considering patient-centered obstetric nursing care: why and how?

facts and opinion

Considering Patient-Centered Obstetric Nursing Care: Why and How? VIRGINIA H. ASPY, RN, EdD, and FLORA N. ROEBUCK, EdD

The authors assay the need,for, the procedures involved in, and the beneJtJ derivedJrom a primary nurse approach to providing patient-centerrd nursing care for those pregnant women who receive their major prenatal and postnatal care through clinic facilities rather than from private physicians.

There is a large population of pregnant women who receive their obstetric care primarily through clinic facilities. A need for the development of patient-centered primary nurses to deliver obstetric care to this population is evident. I t arises from the nature of clinic procedures. Tha t is, in most clinics, the patient usually is not sequentially followed by any one physician; rather the patient is seen by whichever physician is on duty at the time of the patient’s appointment. Thus, the patient does not have the opportunity to build a continuing relationship nor to per- ceive any one health professional as a “significant other” whose advice and instructions are therefore received as personally relevant, mean- ingful, and motivational. Further, this lack of continuity with a single health professional mcans that in- tegrated, intensive instruction in pe r sona l ca re , n u t r i t i o n , a n d mothering usually is not provided for either the prenatal or postnatal stages of obstetric care.

T h e use of patient-centered obstetric nursing care in a clinic program should provide for a continuing dialogue between the patient a n d a single health professional. Such a relationship, beginning pre-

natally and extending postnatally, could have highly significant patient benefits. It has the potential of demonstrating 1) increased quality of patient-care delivered to a segment of the population which normally is deprived of patient-centered care, 2) increased quality-of-life for mother and infant as a result of the patient- centered care and instruction provided by the primary nurse, 3) im- proved health care of the newborn as a result of the patient-centered care and instruction provided by the primary nurse, and 4) increased continuing benefits for patient and family as a specific result of the follow- up instruction provided by the primary nurse in helping the patient to locate and utilize community resources.

Furthermore, if the objectives of such a program were carefully formulated and the results adequately investigated, it could make a signifi- c a n t contr ibut ion to t h e establishment of professional nursing as the partner rather than the “hand- maiden” of the medical profession through 1 ) developing a n d adequately researching the effects of primary nursing obstetric care on patient outcomes, 2 ) demonstrating and researching adequately the ef-

fects of the nurse as a consultant to the physician relative to the total en- v i ronmen t of t h e p a t i e n t , a n d 3) demonstrating and researching the utilization of nurses in gathering research data and its effect on nurse job satisfaction and turn-over rates.

Finally, such a program might have long-lasting effects on clinical practice by demonstrating the cost- effectiveness of this approach to the delivery of patient care.

WHY? A great deal of mysticism sur-

rounds the whole experience of pregnancy. It is not uncommon for pregnant women to be bombarded by their friends and relatives with hor- ror stories of labor and delivery. Added to the detrimental effects of such reports is the fact that clinic patients frequently fail to see the same physician or nurse more than once during their prenatal experience. Commonly during labor and delivery, they are denied the support of either a family member or a significant other from nonfamily groups. In a study of the effects of such treatment, Clark concluded that when women had erroneous information or inaccurate expectations about labor or did not have the support of a significant other, they had poorer labor and delivery experiences a n d negative feelings about repeating the experience. ’

In an effort to counteract the dele- terious effects of treatment-centered and almost mechanized obstetric care, divorced from interpersonal considerations, the Family Hospital in Milwaukee, Wisconsin, was estab- lished. According to Timberlake,’ staff at Family Hospital attempted to meet the major expressed needs of childbearing couples to give birth in a relaxed, warm, home-like climate, while in contact with loved ones, and for the mother to have some control over the assistance given.

Similar needs a re being expressed by childbearing couples all over t he country. An upsurge in home deliv- eries seems to be the result of an a t - tempt to have these concerns dealt with in a more satisfactory manner. Such a situation is of concern t o nursing for two reasons: 1) the po-

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tential danger to both mother and baby and 2) failure of hospitals and medical care providers to deliver care in an effective and relevant m a n n e r . Pregnancy a n d chi ld- bearing is a family affair, and i t is incumbent on hospital obstetric de- partments to investigate more crea- tive ways to deliver the kind of serv- ice that fosters the family concept. Further, those ways must include methods of delivering patient-centered care for women who cannot af- ford private physicians as well as for the affluent.

This paper proposes that one method of care which can foster the family concept for the public clinic patient is the assignment of primary nurses to provide patient-centered obstetric nursing care. According to Smith primary nursing focuses on the total patient and tries to help the patient achieve goals through intensive use of education and rehabil- itation.' The fact that such a program of extensive patient education can be beneficial is supported by the results of a study by Clark.' She found that after proper education and preparation and with emotional support during labor, more positive outcomes and lessened anxiety and fear were produced.

If patient education, as recom- mended by Clark, is to be effective it must begin in the very early stages of pregnancy and continue through the labor and delivery period. Optimal benefits will be gained if the teaching is consistent and done by the same person. This teacher then becomes a significant other in the life of the pregnant woman and is able to provide support for both the prospective mother and her involved family through the early infancy of the child.

The primary nurse in the clinic setting is one health professional with whom the patient can establish a continuing relationship throughout her obstetric care. Smith empha- sized that primary nursing care was total, comprehensive, and continu- ous care by one care giver to one patient and that i t focused upon the patient.

The importance of establishing a single health professional as a signifi-

cant other to the prospective parent is borne out by such studies as that of Leonard, el al.,4 in which parents who received genetic counseling from a health professional (private physician) with whom they had had a longstanding relationship trans- lated the counseling into action more frequently than those parents who received their counseling from professionals (clinic personnel) with whom they had had only a short- term relationship. By providing each patient with a primary nurse whom she sees on each prenatal clinic visit, upon arrival at the hospital for labor and delivery, and at postnatal clinical visits, the patient has the opportunity to build a relationship which can be supportive throughout her pregnancy and delivery.

By the same token, health professionals involved in the patient's care on a discontinuous basis are handi- capped in building an overall in- sightful gestalt of the patient's devel- o p i n g a t t i t u d e s , values , a n d personal, familial, and contextual problems which might affect the management of the pregnancy and subsequent child care. Thus, establishment of the primary nurse as a significant other on a continuing basis for the clinic patient should result in an increase in the information available to determine obstetric care as well as other, more direct, benefits to patient and newborn.

A final reason for establishing a program of patient-centered obstetric nursing care is that it may be cost-effective when compared with current procedures for the clinical management of pregnancy. In a study of primary medicalfsurgical nursing," primary nursing was reported to cost less than other methods of delivering care to patients. Specifically, primary nursing units in the Evanston Hospital were providing 15% more RN personnel at a salary expense per patient day of $1.38 less than comparable teaching hospitals and $1.40 less than hospitals in Chicago.

Marram, el al.," surveyed nine hospitals each of which had implemented primary nursing in one or more care units. Three of the hospitals reported it as less costly and the

remaining six hospitals reported no increase in operational cost. One hospital whose pr imary nursing units had a higher proportion of RNs explained its cost effectiveness as the result of increased efficiency; i.e., the units were operating much more effectively and with less cost than other units in terms of cost per patient day.

Although the above results were from inpatient units, it seems likely that the outpatient picture would be similar. Certainly, the possibility of cost-effectiveness should be investigated along with other potential benefits of this approach.

HOW? From consideration of the above

rationale and the professional litera- ture available on the operation of primary nursing in acute care facilities, it is possible to formulate appropriate goals and objectives for a program of patient-centered obstetric nursing care. Once such objectives have been formulated, i t is then possible to plan both procedures for ar- riving at those goals and ways of determining the effectiveness and benefits of such a program.

Goals and Objectives

Appropriate overall goals of a patient-centered obstetric nursing program (PCONP) are to 1) increase the quality of obstetric care benefits to the patient and the newborn, 2) enhance the professional contributions of the nurse as a health care team member in the management of obstetric care, 3) increase individual nurse satisfaction with obstetric nursing, and 4) provide these advan- tages in a cost-effective manner. Fur- ther, 5) it seems desirable to eval- uate, in a systematic manner, the effectiveness of the program.

In order to reach these goals, several specific objectives must be at- tained. These objectives are as fol- lows:

A. Given the appropriate selection and training procedures, the primary nurse will:

1. Function in an interpersonally effective manner in order to facilitate the patient's perception of

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2 .

her as a significant other as indicated by ratings above the 3.0 level when Carkhuffs Inter- personal Process Scales’ are applied to periodic tape ratings of nurse-pat ien t consu Itat ions. Function effectively to provide indicated nursing care and instructions to supplement the physician’s directives and to enable a n d motivate the pat ient to adapt personal life styles and/or situations in order to follow the physician’s directives as indicated by a) patient self-reports at suc- ceeding check-ups, and b) super- visor’s evaluations of nursing effect iveness.

tion in the care of her baby, re- questing rooming-in more frequently, breastfeeding baby more frequently, and higher scores on the observational measures of Mother-Infant Interpersonal Re- lations.

6. Care for her newborn upon re- turn to the home situation in a more effective manner, as indicated by more physical contact, less bottle propping, higher kept- appointment rate of clinic visits for both mother and baby, and theoretically, bet ter physical health of infant, to be checked upon at the time of the first and second postnatal clinical visits.

health care problems, 5) less ab- senteeism, and 6) more systematic patient-teaching.

Procedures To achieve the objectives a n d

goals identified above, activities in several areas would need to be con- ducted. Those activities fall into the categories of a) patient assignment, b) training, c) organization, and d) functioning.

Patienl Assignment. Upon first presentation at the clinic, patients who do not have a private physician for their obstetric care would be assigned to the case load of a primary nurse. The nurse to whom the pa-

l .

2 .

3 .

4

5 .

tient is assigned would meet the pa- B. Given assignment as an obstet- 7. Will more systematically present tient upon her first visit and stay ric patient in the case load of a pri- self for postnatal check-ups and with her throughout the stay. Sub- mary nurse, the patient will: participate in well-baby clinics sequent visits by this patient would and such other clinical services as be scheduled so that she will be at - may be indicated for the health Build, across time, perceptions of

other as measured by increasing visit. In addition, the primary nurse not so assigned) as indicated by scores on periodic administra- will make every effort to encourage regularity in making and keeping tions of a satisfaction-with-care the patient to schedule meetings be- appropriate and varied clinical attitude survey. tween other family members and the appointments. Present self for prenatal care primary nurse and to brine preq-

the primary nurse as a significant of the child (than will patients tended by the Same at each

more systematically (than pa- t ients not so assigned) as indicated by regularity in keeping clinic appointments. Follow medical instructions for personal care and management of her pregnancy more consist- ently (than patients not so assigned) as indicated by a) self-reports of management efforts, and b) confirming good results of physician’s examinations a t subsequent clinic visits. Experience less emotional dis- comfort and increased feeling of security upon hospitalization for delivery (than will patients not so assigned) as indicated by fewer expressed physical complaints and a higher ratio of questions asked about their own postpartal care and newborn care to questions about the labor and delivery process. Be so motivated that the mother- baby bonding occurring during hospitalization following delivery will be more successful (than that of patients not so assigned) as in- d i c a t e d by a t t e n d a n c e at mothers’ classes, active participa-

C. Given the establishment of the patient-centered obstetric nursing program, physicians will increas- ingly utilize the primary nurse as a contributing member of the health care team 1) by seeking her help in identifying particular sources within the patient’s social and familial con- texts of patient failure to carry out indicated management procedures, 2) through consulting with the nurse about ways to effect remedial solutions or ameliorations of patient failure to comply with directives and 3) by indicating greater appreciation of nursing contributions through the achievement of increased scores on the health care professionals attitude survey .

D. Given functioning as a primary nurse in providing patient-centered obstetric care, the primary nurse will experience increased job satisfaction as evidenced by 1) reduced turnover rates, 2 ) increase in scores on pre- and post-Nursing Climate Semantic Differential, 3) increased incidence of out-of-hours follow-up and/or problem solving visits with patients, 4) increased initiative in seeking resources and solutions for patient

- . - nancy-related home and family con- text joys and concerns for discussion at such meetings.

Training. Nurses selected to become primary nurses should receive training in several areas. These include interpersonal skills training, teaching skills, mother-baby bonding techniques, patient interview and counseling techniques, community resource availability and loca- tional skills, and pregnancy management as a to ta l envi ronmenta l problem. In addition, i t would be necessary as a result of the organiza- tional changes described below to conduct additional training of in-patient unit nurses and clinic personnel in order to facilitate coordination of the program.

Organization. Several departures from the usual clinical and unit organization and procedures would be involved in such a program. The primary nurse would pick u p staff patients from the obstetric out-patient clinic. The nurse would follow the patient through antepartal, labor and delivery, and postpartal periods. She would also be responsible for the care of the newborns of her patients.

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T o accomplish this, the nurse should be assigned at least two half- days per week in the outpatient clinic for the case assignment and patient followup. The remaining days would be spent in the postpartal/nursery area. Shifts of work among the primary nurses could be staggered in order to assure that there would be at least one primary nurse on the unit from 7AM to 7PM, seven days per week. O n e nurse would be on call during the 7PM to 7AM time. Plans of care developed by the primary nurse would be implemented by her and by an associate nurse who is one of the reg- ularly assigned staff nurses specially trained to supplement the efforts of the primary nurse.

These changes would necessitate the training of all personnel who work on the involved unit in the phi- losophy and practice of primary nursing. Some specific skills to be taught to both primary nurses and other personnel would be inter- viewing techniques, interpersonal skills training, and in-depth mother- baby care skills.

Funclioning. A primary nurse offer- ing patient-centered obstetric care would function in a highly professional manner. These functions include history taking, patient teaching, writing of patient care plans, health education, follow-up consul- ta t ions to community agencies, home visits, and higher levels of interpersonal skills. These nurses would be differentiated from the regular unit personnel in that they would have twenty-four hour re- sponsibility for their assigned patients both in the outpatient clinic and when they are admitted to the hospital. This entails flexible hours of work; time spent in the outpatient clinic; writing of detailed plans of care; some home visits, as indicated; close collaboration with physicians; and a great deal of health education for patients and their families.

Evaluation When a program is systematically

developed to reach pre-specified objectives, it becomes possible to design “tight” research which elimi- nates the possibility of benefits being

explained by a rival hypothesis. The program of patient-centered obstetric nursing care, as delineated above, lends itself well to such evaluation simply through establishing one or more control groups for comparative purposes and conducting systematic assessment and analysis procedures. Such an evaluation might include the following objectives:

1. Given the establishment of the patient -cen tered obstetric nursing program, with patients assigned on a random basis to the case load of a primary nurse (PN group), to the case load of a primary nurse and a continuing physician (PN+P group), or to a control group, systematic evaluation of the program will in- dicate statistically significant increased benefits for the PN and the PN+P groups over the control group but not statistically significant increased benefits for the PN+P group over the PN group.

2. Given establishment of the patient-centered obstetric nursing program, the program will compare fa- vorably with cur ren t (control) procedures as indicated by cost-benefit accounting of nursing hours per patient day, nursing cost per patient day, sick pay, unscheduled absences, patient satisfaction with nursing care per nursing hours per patient day, and average number of days re- quired hospitalization per patient.

3. Given the establishment of the patient-centered obstetric nursing program and its functioning over a period of time of two calendar years, the program will demonstrate its overall value to the population of concern as indicated by increased patient requests for assignment to a primary nurse.

Establishment of Controls Patients to be included in the re-

search aspects of such a program should be restricted to those patients over eighteen years of age who do not have a private physician for their obstetric care. During a first research year, high-risk and “normal” patients could form strata from which random assignments would be made.

Upon first presentation at the clinic, patients to be included in the

evaluation should be randomly assigned to either a control group or to one of the experimental groups in the patient-centered obstetric nursing program. Those patients assigned to the control group should receive obstetric care in the same manner as is currently being given in the clinic and other affected services. In the experimental groups, patients should receive primary nursing care as outlined above while all services other than those given by the primary nurse should be admin- istered in the same manner as is currently being given.

Assessment and Analysis Evaluation activities could appro-

priately be based upon a sequential- sampl ing randomly-assigned matched-pairs group (primary nursing vs. control) design. Statistical procedures for determining signifi- cance of detected differences between groups might include t-tests, analysis of variance, and analysis of co-variance. Indexes which could be used in evaluating such a program include:

1. Patient scores on satisfaction- with-care attitude survey

2. Frequency and regularity of clinic appointments in pre- and postnatal phases of obstetric care

3. Frequency and seriousness of demands for nursing attention during hospitalization for delivery 4. Patient self-reports of manage-

ment compliance with physicians’ directives

5. Measures of effectiveness of mother-baby bonding

6. Measures of effectiveness of care of newborn, including physician’s examination of infant’s physical health

7. Utilization of well-baby and other clinical facilities to maximize the health and well-being of the child

8. Nurse scores on Interpersonal Process Scales

9. Supervisory evaluation of functioning as primary nurse

10. Turnover rates of primary nurses

11. Nurse scores on Nursing Cli- mate Semantic Differential

12. Incidence of out-of-hours follow-up visits with patients

300 Septernber/October I979 JOCN Nursing

13. Initiative in seeking resources and s o l u t i o n s f o r p a t i e n t s w i t h hea l th care problems

14. Physician scores o n H e a l t h C a r e Professionals Att i tude Survey

15. Nurses’ log of incidence of consul ta t ive discussions with physicians

16. Cost-benefit account ing of nursing hours per patient day, nursing cost per patient day, sick pay, unscheduled absences, pat ient satisfaction with nursing care per nursing h o u r per pat ient day, and average n u m b e r of d a y s of r e q u i r e d hospitalization per pat ient .

SUMMARY We have presented a possible way

t o provide family concept nursing for pat ients whose major source of pre- and postnatal care is t h e publ ic clinic ra ther t h a n a pr ivate physician. We have also suggested suit- able objec t ives a n d a p p r o p r i a t e m e a n s of evaluat ing such a program. S u c h a program would result in significant heal th benefit for a segment of t h e populat ion who a r e now re- cei vi n g p r i m a r i l y o n ly crisis- p re- vention care. C a r e of t h e kind pro- posed here, however, is fa r m o r e t h a n crisis prevention. I ts benefits extend beyond the immediate hea l th needs of t h e pregnant individual to t h e cont inuing growth and develop- m e n t in physical, intellectual, and emotional areas of t h e new genera- tion. In this manner , obstetric care and family heal th care become syn- onymous.

References Clark AL: Labor a n d birth: Ex- pectations and outcomes. Nurs Fo- rum 14:413-428, 1975 Timberlake B: The new life center. Am J Nurs 75:1456-1461, 1975 Smith CC: Primary nursing care-a substantive nursing care delivery sys-

tem. Nurs Admin Quart: Primary Nursing I , Winter 1977

4. Leonard CO, Chase GA, Childs B: Genetic counseling. N Engl J Med 287:433, 1972

5. Anderson R: The operational level. The Evanston Story: primary nursing comes alive, Nurs Admin Quart: Pri- mary Nursing 1:27-29, Winter 1977

6. Marram GD, Schlegel MW, Bevis EO: Primary Nursing: A Model for Individualized Care. St. Louis, CV Mosby, 1974

7. Carkhuff RR, et al: The Skills of Teaching: Interpersonal Skills. Am- herst, Massachusetts, Human Re- source Development Press, 1976

Supplemental Bibliography

Anderson C: Operational definition of “support”. JOGN Nurs 5:17-I8 Uan./ Feb.) 1976

Arnsdorf MB: Perceptions of primary nursing in a family-centered care setting. Nurs Admin Quart : Primary Nursing 1:2, Winter, 1977

Baird SF: Crisis intervention theory in maternal -infant nursing. JOGN Nurs 5:30 Uan./Feb.) 1976

Bean M: Birth is a family affair. Am J Nurs 75:1689-.I692 1975

Carlson B, Sumner E: Hospital “at home” delivery: A celebration. JOGN Nurs 5:2 1-27 (March/April) 1976

Chiota BJ, Goolkasian P, Ladewig P: Ef- fects of separation from spouse on pregnancy, labor and delivery, and the postpartum period. JOGN Nurs 5:21-24 (Jan./Feb.) 1976

Ciske KL: Misconceptions about staffing and patient assignment in primary nursing. Nurs Admin Quart: Primary Nursing 1:2, Winter, 1977

Levine NH: A conceptual model for obstetric nursing. JOGN Nurs 5:9-15 (March/April) 1976

Lubic RW: Developing maternity services women will trust. Am J Nurs 75:1685 1688 1975

Meyer BJ: Childbirth at home-a family-centered affair. JOGN Nurs 5:20 (March/April) 1976

Nielsen IL: A midwife-physician team in private practice. Am J Nurs 75:1693- 1695 1975

Olsen A: Change takes time. Nurs Ad- niin Q u a r t : Primary Nursing 1:2, Winter, 1977

Pisani SH: Primary nursing-aftermath of change. Nurs Admin Quart: Pri- mary Nursing 1:2, Winter, 1977

Poland NL: The effects of continuity of care on the missed appointment rate in a prenatal clinic. JOGN Nurs 5:45- 47 (March/April) 1976

Rising S S : The fourth stage of labor: Family integrat ion. A m J N u r s 74:870-874, 1974

Rubin R: Maternity nursing stops too soon. Am J Nurs 75: 1680- 1684, 1975

Sobczak CL: Pharmacy a n d primary nursing: Potential for conflict and co- operation. Nurs Admin Quart: Pri- mary Nursing 1:2, Winter, 1977

Wheelrr LA: A concept of maternity care. JOGN Nurs 5:15 -17 Uan./Feb.) 1976

Address for correspondence: Virginia Aspy, EdD, 1836 Metzerott Road, Apt 1723, Adelphi, MI) 20783.

Vir,ginia A ~ p y attended St. Anthony Hospital ( R N ) and Spalding Colle%ge (BS), both in I’ouisuille, Kentucky; liniwrsity of Florida ( M N ) , Gainesuille; and East Texas State University ( E d D ) , Commerce. She has experience in all phases of nursing, from staff nurse t h r o y h nursing education. Dr. Aspy is currently director of nursing at Suburban Hospital, Bethesda, Maryland.

Flora Roebuck is professor oleducation applied in medicine, Johns Hopkins UniuersiQ, Balti- more, Maryland. Dr. Roebuck works in the Adolescent Pregnancy I’rqfram, department of obstetrics and gnecolo~gy. She received her BS from the Uniuersity of North Carolina, Chapel Hill, her M E d Jkom Cornell IJniuersity, I th - aca, New York, and her EdDfrom the liniuer- sity of Florida, Gainesuille.

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considering patient-centered obstetric nursing care: why and how?

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