coaching and guidance
• Consultation
• Research skills
• Ethical decision making skills
• Clinical professional leadership
• Collaboration

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Critical Elements in APN Environments

• Business aspects
• Policy-making considerations
• Reimbursement/ payment mechanisms
• Regulatory and credentialing requirements
• Organisational structure and culture
• Marketing and contracting
• Outcome evaluation and performance improvement

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Certified Nurse-Midwifes

• Historical perspective
• 1925 Mary Breckinridges Frontier
• Nursing Service (FNS)
• 1951 Metropolitan Life Insurance Co.
• FNS maternal mortality rate of
• 1.2/1000
• Nationally 3.4/1000

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CNMs History

• 1963 11 practicing as CNMs
• Late 60s early 70s led to dramatic change
• Womens movement
• Increased utilisation by federal programs
• Official recognition by ACOG in 1971
• Increased birthrate from baby boomers
• Shortage of obstetricians
• Discovery by middle- upper-income families
• 26 in private practice 1977
• 1984 CNMs recognised in all states

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CNMs

• 2000 6700 CNMs, 85 practicing as CNMs (1996
  National Sample Survey of RNs)
• Combination of 2 roles nursing midwifery
• Alignment with non-nurse midwives
• 1999 required a BS for ACNM accreditation
• Currently, 68 MS 4 PhD 2 men

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CNM Scope of Practice

• 1971 ACNM, ACOG NAACOG directed by a
  physician, dated view
• Regulated by each state, agency health plan
• Pregnancy care primary care of women
  preconception, gynecologic, contraceptive, and
  infertility care
• Other circumcision, vacuum extraction delivery,
  endometrial biopsy, colposcopy, elective
  termination of pregnancy

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CNMs Management Processes

• Perspective as normal, presence is therapeutic
• Independent management
• Consultation
• Ongoing health problem
• Non-obstetrical problem during pregnancy
• Obstetrical complication
• Co-management or collaboration
• Referral

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The Future for CNMs

• Confirmation of direct entry, cutting edge of
  transdisciplinary workforce
• Political clout of nursing, ACNM voted
  overwhelmingly to retain nurse
• Pew Health Professions Commission on the Future
  of Midwifery (1999)
• AUTONOMY

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Nurse Practitioner Role

• Grew out of a physician shortage in 60s 70s
• Underserved areas and populations
• 1965 PNP, University of Colorado
• Competent to manage 75 of well ill children in
  community health centers (Ford Silver, 1967)
• FNPs, ANPs, AE NPs, GNPs, School NPs
• 1990s shortage of house officers led to
  increased numbers of acute care NPs

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Nurse Practitioner Development

• 1998 769 NP Programmes
• Prescribing rights in all 50 states
• Nursing was divided
• 1980 Sermchief vs Gonzales, advanced nursing
  roles may evolve without statutory constraints
• Third party payment for NP services 85

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NP Role in Primary Care

• Institutes of Medicine Committee on the Future of
  Primary Care (1996)
• Primary care is the provision of integrated,
  accessible health care services by clinicians who
  are accountable for addressing a large majority
  of personal health care needs,developing a
  sustained partnership with patients, and
  practicing in the context of family and community.

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• There are over 148 studies that demonstrate that
  comparable health care services provided by NPs
  are of equal quality of those provided by
  physicians and when measured consumer
  satisfaction is generally greater.

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• We have seen the future in the community and it
  is ours!