If you use nurse midwives, define their role clearly to avoid risks
May 1, 1996 10 minutes read
If you use nurse midwives, define their role clearly to avoid risks
Nurse midwives are patient pleasers if used correctly
Nurse midwifery programs can produce some of the highest marks for patient satisfaction and cost-effective care. But if not administered correctly, nurse midwifery programs also can heighten exposure to negligence claims for bad outcomes in obstetrical patients.
Nurse midwives' philosophies on patient care are highly compatible with the goals of managed care organizations. For that reason, the American College of Nurse Midwives in Washington, DC, has seen steady growth in the profession and expects nurse midwifery programs to continue to expand. If you allow nurse midwives to practice at your facility or expect to add them to your medical staff, take steps to make sure your policies clearly delineate the scope of their practice and have a clear mechanism for physician consultation and referral, warn legal and risk management experts.
"Proceed cautiously. Set up very specific guidelines," advises Luke Pittoni, JD, a medical malpractice defense lawyer in New York City with the law firm of Heidell, Pittoni, Murphy & Back. "There is nothing wrong with having nurse midwives on staff. They usually are very knowledgeable. Many of them were obstetric nurses before. But they must know when medical care is absolutely necessary."
Pittoni recently was involved in the defense of two negligence cases in which hospitals and physicians were sued, along with the nurse midwives, for the nurse midwives' delay in calling in an obstetrician. The following two issues were the basis of the lawsuits: giving a drug used to induce labor without the physician present and not recognizing classic signs of an intrauterine infection, which resulted in calling in a physician late and requiring a cesarean.
"You need to make sure that someone cannot look back and say, 'So you made this decision without a doctor,'" Pittoni adds.
Creating such policies requires the risk manager to walk a fine line between respecting the philosophies and capabilities of nurse midwives and protecting a hospital from liability.
By definition, a nurse midwife is someone educated in both nursing and midwifery, according to the American College of Nurse Midwives. Successful nurse midwifery programs allow midwives to manage women's health care independently within a system that provides for consultation, collaborative management, or referral to a physician if the patient's condition necessitates such a transfer.
Typically, hospitals that have problems with nurse midwives do not have definitive midwife-physician collaborative programs, risk experts tell Healthcare Risk Management. When a normal delivery becomes complicated, problems can arise if a nurse midwife does not have a clear path to follow to seek medical help.
To create a workable and successful nurse midwifery program, risk managers need to ensure that nurse midwives have enough autonomy so that hospitals can reap the benefits -- economic and otherwise -- of their practice, while having necessary prophylactic mechanisms in place in the event that an obstetrical patient needs medical care.
Ten key issues
Following are 10 issues to consider when crafting a policy on nurse midwives.
1. Certified nurse midwives or lay nurse midwives.
Since nurse midwifery programs extend a greater amount of professional autonomy to these advanced-practice nurses than do other nursing programs, it is important to make sure nurse midwives have the necessary skills and education. While many lay midwives have been practicing independently for years, they may not be certified by a state or national board in this profession.
Due to the differences in practice standards, ethics, and training, risk management experts caution others about allowing lay midwives to practice in a hospital or other institution. They say the best way to ensure core competencies is to only grant privileges to certified nurse midwives.
The Kaiser Permanente Health Care System, which uses nurse midwives extensively in its hospitals throughout California, only hires certified nurse midwives for that very reason, says Harriett Clark, JD, vice president, assistant general counsel, and assistant secretary of Kaiser Foundation Health Plan in Oakland, CA.
Some state nursing boards and the American College of Nurse Midwives Certification Council both offer certification programs. Kaiser Permanente requires its nurse midwives to be certified by their state nursing boards rather than the national organization so that its midwives are aware of state laws on midwifery practices.
If state nursing boards do not offer a nurse midwife certification, then risk managers gener-ally say the midwife should be certified by a reputable national organization such as the Certification Council.
2. Collaborative or independent practice.
Depending on state law, some nurse midwives can function as independent practitioners. Some nurse midwives maintain women's health practices that are akin to an OB/GYN's.
A nurse midwifery program should not be completely autonomous, but collaborative with the medical staff, say risk managers with experience in this area. Midwives should be allowed to practice with a certain degree of independence, provided that medical staff are available for consultation or referral in the event a medical problem arises.
"I do not believe in independent practice for nurse midwives," says Kenneth Bell, MD, medical director of the Kaiser Permanente Medical Center in Anaheim, CA, and clinical professor of OB/GYN at the University of California at Irvine. "In the big picture it is dangerous." But the appropriate sharing of autonomy and collaboration creates an optimal model for baby delivery -- one that is both cost-effective and preferred by patients.
Kaiser Permanente Medical Center in Anaheim has used nurse midwives for more than six years. Nurse midwives there have delivered more than 25,000 babies, largely without incident because nurse midwives and obstetricians work together. If a patient requests a physician for treatment, a physician takes over, Bell says.
"There are no barriers to a nurse midwife calling a physician," Bell says. "If anything is questionable, the rule is that they call the obstetrician. There is no reason not to do it."
Nurse midwifery programs also need to be collaborative with medical practices because the two take different approaches to childbirth.
"Do your homework about what it is that nurse midwives are educated to do," says Deanne Williams, CNM, MS, director of professional services for the American College of Nurse Midwives. "They work collaboratively with a maternal-child health team."
"Nurse midwifery management does not parrot medical management. For example, there are some unique things that nurse midwives do to keep cesareans low and to decrease the number of episiotomies." Nurse midwives emphasize natural childbirth, low-tech approaches, and as little invasive medicine as possible.
Eliminate the wrong incentives
While collaborative nurse midwifery programs mean nurse midwives agree to relinquish some management of their patient to a doctor if necessary, it is complex issue. But experts say health care facilities can take steps to encourage a collaborative approach by eliminating incentives to remain independent.
Some hospitals reduce a nurse midwife's fee if a physician is brought in for consultation, Bell says. This type of policy sends the wrong message and exposes a hospital to liability.
"Our nurse midwives do not get paid any more or less if a patient is seen by an obstetrician," Bell says. "Their professional judgment is only questioned if an obstetrician is not called. In our system, nurse midwives have a strong incentive to call because if they do not and there is a problem, they are responsible."
Kaiser Permanente always has an OB/GYN-trained physician or resident available in the hospital or on call for consultation. Nurse midwives are told the name of the physician they can call each day if a problem arises, Bell says.
3. Indigent care only.
Health care facilities also need to consider who nurse midwives will treat and establish treatment avenues accordingly. Many hospitals employ nurse midwives to care for their indigent population as a way to contain costs. But as nurse midwives become more popular, hospitals need to be prepared for patients who request them, Williams says.
"It is very important to be clear what it is that you expect the nurse midwives to do because there is a huge difference if you want them to only care for the indigent or if you want them to provide a variety of options to all women, Williams says.
4. Credentialing.
Like any other member of the medical staff who is performing procedures at a hospital, nurse midwives should be credentialed, which means meeting the hospital's standards for privileges.
Credentialing takes on added importance for nurse midwives because they often will be performing these procedures without the supervision of a doctor, says Kathleen Catalano, RN, JD, director of quality and risk services for Tenet Healthcare System in Dallas. Often, state board certification is a prerequisite for hospital credentialing, so midwives would need both credentialing and board certification.
Pattern certification after MDs' process
The American College of Nurse Midwives recommends that nurse midwives be credentialed similarly to physicians. "Treat them like you treat the doctors," Williams says. "Ask for the same information, put them through the same process. Give them the same due-process rights. Some of the paperwork will look a little different [than it does for the doctors], but that shouldn't create barriers for credentialing nurse midwives." (To learn more about the types of documentation nurse midwives can present to substantiate their qualifications, see related story, p. 59.)
5. Proctoring.
After nurse midwives are granted hospital privileges for the first time, they should be proctored much like new doctors are, risk management experts say. At Kaiser Permanente's hospitals, new nurse midwives are subject to the same policies on education, training, and proctoring that beginning doctors are, Clark says.
Nurse midwives there are observed by their sponsoring physician until the medical staff are comfortable with their skill level.
Should any new privileges be requested, the nurse midwife should be proctored in those skills too, says Karen Fernandes, RN, BSN, CPHQ, senior quality/risk specialist for Tenet Healthcare.
6. Standards of practice.
Nurse midwifery policies also must include standards of practice. These standards can be determined by state law, custom, and national standards, Williams advises.
Many hospitals with nurse midwifery programs use the American College of Nurse Midwives' standards of practice as a framework for their policies. Nurse midwife privileges should tie in very closely to these standards, Fernandes recommends.
In addition to national practice standards, risk managers also should consult state laws and regulations. States often restrict midwives from participating in certain procedures. For example, in California, the applicable statute states that nurse midwives can only deliver babies in "normal" childbirth, Clark says. If read literally, the statute would bar nurse midwives from conducting episiotomies or using forceps, even though both procedures are regularly practiced.
Although Clark says the statute is antiquated and impedes efficiency, Kaiser restricts nurse midwives from independently conducting these procedures, she says. Questions also can arise when the nursing and medical professions overlap. At Kaiser, nurse midwives questioned whether they could perform circumcisions. The system declined to let midwives perform them, judging the procedure to be a medical procedure outside the normal scope of childbirth, Clark says.
Obtain legal advice on practice scope
Legal and risk management experts caution others to err on the side of caution when creating scope-of-practice policies. If questions arise, they suggest consulting with the hospital's attorney for an interpretation of state laws and regulations on nurse midwifery practices.
The American College of Nurse Midwives also advises risk managers to consider the setting in which a nurse midwife will be practicing when creating policies on scope of practice. For example, if a nurse midwife will be practicing with physicians in a freestanding birth center, the scope-of-practice guidelines also should include selection criteria to determine which candidates are appropriate for midwifery care and which are appropriate for physician care. Midwives practicing in a rural setting, on the other hand, may find themselves needing to use a broader set of skills and therefore have a broader scope of practice, Williams says.
7. Prescriptive authority.
As of June 1995, certified nurse midwives had prescriptive authority in 41 states, though the extent of this authority ranges dramatically from state to state. In addition, state regulations may require the development of a formulary or written practice guidelines to identify the medications and circumstances under which medications can be prescribed, Williams says.
California restricts the number of prescriptions a midwife can write, Clark says.
Risk managers should consult state laws to learn the extent of a nurse midwife's prescriptive authority in their state. In addition, they should consult with their hospital's medical director to determine the extent to which the hospital will allow the midwives to prescribe medications.
8. Peer review, quality assurance, and recredentialing.
Nurse midwives should be subject to the same quality assurance and renewal-of-privilege mechanisms as other medical staff.
"You need to have continuous monitoring so if something needs to be improved, you know it," Clark says.
Williams suggests including a nurse midwife on the quality assurance committee to gain a broader perspective when conducting these reviews.
9. Insurance.
Nurse midwives must maintain separate professional liability policies. Proof of insurance should be presented when the midwife applies for credentialing and renewal of privileges.
Malpractice coverage levels can vary
The amount of coverage will vary according to the litigiousness of each jurisdiction. But risk managers caution their colleagues to make sure the policies are sufficient in light of the procedures each midwife is credentialed to perform. At Tenet's hospitals, every nurse midwife is required to have a minimum limit of at least $1 million, Catalano says.
10. Physician relationships.
Establishing a good working relationship with the medical staff is a crucial element of a successful midwifery program. To facilitate the collaborative practice goal, the nurse midwives should be part of the obstetrics department. This structure will increase the lines of communication and foster relationships between the midwives and the doctors.
Once physicians have a chance to work with nurse midwives and see the range of their skills, they are happy to make room for them. "I am interested in helping sick people," Bell says. "Pregnant women are not sick. They are healthy. But they can get sick, and when that happens I am there for them." *
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