Interprofessional collaboration: changing the future.

Abstract

Collaboration with physicians, nurses, and other health care providers has been an essential component of the care provided by certified nurse-midwives/certified midwives (CNMs/CMs) since the birth of the nurse-midwifery profession in the United States. However, there has been an explosion of interprofessional collaboration in health care recently. Today, interprofessional practices with midwives working as laborists1 or teachers within medical education2, 3 are increasingly common, interprofessional courses in education programs are multiplying at a rapid rate, and interprofessional collaboration among our professional associations is unprecedented in quantity and scope. Readers will find several articles addressing interprofessional collaboration within this issue4-8 and future issues this year that provide a few examples of what is happening in this arena. Given this exponential growth, it is important to consider how the expansion of interprofessional collaboration is going to affect the health care system and our work as midwives. In short, the goals of interprofessional collaboration are improved communication, better patient care, increased access to care, and lower health care costs.9 Essential characteristics of successful interprofessional collaborative teams have been identified. They include individual professional competence, mutual respect and understanding of team members’ skills, and a shared goal, among others.10, 11 Interprofessional teams in health care can be extraordinarily productive when these characteristics are in place, and many of the current interprofessional collaborative initiatives have been formed based on these principles. As a result, patient outcomes are improving, and professional opportunities for midwives are expanding into new areas. A recent study by Nigagal et al provides a good example of how collaborative teams can improve outcomes in the clinical domain.1 These researchers compared the birth outcomes of nulliparous women with a term singleton fetus who gave birth with the care of a practice model that has a midwife laborist in collaboration with an obstetrician versus women who were cared for by a private practice of either midwives or physicians. Among other positive outcomes, fewer women in the interprofessional collaborative practice had a cesarean birth than women who were cared for by a midwife or physician in a private practice (15.9% vs 29.8%; adjusted odds ratio, 1.86; 95% confidence interval, 1.33–2.58). Another example from clinical practice is the rapidly expanding adoption of simulation-based team training that gathers interprofessional groups to practice responses to obstetric emergencies. Simulation projects have improved clinician communication and patient outcomes.12-15 For example, Inglis et al reported a significant decrease in neonatal brachial plexus injuries after simulation training for management of shoulder dystocia (30% pretraining vs 10.67% posttraining, P <.01).15 The training was conducted by a midwife, nurse, and maternal-fetal-medicine specialist, and all members of the staff participated. Education is the domain experiencing the newest expansion of interprofessional collaborative initiatives and one that will be most fascinating to watch as these projects proliferate. It has become increasingly apparent that clinicians’ professional training is mostly conducted in individual silos without guidance or experience in working collaboratively with other health care professionals. Students are inculcated with the unique professional values and mores of their respective discipline.16 Then without any educational preparation in collaboration, new graduates in midwifery, nursing, and medicine are thrown into a fast-paced clinical reality in which the need to communicate and collaborate with clinicians from other disciplines occurs repeatedly, constantly, every day. Interprofessional interaction during educational preparation is a no-brainer if we want successful collaboration to be the norm in practice. Several innovative education projects in interprofessional collaboration will be featured in the Journal's upcoming theme issues on Innovations in Midwifery later this year. Innovative interprofessional courses for midwifery and medical students are well accepted among those who participate and may well produce a generation of clinicians trained to work in the health care teams that are rapidly becoming the standard structure for delivery of health care services. For providers who learn to collaborate and communicate, the ability to interact successfully with members of other professions becomes a solid bedrock that supports individual professional growth and development throughout one's career. Conversely, the inability to collaborate well becomes a strong undertow that can adversely affect one's work, to the extent that patient care is disrupted. Interprofessional initiatives occurring at the professional association level will affect all women's health care stakeholders in the near future. CNMs/CMs and the staff in the American College of Nurse-Midwives (ACNM) national office are working together with our colleagues in midwifery, nursing, and medicine more right now than has ever occurred in our shared history. Three midwifery professional organizations developed the landmark consensus statement on normal physiologic birth.4 The US Midwifery Education, Regulation, and Association (MERA) Steering Committee and Workgroup involves representatives from 7 US midwifery organizations who are working to strengthen midwifery in the United States, using the International Confederation of Midwives’ standards.5 ACNM is working with the American College of Obstetricians and Gynecologists (ACOG) to develop women's health care guidelines, create innovative interprofessional education models, and review ACOG-generated documents. ACOG's Task Force on Collaborative Practice includes invited members from a diverse group of professional organizations, including ACNM, the American Association of Nurse Practitioners (AANP), and the National Association of Nurse Practitioners in Women's Health (NPWH), who are reviewing and updating ACOG's 1995 Guidelines for Implementing Collaborative Practice. As ACNM's representative to the ACOG Committee on Obstetric Practice, I came out of an elevator in the ACOG national office in Washington, DC a few months ago and ran right into 2 midwives who also had flown in from different states to participate in interprofessional collaborative initiatives that include ACOG and other partner associations. You know something is really happening when you see the evidence at the doors to the elevator! ACNM is also working with the Society of Maternal-Fetal Medicine (SMFM) on a new Perinatal Safety Statement and contributing input to the new series of consensus documents that are being put out by SMFM and ACOG jointly, such as the recently released Levels of Maternal Care document.17 The Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) is also participating in many of these ventures, including the ACNM-led Healthy Birth Initiative, which contains extensive resources detailing the evidence about the value of normal physiologic birth for consumers, health care administrators, and clinicians. Representatives from ACNM, SMFM, AWHONN, and ACOG co-authored a new blueprint for transforming communication and safety culture in intrapartum care, which will be co-published in this Journal, the Journal of Obstetric, Gynecologic, and Neonatal Nursing, and Obstetrics & Gynecology All women's health care providers will want to keep an eye on the work of the National Partnership for Maternal Safety.18 This group includes ACNM and other members of the Council on Patient Safety in Women's Health Care who are collaborating to create a series of patient safety bundles aimed at streamlining care to reduce maternal mortality and morbidity. ACOG, with ACNM, the Association of Maternal and Child Health Programs (AMCHP), and AWHONN as subcontractors, has won a grant from the Health and Human Resources Administration to implement and disseminate these bundles in institutions across the United States. As these safety bundles are incorporated at the institutional level, they will have a clinically significant impact on improving the care that women receive. The health care system is obviously changing, and it is clear to me that each shift is bringing midwifery closer to the center of women's health care services. It is also certain that these services are going to look and function differently in the next decade. Given this is ACNM's 60th anniversary, and the theme is “Honoring Our Past, Celebrating Our Present, and Forging the Future,” this is a good moment to take a close look at how interprofessional collaboration is going to affect the midwifery profession. It is quick and easy to recognize midwives’ history in this arena. Since the beginning of nurse-midwifery in the United States, CNMs have worked in maternity care, public health, nursing and midwifery education, inpatient and outpatient settings, global health, sexual and reproductive health care, and more. As Patricia Aikins Murphy stated in a previous editorial in this Journal, midwifery is a philosophy, not a function. 19 Throughout our history, midwives have had outstanding partners in medicine, nursing, and related fields. Midwives have lived in interprofessional teams for decades, and we know their contours. Midwives can celebrate current interprofessional initiatives, several of which you will read about in this Journal this year. In each article about innovation, you will see evidence of honoring our philosophy while being flexible in our functions. The result is an expansion of the midwifery philosophy into farther reaches within the health care system. Some of today's interprofessional projects will become standards of care or core components of clinician education in the future as midwifery evolves and midwives find new areas in health care that need our expertise. This is a pivotal moment in health care. The processes we use to deliver care are being reshaped, and health care services in the coming years are going to depend on the work of high-functioning interprofessional teams a great deal more than today. Interprofessional practices are going to be much more common, and midwives will be comfortable and competent working within these teams. It is encouraging to me to see that students in midwifery and other professions are not struggling with the concept of interprofessional collaboration. In fact, they are inventing it and are ready to implement what is going to be a healthy, robust, and productive future in women's health care. It is also exciting to see what national professional associations are doing for the joint benefit of midwives and our colleagues in medicine and nursing right now. This work is forging a future in which interprofessional collaboration is not a new exciting theme, but a pillar of the health care system.