It Takes a Village: Interprofessional Midwifery

By: Tonya Nicholson, DNP, CNM. WHNP-BC, CNE, FACNM, Associate Dean of Midwifery and Women’s Health, FNU

As a new nurse-midwife, whenever I heard the words “interprofessional” practice, I cringed. I pictured my past experiences as a nurse in which we participated in multidisciplinary care teams. These teams would meet and basically one of the following would happen:

The physician would always lead the team, and the meeting would result in a new group of physician orders that had minimal input from other disciplines.

The physician wouldn’t come, and the nurses would use the hour to gripe about interprofessional rhetoric and the impossibility of any real application of the idea.

As a nurse, I often felt that I could handle nutrition, ambulation and medication teaching–so why did we need all the other groups?

In my first job as a nurse-midwife, I began to discover some distinct client advantages for interprofessional practice. The nurse-midwives in this practice were integrated into a multi-specialty clinic. We had an open exchange of ideas with our collaborating physicians as well as the luxury of readily available referral resources like physical therapy, diabetic education and neurology.

However, the practical application was that the nurse-midwife or the physician functioned as the head of the team and would send the client out to other professionals as the need arose. We would review reports on those visits and might randomly discuss a mutual client if we met at the water cooler. But we called it a team. And we felt progressive.

This limited view of interprofessional teams was recently challenged through a personal experience. I witnessed true interprofessional teamwork in action. My son (Seth) had a serious accident at age 20 that resulted in paraplegia. After several days in a trauma unit, we were transferred to a rehabilitation facility that specializes in spinal cord injuries.

We were quickly introduced to a true team approach and found our family at the team’s center. It felt like a village was helping to raise Seth out of his wheelchair. The team met regularly and with concentrated focus. There were representatives from the medical staff, nursing, PT, OT, dietary, social services, and recreational therapy. Team rounds occurred in our room three times weekly. At every incidence of rounds, Seth was an active participant in reporting his experience, discussing his needs, setting and refining goals, and asking questions. Unless there was a pressing medical need, Seth’s input constructed the skeleton of the plan for the week. All team members’ input was actively sought out and valued.

Leadership of the rounds was rotated. On Monday, the rounds were led by the physician. On Wednesday, the rounds were led by the Therapy Department. On Friday, nursing took the lead. This leadership was simply for organizational purposes. The true leader in any meeting emerged as the needs and objectives of care became clear. This was a thriving example of interprofessional teamwork.

As a healthcare provider, I was learning valuable lessons about teamwork that can be applied to any specialty:

The patient should always be at the center of the team. Every other member’s contributions should focus on the outcomes established by the patient.

Leadership should be fluid. The most appropriate team leader is the one with the most knowledge and skills to accomplish the immediate goal.

Respect amongst members must be overtly evident so that the client is confident in every member of the team.

I began to think about how this authentic team approach could effectively be translated into prenatal care. How would this look? Who would be the players? How could this concept be applied in my clinic? Could the team approach help to enhance a woman’s experience as she transitions to motherhood?

At the initial prenatal visit, one of the primary concepts that I cover is that of roles. I verbalize that the woman holds great power in this relationship and is a partner in her care. She is the team leader. I have found that most women have one or two people with whom they discuss all decisions. This is very often a mother or sister. This person must be valued by the provider and their input must be acknowledged. I describe my role as secondary. I explain that I will walk beside her through this experience and watch carefully for any warning signs. If they occur, we will discuss a plan and move forward as appropriate.

Pregnant women are generally healthy so the team is comprised of core members and “as needed” members. The ongoing relationship of the nurse practitioner or certified nurse-midwife and the collaborating physician is vitally important and forms the a strong foundation for the team. The core members’ focus is on wellness.

The team can be introduced to the client in individual appointments or in group care settings. These members would include social services, nutritionist, childbirth and lactation educators. The “as needed members” might include the collaborating physician, perinatologist, chiropractic provider, psych provider, etc. Literature on all services can be provided in a packet of goodies given at the first visit and utilization of the services encouraged at prenatal visits.

The team could also hold a monthly “meet and greet” so that the clients become aware of the services and value of the various members. This can be done so that the clients individually speak with each team member and rotate to the next team member after a short timed period (think speed dating) or in a more casual setting where there is freedom to mingle and chat.

As the nurse-midwife, I will discuss with the client the need for involvement of the “if needed” members based on ongoing risk assessment. The collaborating physician and I will meet at least monthly to discuss any complex client situations so that we are in agreement on the plan. If a referral to the collaborating physician is needed, I take the opportunity to remind the physician of each particular client’s needs and desire and make every effort to walk the woman down to his office for a personal introduction. The woman can then observe our interaction and trust in one another. Her confidence in her care team is nurtured.

Interprofessional teams in the prenatal setting can help to ensure that the most comprehensive and effective care is given to each woman and her family. By maintaining the client at the center of the team, we promote safe outcomes and a positive experience. Each team member contributes to the health of the mother and family.

After all, it takes a village…..