Measuring outcomes of midwifery care: development of an instrument to assess optimality.

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home (N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

The 1999-2000 ACC task analysis of nurse-midwifery/midwifery practice: a consideration of the concept of professional issues.

The American College of Nurse-Midwives (ACNM) Certification Council periodically conducts a task analysis study as evidence supporting the content validity of the national certification examination in nurse-midwifery and midwifery. The purpose of this article is to report findings related to the examination of the relationship between professional issues and safe beginning-level midwifery as measured by the 1999-2000 Task Analysis of American Nurse Midwifery and Midwifery Practice. Study findings suggest that newly certified midwives place strong emphasis on the importance of tasks related to the ACNM "Hallmarks of Midwifery," which characterize the art and science of the profession: these include tasks dealing with health promotion and cultural competency. The beginning midwives, however, gave consistently low ratings to tasks related to ACNM "Core Competencies" that mirror the professional responsibilities of midwives; these include tasks related to the history of midwifery, research, or health policy. The study has implications for nurse-midwifery/midwifery educators, experienced midwifery mentors, and other persons interested in reinforcing the relevance of these important professional issues to the new midwife.

Effective strategies that enhance adherence to breast cancer screening guidelines.

Mammography has long been recognized as the most effective cancer screening modality. Nevertheless, substantial numbers of women either do not utilize mammography or do not do so in compliance with recommended screening guidelines. A substantial body of literature has been published that discusses strategies likely to be effective in increasing mammography screening. Health care provider recommendation for a mammogram is the single most effective intervention. This paper reviews the more recent literature to highlight a selection of the additional strategies that are most likely to be effective among all women, and among women of various vulnerable cultural and population subgroups. African American, Hispanic, Pacific Asian, and Native American communities are included in the discussion. The paper also addresses other communities with special needs, such as those who are lesbians, elderly, low users of health services, and those who are physically or mentally challenged.

Promoting screening and early detection of cancer in men.

Gender is a factor in the risk assessment for many diseases. It may also impact on the way in which men assess their personal health or illness status and take action to prevent illness or promote well-being. This paper is focused on three objectives: (i) to foster an understanding of gender differences in health promoting behaviors; (ii) to review three health issues affecting males for which dissemination of health education, increased personal awareness and early detection may be beneficial in the reduction of morbidity and mortality; and (iii) to offer suggestions for nurses and other health care professionals to promote positive patient-provider interactions within a health-care framework for action.

Examination adaptation: translating the national nurse-midwifery/midwifery certification examination.

The national certification examination in nurse-midwifery/midwifery was adapted to the Puerto-Rican Spanish language. Specific attention was paid to creating a version of the examination that was both culturally and linguistically relevant, while remaining appropriately representative of national standards of practice. The procedures used in translation and cultural adaptation are described. The process used in review of the examination followed usual and customary practice. This included consideration of item critiques received from candidates (qualitative data) and the computation of standard measures of item performance, including item difficulty indices and the standard error of measurement (quantitative data). Additional analyses conducted for this specific purpose included the calculation of an index of differential item performance between both language versions. All measures of assessment indicated that the adapted language version was of high quality and psychometrically equivalent to the English language version, which was the comparison standard.

The 1999 ACC task analysis of nurse-midwifery/midwifery practice phase I: the instrument development study.

The national certification examination (NCE) in nurse-midwifery and midwifery is developed, administered, and evaluated by the ACNM Certification Council (ACC). The blueprint for the NCE is based upon a comprehensive list of tasks that describe the knowledge, skills, and abilities expected of the midwifery practitioner at entry into the profession. In 1999, the ACC initiated the third in a series of task analysis studies to ensure the currency and relevance of the task list. This study was considered particularly timely, given that the professional organization, the American College of Nurse-Midwives, had approved pathways to midwifery for individuals whose first degree was not in nursing (the certified midwife) and also had expanded the core competencies for midwifery practice to include responsibilities in the domain of primary care. This manuscript reports the results of the pilot study, in which the specific list of tasks was developed. Three hundred and six ACNM members responded to a preliminary list of tasks, indicating their opinion about whether each specific task was relevant to entry-level midwifery practice. The task list finally derived consists of 219 tasks and 177 clinical conditions, dispersed among seven domains of practice (antepartum, intrapartum, newborn, postpartum, well-woman/gynecology, primary care/health assessment, and professional issues.) The task list represents a comprehensive profile of entry-level practice for nurse-midwives and midwives certified by the ACC.

Integrating qualified nurses and non-nurses in midwifery education: the two-year experience of an ACNM DOA Accredited Program.

In 1996, the Division of Accreditation (DOA) of the American College of Nurse-Midwives (ACNM) preaccredited the first direct entry program of midwifery education for candidates who already possess undergraduate degrees in non-nursing disciplines. Inaugurated through the partnership of the State University of New York Health Science Center at Brooklyn and the North Central Bronx Hospital, this 1-year, postbaccalaureate, certificate program of studies graduated two integrated classes of 22 registered nurse (RN) and nine direct entry (DE) students between 1997 and 1998. This article presents the experience of the first 2 years of this innovative program, focusing on the profiles of the DE students, their achievements, and their experiences entering the workforce. All of the data comparing nurse and non-nurse student progress through the program of studies strongly support the conclusion that, within an ACNM DOA preaccredited/accredited midwifery education program, DE students can achieve standards of academic excellence and clinical competency that are at least equivalent to those demonstrated by their RN peers.

Surgery during pregnancy.

The anatomic and physiologic changes of pregnancy complicate a woman's response to elective or emergency surgical intervention. Alterations related to perioperative positioning, fluid volume replacement, effects of medicinal and anesthetic agents, and maternal/fetal assessment are discussed. Emotional and ethical/legal concerns are considered. A postoperative assessment guideline is presented.

Undergraduate computer literacy. Evaluation and intervention.

Undergraduate nursing students (juniors) entering an upper division nursing program were asked to rate their overall computer skill, ability to use word processing, spreadsheet, presentation/graphics programs, and their ability to use the Internet and e-mail. Because of the number of students who rated themselves as not computer literate an intervention was planned. A graduate student, using a tutorial manual, worked with students for six 1.5-hour skill-enhancing sessions during their first semester. After the sessions students again rated their skill levels. An analysis of the before and after data showed a mean gain score of 5.5 points, with each skill showing a significant increase from the before to the after assessment.

Nurses' unique roles in randomized clinical trials.

Nurses are in an ideal position to promote patients' awareness of the role played by clinical trials in the advancement of health science and the subsequent improvement of patient care. The history of clinical trials and the four phases of clinical trials are described. Nurses' professional roles in clinical trial participation, such as helping the patient to identify open clinical trials and acting as clinical interpreter and patient advocate during the patient's participation in a trial, are detailed. Professional considerations that must be addressed by the nurse are reviewed and include ensuring that the trial has received approval from an Institutional Review Board for the participation of human subjects; that the responsibilities of participation are congruent with the nurse's personal values and workplace obligations; and that once engaged, the nurse can make the commitment to sustain participation in the trial. Most important, the nurse must keep the patient's needs and values uppermost in mind during the evaluation of potential clinical trials. Nurses have a critical role to play in the promotion of clinical trials, the recruitment of patients for clinical trial participation, the education of the patient and family, and the clinical care and support of patients throughout their participation in clinical trials.

The measurement of stress in pregnancy.

Stress is thought to be one of the biopsychosocial factors that contribute to adverse pregnancy outcomes, such as preterm labor and low birthweight. Identification of these factors (as in total number), and measurement of their individually perceived importance (severity) could lead to opportunities for intervention, and improved pregnancy outcome. A pilot study of the Daily Hassles Scale, was conducted in order to determine the appropriateness of its use among pregnant women. Daily hassles were thought to be a valid proxy for prenatal stress. Content and construct validity were determined among a sample of four content experts and 30 pregnant women. The Daily Hassles Scale proved to be a reliable (internally consistent) measure of stress (alpha reliability coefficient of 0.90). Further adaptation of the scale to include hassles specific to pregnancy and further testing of its usefulness among diverse multicultural and ethnic populations is warranted.

Midwifery education models. A contemporary review.

Midwifery education has a rich tradition of blending innovation with educational methods that have demonstrated their value to the profession. Examples of innovations that have influenced midwifery education include the use of the asynchronous modular system, the development of distance methodologies, and most recently the use of computer and telecommunications technologies to mediate education. This study was designed to explore trends in approaches to the education of midwives in both traditional and distance education programs. Program directors were surveyed and interviewed to assess their degree of instructional synchrony, their use of distance modalities, and their predominate methods of curriculum presentation. Results of the survey suggest that programs are using a variety of these approaches to educate their students. Decisions to integrate new educational technologies appear to be based on institutional values, community resources, and student needs.

Incorporating electronic-based and computer-based strategies: graduate nursing courses in administration.

The use of electronic technology allows faculty to improve their course offerings. Four graduate courses in nursing administration were contemporized to incorporate fundamental computer-based skills that would be expected of graduates in the work setting. Principles of adult learning offered a philosophical foundation that guided course development and revision. Course delivery strategies included computer-assisted instructional modules, e-mail interactive discussion groups, and use of the electronic classroom. Classroom seminar discussions and two-way interactive video conferencing focused on group resolution of problems derived from employment settings and assigned readings. Using these electronic technologies, a variety of courses can be revised to accommodate the learners' needs.

Use of prenatal services by Hispanic women in San Diego County. A comparison of urban and rural settings.

The purpose of this study was to investigate patterns of prenatal care use among urban and rural Hispanic women in San Diego County, California. A cohort study of Hispanic women delivering at one of five San Diego County hospitals between July 1991 and January 1992 was conducted (N = 587). Data were collected by in-person interview and medical record abstraction. Logistic regression was used to identify variables associated with late entry into prenatal care, while simultaneously adjusting for important confounding variables. Three factors were found to be significantly associated with late entry into prenatal care. Women who resided in urban areas were two times more likely to enter prenatal care late as compared to women who lived in rural areas (odds ratio = 2.11; 95% confidence intervals (CI) = 1.12, 4.0). Women who reported not having initially "wanted" the pregnancy were 2.2 times more likely to enter prenatal care late (95% CI = 1.05, 4.59). The risk of entering prenatal care late increased by 20% for each additional barrier to care that was reported (95% CI = 1.09, 1.34). Results indicate that timely entry into prenatal care may be improved among San Diego Hispanic women by targeting specific barriers to prenatal care identified in this study and by providing greater family planning assistance to this population to decrease unwanted pregnancies.

Direct entry midwifery education. Evaluation of program innovations.

During the 1996-1997 academic year, the State University of New York Health Science Center at Brooklyn, in partnership with North Central Bronx Hospital, implemented the first direct entry (DE) midwifery education program to be preaccredited by the American College of Nurse-Midwives. Five DE midwifery students were admitted and graduated. During their one-year course of studies, these students were provided supplementary didactic and clinical instruction in the medical sciences and basic health skills in addition to the identical course of midwifery studies offered to their registered nurse-student peers. The experience of students and faculty during this first year was that there was no significant difference in academic performance between the DE and nurse-midwifery students. Moreover, once oriented to the clinical environment, DE students progressed through the clinical practicums, and acquired entry-level midwifery skills, at a pace equivalent to that of their nurse peers and consonant with all expectations of safe practice. In addition, the Basic Health Skills and Integrated Medical Science course offerings served as effective instructional supplements to the curriculum by providing DE students with an opportunity to equalize their knowledge base with that previously acquired by registered nurse-prepared students; an unanticipated discovery was that some nurse-midwifery students could equally benefit from enrollment in these courses.

Enhancement of basic computer skills. Evaluation of an intervention.

A series of self-paced tutorials was developed for use by graduate students on the assumption that acquisition of skills in accessing e-mail accounts, use of the World Wide Web, file-transfer protocols, Excel spreadsheet, and PowerPoint presentation software would help students succeed in their program of graduate studies. The postproject evaluation tool was sent to participants via e-mail, to reinforce the acquired skills and demonstrate the successful accomplishment of project objectives. Pre- and postevaluation data indicated an increase in self-rated skill level after participation in the tutorial series. Analysis showed an overall mean gain score of 2.3 points, with pre- and posttutorial gain scores significantly increased for all topic areas.

Development and outcomes of the multiple-choice format national certification examination in nurse-midwifery and midwifery.

The national certification examination in nurse-midwifery and midwifery now is offered exclusively in the multiple-choice format. The strategies used to develop equivalent examination forms are described. The manner of criterion-referenced standard setting is explained. Outcomes of the first five multiple-choice examination forms include an aggregate first-time failure rate of 8.3%. Multiple- and logistic-regression analyses indicate that examination scores of African-American and Hispanic ethnic candidates, and older candidates, are lower with regard to statistical significance; however, these differences are too modest to be of practical significance. No substantive relationship was observed between any demographic or academic variable and the probability of passing the examination. The experience gained by the ACNM Certification Council during development, administration, and evaluation of these first five multiple-choice examination forms has provided strong support for the transition to multiple-choice testing for the assessment of entry into practice of this competency-based profession.

Breast cancer among men: raising awareness for primary prevention.

The American Cancer Society estimated that in 1993 1,000 new cases of male breast cancer would be diagnosed in the United States and 300 men would die from the disease. The clinical picture of breast cancer among men resembles that seen in women, and the development of the disease among men has been attributed to similar hormonal and genetic causes. The mortality rate from breast cancer is also similar, when corrected for chronological age and stage of the disease at the time of diagnosis and treatment. Guidelines for patient education, health screening, and patient support are presented.

Transfer rates from freestanding birth centers. A comparison with the National Birth Center Study.

This article reviews retrospective data derived from Sharp The BirthPlace. San Diego for 1993-94 and from the University of California. Irvine, Birthing Center for 1994 and compares these findings to data obtained from the National Birth Center Study (NBCS). The focus of this article is on intrapartum transfer rates from the two freestanding birth centers as a critical clinical indicator. Cause-specific transfer rates were calculated for eight clinical conditions. Data suggest that cause-specific intrapartum transfer rates are influenced by factors such as risk profile of the client population, distance to the referral center and mechanisms of transfer, definitions and diagnostic criteria used, and clinical practice guidelines. Reports from the literature, such as NBCS data, might serve as points of reference, but are likely not appropriate baseline indicators (benchmarks of "best practice") for clinical events, against which individual performance can be measured; rather, these benchmarks should be individually defined, based on characteristics unique to each birth center.