Certified Nurse-Midwife and Women s Health Care Nurse Practitioner

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1 Certified Nurse-Midwife and Women s Health Care Nurse Practitioner Practice Agreements at Chicago Revised March 2007

2 TABLE OF CONTENTS SIGNATURES OF AGREEMENT 3 ORGANIZATION RELATIONSHIPS AND MEMBERSHIP 4 DEFINITIONS 5 OUTPATIENT PRACTICE 6 INPATIENT PRACTICE 7 RESEARCH, EDUCATION AND QUALITY ASSURANCE 9 APPENDIX A JOINT STATEMENT WITH ACOG APPENDIX B COLLABORATIVE MANAGEMENT IN MIDWIFERY PRACTICE FOR MEDICAL, GYNECOLOGICAL AND OBSTETRICAL CONDITIONS APPENDIX C STANDARDS FOR THE PRACTICE OF NURSE-MIDWIFERY APPENDIX D DEVIATIONS FROM NORMAL 2

3 SIGNATURES OF AGREEMENT The following practice agreements for the practice of Certified Nurse-Midwives and Women s Health Care Nurse Practitioners at the have been reviewed and endorsed by: Professor and Head, Department of Obstetrics and Gynecology Coordinator, Nurse-Midwifery Practice 3

4 ORGANIZATIONAL RELATIONSHIPS AND MEMBERSHIP The Certified Nurse-Midwives (CNM) and Women s Health Care Nurse Practitioners (WHNP) at the receive privileges through the University of Illinois Medical Center Medical Staff as Staff Associates in the Department of Obstetrics and Gynecology. CNMs and WHNPs provide service in a health care system that has available consultation and assistance from board certified or board eligible obstetrician and gynecologist physicians. This is consistent with the Joint Statement of Practice adopted by the American College of Nurse- Midwives (ACNM) and the American College of Obstetricians and Gynecologists (Appendix A). Credentials Credentials of a Certified Nurse-Midwife at the include: 1. Holds the following current licenses: A. Professional Registered Nurse in the state of Illinois B. Advanced Practice Nurse (Nurse-Midwife) in the state of Illinois C. Advanced Practice Nurse Controlled Substance In the state of Illinois D. Controlled Substance Registration Certificate, DEA Registration Number 2. Education: A. Successful completion of a graduate program in nurse-midwifery accredited by the ACNM B. Holds a graduate s degree from an accredited university 3. Certification: Certification by ACNM, or its designate 4. Continuing Competency: For those with non-expiring certificates, continuous participation in Continuing Competency Assessment through ACNM 5. Eligibility for faculty status at the University of Illinois at Chicago Credentials of a Women s Health Care Nurse Practitioner at the University of Illinois Medical Center include: 1. Holds the following current licenses: A. Professional Registered Nurse in the state of Illinois B. Advanced Practice Nurse (Nurse-Practitioner) in the state of Illinois C. Advanced Practice Nurse Controlled Substance In the state of Illinois D. Controlled Substance Registration Certificate, DEA Registration Number 2. Education: A. Successful completion of an accredited graduate WHNP program B. Holds a graduate degree from an accredited university 3. Certification: Certification by the National Certification Corporation 4. Eligibility for faculty status at the University of Illinois at Chicago 4

5 DEFINITIONS Definitions for the independent and shared management of women will follow the ACNM position statements; Joint Statement with ACOG (Appendix A) and Collaborative Management in Midwifery Practice for Medical, Gynecological and Obstetrical Conditions (Appendix B). Medical, obstetrical and gynecological conditions can occur which require physician participation. When these situations occur, the APN can continue to have a variety of roles. The definitions from the position paper will be used to describe the relationship of the APN to her/his colleagues and are taken verbatim from the position paper. For the purpose of these agreements, Nurse-Midwifery and Women s Health Nurse Practitioner will be considered synonymous and the verbiage has been altered to reflect this use. The definitions are as follows: Midwifery* and Women s Health Nurse Practitioner practice is the independent management of women's health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn and the family planning and gynecological needs of women. The APN practices within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the client. APNs support women as partners in health care choices and practice in accord with the current Standards for the Practice of Nurse-Midwifery, as defined by the American College of Nurse-Midwives (Appendix C). CNMs and WHNPs employ a Collaborative Practice Agreement in compliance with Illinois state law. In the event that the collaborating physician is not available, another physician within the UIMC practice is available for consultation and collaboration. The APN consults with the attending physician in the outpatient setting and with the attending physician, or their designee, in the inpatient setting. The following are patterns of collaboration or co-management of care for the high risk client: Consultation is the process whereby an APN who maintains primary management responsibility for the woman's care seeks the advice or opinion of a physician or another member of the health care team. Collaboration is the process whereby an APN and physician jointly manage the care of a woman or newborn who has become medically, gynecologically or obstetrically complicated. The scope of collaboration may encompass the physical care of the client, including delivery, by the APN, according to a mutually agreed-upon plan of care. When the physician must assume a dominant role in the care of the client due to increased risk status, the APN may continue to participate in physical care, counseling, guidance, teaching and support. Effective communication between the APN and physician is essential for ongoing collaborative management. Referral is the process by which the APN directs the client to a physician or another health care professional for management of a particular problem or aspect of the client's care. * Midwifery refers to the education and practice of certified nurse-midwives (CNMs) who have been certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board, Inc. (AMCB), formerly the American College of Nurse-Midwives Certification Council, Inc. (ACC). 5

6 OUTPATIENT PRACTICE This section outlines the guidelines for the care of women in the outpatient setting by Certified Nurse-Midwives (CNM) and Women s Health Care Nurse Practitioners (WHNP), collectively identified as Advanced Practice Nurses (APN). 1. Primary APN Management A. APNs provide independent management of an essentially healthy woman from puberty through menopause. B. The management includes the following: a. Informs the woman of the scope of practice of nurse-midwifery/women s health nurse practitioner and of her rights and responsibilities as a patient. b. Provides health care through observation, assessment and management according to accepted clinical guidelines and medical staff privileges. c. Implements diagnostic and laboratory tests for screening or diagnostic purposes. d. Prescribes therapeutic agents, devices and therapies according to accepted guidelines and state law. e. Recognizes deviations from normal that require consultation, collaboration or referral to the physician (See Appendix D). f. Manages patients with selected deviations from normal when: 1) The diagnosis is clear with an expected normal and predicable outcome, or 2) A management guideline exists within resources used by the Department of Obstetrics and Gynecology, or 3) Physician consultation results in a mutual decision for continued primary APN management of the patient s care. The documentation of the physician consultation and collaboration will include the assessment, plan of care and recommendations for continued physician involvement will be documented in the chart. 2. Collaboration in Outpatient Practice A. Collaborative management is the mutual decision between the physician and the APN to share management of a patient who has a significant deviation from normal (See Appendix D). B. The goal of collaborative management is to establish a plan of care for the patient while ensuring her of continued contact with the primary APN in her original site of care. C. The plan for collaborative care is dependent upon the specific patient and situation. Examples include the following: a. Management with the APN with frequent verbal consultations with the physician. b. Alternating visits between the APN and the physician D. Documentation of discussions and management of care will be placed by each provider in the patient s chart. Clear communication is essential for collaborative management. 3. Referral (Transfer) of Patients A. When a patient develops a condition, which requires complete physician management, she is referred to the appropriate physician or practice site (See Appendix D). B. When the APN refers a patient, she/he clearly documents the discussion resulting in referral, the plan of care, the current status and the referral in the patient record. The APN relinquishes responsibility when the patient presents for care from the physician. Until that point, the APN is responsible for follow-up of the patient. C. The physician accepting the patient for care should also document their acceptance and status of the patient in the patient record. D. The patient may be referred back into the APN s care at any time that condition resolves or becomes appropriate for collaborative management (See Section 2 above). 6

7 INPATIENT PRACTICE This section outlines the guidelines for the care of women who present themselves for evaluation in the Triage area of Labor and Delivery and women who are admitted to the Obstetrical Service. 1. The APN individualizes management and care to meet the needs of the woman who is hospitalized. The APN respects the woman s plan for labor and birth, while integrating her chosen support persons into the process and maximizing mother and newborn interaction. A. The Certified Nurse-Midwife independently manages the care of an essentially healthy woman during her pregnancy, through labor and birth and through the postpartum period. B. The Women s Health Care Nurse Practitioner independently manages the care of an essentially healthy woman during her pregnancy, in triage, and through the postpartum period C. The essential features of inpatient management are similar to the outpatient area in that it includes the following: a. Continues to inform the woman of her condition, progress, and consultation to other health providers. b. Provides health care through observation, assessment and management according to accepted clinical guidelines and in accordance with medical staff privileges. c. Implements diagnostic and laboratory tests for screening or diagnostic purposes. d. Prescribes therapeutic agents, devices and therapies according to accepted guidelines and state law. e. Recognizes deviations from normal that require consultation, collaboration or referral to the physician (See Appendix D). f. Manages patients with selected deviations from normal when: 1) The diagnosis is clear with an expected normal and predicable outcome, or 2) A management guideline exists within resources used by the Department of Obstetrics and Gynecology, or 3) Physician consultation results in a mutual decision for continued primary APN management of the patient s care. The documentation of the physician consultation will include the assessment, plan of care and recommendations for continued physician involvement and will be documented in the chart by both the physician and the APN. D. Physician consultation occurs between the APN and the attending physician, or their designee (senior resident). After discussion, the physician and APN will decide whether medical management or nurse-midwifery/physician collaborative care is appropriate for the patient. A note documenting the consult should be written into the chart by the attending physician, or their designee. If collaborative care is chosen, the nurse-midwife will communicate the status of the patient to the attending MD or their designee (senior resident) as mutually decided. E. Triage and Birthrooms are considered intensive care areas. The patient must be assessed every 2-3 hours. A progress note is entered when a change in status, consultation or other events warrants it. 2. Triage A. The APN can evaluate, manage, treat and discharge women presenting to the Triage Unit. B. The APN diagnoses the presence of active labor. The APN may also certify a woman is in false labor. Patients who are not in active labor may be discharged from Triage by the APN. C. The APN communicates deviations from normal to the attending physician, or their designee (See Appendix D). D. The APN admits, via delegated authority, women to UIMC as indicated by their condition. The APN performs and documents the admitting history and physical as well as enters the admission order under the appropriate attending physician. 7

8 E. The APN communicates the admission of a patient to Birthrooms to the attending physician. 3. Intrapartum Care A. The CNM manages the labor of the essentially healthy woman according to evidencebased practice and within the scope of their CNM Medical Staff privileges. B. The CNM communicates deviations from normal to the attending physician, or their designee (See Appendix D). C. Emergency measures a. Emergency measures may be ordered or instituted. b. The following list is examples of emergency measures which may be ordered or instituted while awaiting the arrival of a physician. This list is not intended to be all inclusive of emergency measures utilized in the Birthrooms, and includes: 1) Manual removal of placenta 2) Administration of Terbutaline 0.25mg IV or SQ (one dose only) for fetal bradycardia. 3) Resuscitative care of the newborn c. The CNM may also assist the physician at a Cesarean section as needed. 4. Postpartum Care A. The APN will evaluate, manage, and treat women during the postpartum period. B. The APN communicates deviations from normal to the attending physician, or their designee (See Appendix D). C. The APN evaluates the patient and orders the hospital discharge. The APN is responsible for entering the discharge summary and forwarding it to the attending physician. 8

9 EDUCATION, RESEARCH, AND QUALITY MANAGEMENT Promotion and evaluation of high quality care are a priority to the Nurse-Midwifery and Women s Health Care Nurse Practitioner Practice of. CNMs and WHNPs are strongly encouraged to participate in all aspects of quality management: quality assurance, peer review and quality improvement. Research and continued/lifelong learning and professional development are also expectations of all APNs. 1. Education A. Continuing Education and Learning a. The APN will participate in continued learning, demonstrated by enrollment and completion of the Continuing Competency Assessment Program or the Certificate Maintenance Program of the professional organization. The APN will furnish proof of this enrollment and completion. b. The APN staff is encouraged to participate in departmental continuing education offerings, including journal Club, Morbidity and Mortality Review, Grand Rounds, and other continuing education offerings. B. Education of other professionals a. The role of the APN at UIMC includes participation in the education of nursemidwifery and nurse-practitioner students, as well as staff, students, residents and practitioners in other nursing, medicine and allied health fields. This may include: 1) Clinical precepting and supervision 2) Lecture 3) Seminar 4) Laboratory practice and assessment 5) In-service lectures b. Use of the appropriate clinical evaluation tools is expected to provide feedback regarding progress and expectations. This educational expectation is deferred for up to one (1) year in the case of a new clinician, in order to allow for personal role development. 2. Research A. The APN is expected to participate in appropriate on-going research approved by the Institutional Review Board and/or site research review panels, including resident research. B. The APN may conduct original research which has received proper approval within the university system, although this is not an expectation. C. The APN always has the opportunity to express concerns, or opt out of being involved in on-going research. The APN is encouraged to discuss any concerns with the researcher, or to the APN practice management. 3. Quality Management A. Quality assurance monitors structural, procedural and outcome indicators as they relate to accepted standards. The APN practice is part of the UIMC QA program. B. Peer Review: peer review is the assessment and evaluation of midwifery/whnp practice by other midwives and WHNPs. All members of the practice participate in peer review. C. Quality Management: Quality Management is the modification of the process for providing care in order to improve outcomes. APN Practice modifications are implemented based on measures of parameters such as appropriate use of technology and resources, population-specific care, clinical outcomes, patient satisfaction and access to care. APNs are expected to participate in and evaluate such Quality Management measures. 9

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