Influencing Collaborative Maternity Care Through Obstetric Hospitalist Education

INFLUENCING COLLABORATIVE MATERNITY CARE THROUGH OBSTETRIC HOSPITALIST EDUCATION

A Doctoral Project submitted to the Faculty of the Graduate School of Arts and Sciences of Georgetown University in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

Liane E. MacPherson, M.S.

Washington, DC November 20, 2020

ii INFLUENCING COLLABORATIVE MATERNITY CARE THROUGH OBSTETRIC HOSPITALIST EDUCATION

Liane E. MacPherson M.S.

Thesis Advisor: Cynthia L. Farley, Ph.D.

ABSTRACT

The importance of collaboration in maternity care in the U.S. is apparent with deficits in both care disparities and quality, despite disproportionate expenditures to improve care.

Utilization of experienced, well-trained clinicians, such as obstetric and midwife hospitalists, offers a strategy to improve outcomes, reduce cost, and enhance patient experiences: goals consistent with the Quadruple AIM strategies. Obstetricians may have knowledge deficits regarding the training, role, and scope of practice of Certified Nurse-Midwives or Certified

Midwives. This lack of familiarity may impede the development or acceptance of a collaborative hospitalist model.

The objective of this project was to determine knowledge and attitude change in obstetric hospitalist physicians about midwives utilizing an online education module with a pre- and post- survey. The study sample included physicians employed by a large, nation-wide obstetric hospitalist group. Approvals were obtained through Georgetown Institutional Review Board

(IRB) and company administration; the invitation was made via company email. Sixty-five physicians voluntarily completed all components. Findings showed an overall increase in knowledge about and positive attitudes toward midwives post-intervention. A common area of knowledge deficit identified by physicians was in the education of midwives. Online education

iii can be an effective tool for physician education and promote understanding of the training and scope of practice of midwives. As needs for team-based, patient-centered care continue to evolve, dissemination of knowledge of what midwives contribute to the maternity care arena is essential.

iv ACKNOWLEDGEMENTS

This project would not have been possible without the help and support of many. I hold enormous gratitude to Dr. Slota and the entire academic team at Georgetown University. From the very beginning, to this day, Dr. Slota has been a touchstone. Her optimism, wisdom, and her passion for peace and care of self and surroundings are contagious. I would also like to extend special thanks to Dr. McLaughlin, and Dr. White. Both epitomize the best of academia with generous servings of humility and humor. I owe tremendous gratitude to my revered content expert and past ACNM president, Dr. Avery, an inspiring educator, researcher, and midwifery leader. Your devotion to the world of midwifery and education are remarkable. I want to give great thanks to my two Advisors, Dr. Julia Lange-Kessler and Dr. Cindy Farley. I thank Dr.

Farley, not only for her support and guidance in this doctoral project, but also for the encouragement and support in all my midwifery endeavors spanning 20 years. Dr. Farley has always made me feel like her special mentee, but I know many others who have been lifted by her professional spirit and passion. I also celebrate this accomplishment with my cohort of brilliant women; their support has been unwavering, and we will forever be connected as colleagues and friends. I dedicate this project to my family. My two sons, Gabriel and Jamison who have been my greatest gifts and who have always believed in me. To the amazing

MacPherson clan, and to my biggest fan and loving partner, Dave who had no idea what he was getting into. Finally, I feel tremendous gratitude to my late mother, Elizabeth Charland (1942-

2015) brilliant and strong: She attained her high school diploma in her forties and her insatiable appetite for learning inspires me to this day.

v TABLE OF CONTENTS

CHAPTER I ...... 1 Introduction ...... 1 Problem Statement ...... 2 Background ...... 4 Research Question ...... 6 Current Utilization of Midwives in the United States ...... 7 Project Site Structure and Staffing ...... 8 Schein’s Organizational Culture ...... 8 Challenges in the Collaborative Maternity Care Hospitalist Model ...... 9 Conceptual Framework ...... 10 External Influences, Structure, Outcome and Time ...... 11 Definition of Terms ...... 12 Summary ...... 14 CHAPTER II ...... 15 Literature Review ...... 15 Introduction to Search Criteria ...... 15 Critique and Synthesis of the Evidence ...... 17 Online Clinician Education ...... 18 Interprofessional Perceptions ...... 24 Synthesis of Evidence ...... 28 Project Rationale ...... 30 CHAPTER III ...... 31 Methodology ...... 31 Project Type and Design ...... 31 Purpose and Aims ...... 31 Setting, Sampling, and Population ...... 32 Plan and Implementation ...... 33 Human Subject Review ...... 33 Data Management ...... 34 Educational Intervention ...... 34 Measurement Tools and Questionnaires ...... 35 Pre and Post-Survey Tool ...... 35

vi Data Collection Procedures ...... 36 Data Analysis Plan ...... 36 Conclusion ...... 37 CHAPTER IV ...... 38 Results ...... 38 Participants ...... 38 Characteristics of the Provider Sample ...... 39 Analysis ...... 41 CHAPTER V ...... 44 Discussion ...... 44 Strengths ...... 45 Limitations ...... 46 Implications for Practice ...... 48 Further Study ...... 49 Conclusions ...... 50 APPENDICES ...... 51 BIBLIOGRAPHY ...... 57

vii LIST OF FIGURES

Figure 1 Conceptual Model Of Midwife-Physician Collaboration ...... 11

Figure 2 Flow Diagram Of Survey Respondents ...... 39

Figure 3 Work Relationship With Midwives (N=34) ...... 41

viii LIST OF TABLES

Table 1 Studies Considering Online Education ...... 21

Table 2 Models of care ...... 23

Table 3 Interprofessional Perceptions ...... 28

Table 4 Participant Characteristics (N=65)...... 40

Table 5 Comparison of Minimum Degree Required, Pre-Educational Intervention ...... 42

Table 6 Comparison of Training and Skills, Pre-Educational Intervention, Percentage of “True”

(N=65) ...... 43

CHAPTER I

Introduction

Utilization of experienced, well-trained clinicians, such as obstetric (OB) and midwife hospitalists, offers a strategy to improve outcomes, reduce cost, enhance patient experiences, and improve clinicians’ work environments: goals consistent with the Quadruple AIM strategies

(Berwick, Nolan, & Whittington, 2008; Bodenheimer & Sinsky, 2014; Srinivas et al., 2016).

According to Collaboration in Practice: Implementing Team-based Care, (ACOG, 2016), multidisciplinary teams are integral to meeting global healthcare goals. The Center for Disease

Control (CDC, 2019) recently acknowledged that maternal mortality rates continue to increase despite national attention. While the United States (U.S.) continues to struggle to narrow or eliminate gaps within healthcare, disparities are especially glaring in the maternal-infant domain, where compared to their mothers, women today are 50% more likely to die in childbirth (Shah,

2018). While some of the increase may be attributable to concomitant medical ailments, this explains neither the tremendous disparities between races nor the fact that the U.S. ranks 41st in maternal mortality among developed countries (CDC, 2019). In other countries, integrated collaboration between obstetricians and midwives, and midwifery-led models of care are commonplace (World Health Organization [WHO], 2018; Renfrew, 2016).

Interprofessional healthcare models have been shown to potentiate access to care, improve efficiency, and reduce costs, while still delivering high-quality outcomes (Institute of

Medicine [IOM], 2011; Smith, 2016; WHO, 2018). Both the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM) agree that collaboration and interprofessional respect promotes high-quality maternity care (2018). As

healthcare teams continue to evolve and become more person-centric, models which employ multidisciplinary teams show promise (IOM, 2011; WHO, 2010). Mitigating the obstacles that interfere with such progression is essential to reform the collaborative models to optimize care in the US (Miller, 1997; Schwind, et al., 2016).

Problem Statement

While improvements in infant outcomes were found at the midcourse review of Healthy

People 2020, maternal data were underreported and have been highlighted, both nationally and globally, with increasing concern (NCHS, 2018; Office of Disease Prevention and Health

Promotion, 2019; Shah, 2018). Maternal morbidity and mortality continue to be disproportionately inflated, despite medical technology and high cost when compared to international peers: The United States ranks 41st in industrialized countries (Childbirth

Connection, 2019). The American College of Nurse-Midwives (ACNM) reported that in 2017,

99% percent of births in this country currently occur in hospitals, with 91% of those attended by obstetricians and 9% attended by midwives. Current data suggest that maldistribution of maternity care providers, an increase in unnecessary interventions, diminished access to care, and medical models that often pathologize labor and birth are contributory (ACNM, 2013;

American College of Obstetricians and Gynecologists [ACOG], 2017; Kennedy, Grant, Walton,

Shaw-Battista, & Sandall, 2015; Smith, 2014; World Health Organization, 2016). To date, minimal research has been conducted that examines the maternity care obstetric hospitalist model: not only is this a relatively new domain but also, the addition of midwives adds another dynamic to the rapidly changing environment of inpatient perinatal care delivery.

In response to healthcare reform and national concern over unmet healthcare goals

(Healthy People, 2020), collaborative models between Advanced Practice Registered Nurses

(APRNs), midwives, and physicians have gained interest as leaders considered new strategies to improve care delivery (Mahdizadeh et al., 2015). Certified Nurse-Midwives/Certified Midwives

(CNMs/CMs) constitute less than 12,000 practitioners nationally, or a mere 3% of the 340,000

APRN population (Bureau of Labor Statistics, 2018), making it the smallest specialty within the field of advanced practice nursing. This small representation undoubtedly contributes to limited exposure to both the public and other healthcare professionals to the discipline of midwifery. In maternity care specifically, CNMs/CMs are well-positioned to be key partners in interprofessional team models (Downe, Finlayson, & Fleming, 2010; Woo, Lee, & Tam, 2017).

Efforts to improve maternal-infant health outcomes and narrow the widening healthcare disparities, afford midwives the chance to make significant improvements (Downe et al., 2010;

Woo, Lee & Tam, 2017). As delivery of healthcare moves toward team-based strategies, inpatient hospitalists and obstetric hospitalists continue to grow (Weinstein, 2015). According to

Wilson, (2019), the number of hospitalists has quadrupled in the past two decades. Data regarding the number of physicians and midwives working in this role are challenging to collect because it is so newly established. There is limited information about the collaboration between midwife hospitalists and OB hospitalists, probably due to the very recent development of the role; however, what is emerging, shows great promise (Rosenstein, Nijagal, Nakagawa,

Gregorich, & Kuppermann, 2015). Research examining interdisciplinary collaboration in the private sector between obstetricians and midwives is typically done in the context of mandated consultation and referral arrangements; however, this differs from obstetrician and midwife collaborative hospitalist care. The latter model typically reflects both disciplines working side- by-side, simultaneously in the inpatient setting. Ongoing, real-time interfacing can promote open communication and risk-based work division. The collaborative efforts of midwives and

obstetricians working side-by-side as midwife hospitalists and OB hospitalists represent a new and dynamic relationship that requires education, clear and ongoing communication, role delineation, and coordinated care provision of expectant mothers. The World Health

Organization (2018) recognizes that globally, 87% of maternity care can be safely and effectively delivered by midwives. Interprofessional understanding of the scope of practice, mutual respect, and adaptability of patient-centered care promotes flexibility in which team member is guiding the plan of care according to the woman’s preferences and needs.

While evidence continues to mount in support of collaborative care models, actualization of effective interprofessional teams between midwives and obstetricians remains challenging due to variations in roles from state to state, understanding of scope of practice and qualifications, historical conflicts and turf issues, and physician-led pedagogy within medicine and nursing disciplines (Gorman, 2019; Smith, 2014). Education of all team members is paramount to interprofessional respect, understanding, and success; lack of progress in these areas can contribute to the failure of otherwise promising models of care. Providing online physician education to obstetric hospitalist physicians may support ongoing interdisciplinary growth and relationship building and be mutually beneficial as they work in high functioning care teams.

The purpose of this study was to evaluate the influence of OB hospitalist education on the knowledge and perceptions of midwives. Using a validated tool, obstetric hospitalists within one company, completed a demographic survey, were provided an online education module regarding midwives, and completed pre, and post-survey.

Background

The obstetric (OB) hospitalist, a physician dedicated to the treatment of inpatient clients, has celebrated success and growth since its inception in the mid-nineties due to improved

outcomes, efficiency, and cost (Wachter & Goldman, 2016). In the past dozen years, there has been further development of the role, and the inception of the hospitalist, sometimes referred to as a laborist: a physician devoted to the inpatient care of laboring women (Weinstein, 2003).

Other clinicians who have worked as hospitalists in maternity care include Advanced

Practice Registered Nurses (APRNs), specifically Certified Nurse-Midwives (CNMs)/Certified

Midwives (CMs). For the purpose of this study, the term midwife will be used to reference both

CNMs and CMs: graduates of a midwifery education program accredited by the Accreditation

Commission for Midwifery Education (ACME) who have passed a national certification examination administered by the American Certification Board (AMCB) (ACNM, 2016).

Although midwives are considered experts in women’s intrapartum care, they comprise less than three percent of the nation’s APRNs, and are unfamiliar to many members of the healthcare team. Complicating matters further, is the wide variations of the roles and responsibilities of midwives between states, and countries.

Interprofessional relationships and understanding the certified nurse-midwife/certified midwife role are fundamental for both optimal care provision and a partnership that includes midwives engaged in their full scope of practice. Opportunities to enhance perceptions, knowledge, and attitudes of obstetricians about their midwife colleagues, are plentiful.

Interprofessional healthcare models have been shown to potentiate access to care, improve efficiency, and reduce costs, while still delivering high-quality care (IOM, 2011; WHO, 2010).

The advantages of including advanced practice registered nurses and Certified Nurse-

Midwives/Certified Midwives (CNMs/CMs) as essential members of healthcare teams have been demonstrated as outcomes are analyzed and patient experiences are reviewed (Freytsis et al.,

2017).

The collaborative obstetric hospitalist model describes the utilization of both physicians and midwives within the hospitalist role (DeJoy et al., 2015). The development of collaborative relationships between these disciplines in this model shows great promise, but obstacles, including knowledge deficits and misperceptions within the obstetric and administrative communities, reveal opportunities for improvement in this model of care delivery. Healthcare providers must commit to ongoing education, lifelong learning, and incorporation of changes in clinical care supported by evidence. Efforts to improve these three areas become the basis for a timely and relevant doctoral project.

Research Question

Research requires concise, clear questions for specific clinical problems and the acronym

PICOT has been frequently used to aid in finding an accurate study question (Fandino, 2019).

The “P” in PICOT stands for the patient or population, the “I”, for the intervention or interest area, the “C” for the comparison intervention or current practice, the “O” for the outcome desired, and the “T” for the time to achieve each outcomes. In this project, the population was the OB hospitalist physician (P), the educational module is the intervention (I), the comparison occurs with the pre- and post-intervention surveys (C), the outcomes, or aims of the work are the impact on knowledge and attitudes about midwives (O), and the (T) represents the time period for completion of the surveys and educational module. Despite the lack of interdisciplinary role understanding that obstetricians have about midwives, limited educational offerings are available to fill this need. To improve collaboration between obstetric and midwife hospitalists, this study evaluated the impact of an online education module on knowledge and attitudes of obstetric hospitalist physicians about midwives.

Current Utilization of Midwives in the United States

Until recently, midwives have had somewhat limited employment options, typically as employees- including private practice, home birth, birth center or hospital-based work. Midwives currently attend just over 9% of all births in the U.S., reflecting a slow but steady increase

(ACNM, 2019). With recent creation and growth of the obstetric hospitalist role, midwives may now consider new and innovative opportunities as contributors in this growing domain. This recent role development shows great promise, but obstacles, including knowledge deficits and misperceptions exist within the obstetric and administrative communities about midwifery education, licensure, and scope of practice. With such a small national presence, many obstetricians have had minimal experience or exposure to midwives and are unaware of the benefits of this model. DeJoy (2015) describes, two of the most common collaborative hospitalist models: In the first, the midwife assumes the role of the front-line maternity care hospitalist in a community hospital, and in the second the midwife works with residents in an academic setting.

Both models involve an obstetrician available for consultation and collaboration or referral as warranted.

CNMs/CMs provide much of the hands-on care in this large hospitalist company, while supporting company goals of fiscal responsibility. The partnering of midwifery and obstetrics become increasingly crucial as OB hospitalist programs struggle to meet the demands of this growing market while reducing high-intervention practices such as non-medically indicated inductions, high rates of cesarean, and episiotomy (DeJoy et al., 2015, Weinstein, 2015).

Challenges in providing education to physicians include lack of time, disinterest or disassociation, prejudices against midwives, or a perception that the education is not necessary

(Shaw-Battista, Young-Lin, Bearman, Dau, & Vargas, 2015).

Project Site Structure and Staffing

A large, nation-wide obstetric hospitalist group was used for this project. This new physician role within the obstetric profession offers job opportunities for private practice providers who want an alternative from the burdens of running a business and the ongoing struggles with life-work balance. With an employee base of over 1200 physicians and more than

40 midwives, this company has created a robust operation and offers insight and opportunity for assessment of the current needs within this maternity care model. As of May 2020, this company had over 187 obstetric inpatient contracts in 33 states (OBHG, 2020).

In the past several years, the company began to incorporate midwives into several of their busier programs, to support the growing need, expand the team, improve outcomes and address safety concerns through interdisciplinary collaboration; a strategy well-supported in current literature (DeJoy et al. 2015; Downe, Finlayson & Fleming, 2010).

Schein’s Organizational Culture

According to Schein (2017), organizational culture includes developed layers that considers both overt and intangible traits and encompasses artifacts, beliefs and values, and basic assumptions. Cultural artifacts, or observable habits of this large obstetric hospitalist model, include frequent communication amongst the team members, with the physician as the leader and the midwife assuming a supporting role. Some company physicians embrace a more relaxed, collegial, team approach, while others maintain a more hierarchical stance and demonstrate a supervisory role. Only a handful of the 187 sites across the country have added midwives to their teams but increasing interest in this model suggests the potential for growth. Physicians’ understanding of the midwife profession is often limited or inaccurate and can reduce the potential of the team. Birth room behaviors often differ between the disciplines of obstetrics and

midwifery and is reflected in hospitalist practice. The use of low lighting, optimal client positioning, and birthing preferences such as family involvement, are some examples of midwifery practice, not typically used by obstetricians. More recently, some physicians have boasted about their support of low-intervention strategies, seeking midwifery support and approval for their adaptations; a respectful nod that may be growing within the obstetric hospitalist arena (S. Kubesh, CNM, personal communication, October 18, 2018).

Artifacts and symbols, espoused beliefs, and basic assumptions are key components of organizational culture, according to Schein (2017). The core values that guide the inpatient obstetric hospitalist model are safe, high-quality, timely maternity care for all women who present, mirroring national maternal outcome concerns (DeJoy et al, 2015). Always having hospitalist coverage as scheduled is a non-negotiable, or, according to Schein (2017), an underlying assumption and this responsibility is taken very seriously. All team members are encouraged to participate in patient care plans, team meetings, process improvement projects, and professional education. According to the physician site director, obstetric hospitalist coverage has not lapsed since the program’s inception (J. Morgan, personal communication,

October 18, 2018). The incorporation of midwives into the maternity care model is widely accepted as an opportunity for improvement and positively impacts outcomes such as cesarean rate interventions (Souter et al., 2019).

Challenges in the Collaborative Maternity Care Hospitalist Model

There is a lack of understanding of the midwife role by the physicians within the company. For example, some obstetric hospitalist physicians perform redundant physical or vaginal exams after experienced midwives. Most company leaders still refer to midwives as

‘mid-levels,' rather than independently licensed providers. Even physicians within the hospitalist

model may not fully understand the CNM/CM scope of practice, minimizing the potential of their well-qualified colleagues (van Dis, 2018). Continued team building and education regarding the valuable attributes of both the midwifery and obstetric professions can be an opportunity for growth within the current model and parallel leaders in both disciplines may soften the hierarchical boundaries that are present.

Conceptual Framework

According to Polit and Beck (2017), a conceptual framework or model may be less formal or abstract than a theoretical framework, though it may still serve to underpin the rationale behind a project. Smith (2014) describes a conceptual interprofessional collaborative practice framework created from four dimensions and twelve concepts, (see Figure 1).

Dimensions and Concepts of Interprofessional Collaboration

The dimensions identified include organizational, procedural, relational, and contextual aspects. Smith (2014) identifies guidelines and structures as essential to develop the joint relationship between obstetricians and midwives. Concepts that support this are commitment, shared vision and shared interests. Role clarity, coordination, and shared decision making are the concepts that support procedural dimension. Relational dimension considers influences that impact interprofessional behaviors and related to communication, synergy, reciprocity, trust and communication. Finally, contextual dimension includes regulations, politics and regulations and encompasses the dimension of shared power in the partnership between midwives and obstetricians. These components are guided and analyzed by a theory of derivation strategy in creating concepts and dimensions of the interprofessional framework (Smith, 2014). This model addresses the midwife-physician collaboration explicitly and considers the various aspects of interdisciplinary work and identifies attributes of the involved stakeholders.

Smith’s model (2014) (see Figure 1) identifies key components that address the integration of midwifery skills and knowledge and obstetric skills and knowledge by creating growth, sharing and evolution over time with a keen focus on outcomes, structure, and processes.

The following figure represents the Smith’s model (2014) which was printed with permission, see APPENDIX A.

Figure 1 Conceptual Model of Midwife-Physician Collaboration

(Reprinted with permission. Wiley, 2014)

External Influences, Structure, Outcome and Time

Obstetric practice models are changing due to reimbursement, burnout, malpractice concerns, lifework balance, and increased scrutiny of maternity outcomes in the U.S.

(Weinstein, 2015). Increased understanding of the midwife scope of practice, may support the development of interprofessional collaboration within this model. Smith’s (2014) conceptual

framework for interprofessional collaborative practice aligns with this scholarly work. The overarching themes are developed from a literature review. The authors recognize that this effort is an ongoing process and should be assessed over time. External influences include company growth, reimbursement regulations and hospital contracts, and varied regulations that impact midwives across the country. Data for two measurable outcomes were gathered from the surveys and included understanding of the various types of midwives, knowledge of the scope of practice and skill set of CNMs within the OBHG community. and benefits and challenges of working within a collaborative hospitalist model. Creating a convenient, online educational opportunity that offers physician education credits may encourage participation and promote learning.

Definition of Terms

Interprofessional Collaboration

One widely accepted definition of collaboration by Wood (1991), suggests that collaboration occurs when a group of autonomous stakeholders of a given domain engages in an interactive and evolving process, using shared rules, norms, and structures to participate in joint activities aimed at achieving a shared goal. ACNM and ACOG (2018) also endorse interprofessional collaboration, acknowledging obstetricians and midwives as respective experts in their field and believe maternity care is elevated when communication occurs across care settings and among clinicians. Smith (2014) describes trust, respect, synergy, communication, and reciprocity and key elements in a collaborative relationship.

Interdisciplinary Team

Individuals or groups who come from distinctly different disciplines, to provide a therapeutic approach to care (Pam, 2013).

Midwife

This DNP project addressed midwives as described by the ACNM (2020). Certified Nurse-

Midwives and Certified Midwives have been educated in graduate-level midwifery programs accredited by the Accreditation Commission for Midwifery Education (ACME). CNMs and CMs have passed national certification examination administered by the American Midwifery

Certification Board (AMCB) to receive the professional designation of CNM (requires an active

RN license at the time of the certification exam) or CM.

Midwife Hospitalist

According to DeJoy (2015), midwife hospitalist models vary by site, but commonly include physical presence in the hospital, interdisciplinary care planning, provision of care for labor, birth, and postpartum care to women admitted to the maternity care service. Outcomes, care improvement and best practice protocols are integral to this model.

Obstetric Hospitalist

An obstetric hospitalist, sometimes referred to as a laborist, was originally defined by Weinstein

(2003) as an obstetrician whose focus of practice is managing laboring women in the hospital.

More current descriptions of the scope of practice often include inpatient gynecologic service

(Society of OB/GYN Hospitalists, 2020).

Online Education Module

This doctoral project utilized a narrated PowerPoint presentation consisting of 15 slides containing written and pictorial information to inform physicians of the scope of practice and education regarding CNMs/CMs. The following link access the educational module https://youtu.be/Xx0vz89sdqE.

Summary

Evolving strategies to meet the needs of childbearing families, such as the hospitalist model of maternity care, are trialed in the dynamic domain of healthcare in this country. As traditional maternity care models are reinvented, creative measures, such as collaboration amongst disciplines, will continue to evolve. For new initiatives to be successful, stakeholders need education and preparation to adapt and facilitate the collaboration required to build the organizational infrastructure that promotes sustainable, high-quality maternity care successfully.

CHAPTER II

Literature Review

Consideration of available healthcare literature is paramount when uncovering what is already known, and what is undiscovered. When new healthcare trends are under consideration, such as interprofessional role development of obstetric hospitalists, research may be sparse or absent. During the exploration of fundamental underpinnings to guide the scholarly efforts of this project, the net was widely cast, and separate, but related ideas were considered where data were lacking. This chapter discusses the approach to uncovering the data, appraisal of the findings, grading of the studies and a synthesis of the literature.

Introduction to Search Criteria

Relevant words and terms were combined and searched in PubMed, Cumulative Index of

Nursing and Allied Health Literature (CINAHL), Google Scholar, and ancestry search.

Variations included; midwives “or” midwifery “and” collaboration “AND” obstetricians “OR” physicians “AND” interprofessional “OR” interprofessional practice "AND" Nurse Practitioners

(NPs) “OR” advanced practice nurses “OR” physician assistants (PAs) "AND" hospitalist

"AND" web-based "OR" online education "AND" laborists. Inclusion criteria considered environments that shared gross similarities with the U.S. maternity care model. After the initial search, restrictive filters, such as U.S.-based location, were eliminated due to the paucity of research and the prevalence of collaborative models in other countries. Only English articles were gathered for this project. A date range was not utilized due to overall low yields. Research articles retained for the project were primary and secondary sources that related to the elements of the PICOT question. Commentary and integrative reviews were excluded. Consideration of

most relatable content, quality of a study, and demonstration of interprofessional dynamics were strongly considered when selecting articles.

The initial PubMed search yielded 124 articles and was further narrowed by eliminating those unrelated to the PICOT question. Two descriptive studies were retained that offered insight regarding integrating midwives and obstetricians into a shared care model (Good, 1995; Perdok et al., 2016).

The search in CINAHL identified a total of 123 studies that met inclusion criteria. Four studies (Bergman et al., 2016; Curran, Lockyer, Sargeant, & Fleet, 2006; del-Pino et al., 2019;

Warmelink, Wiegers, de Cock, Klomp, & Hutton, 2017) provided an exploration of relevant topics. These included: online clinician education, physicians’ perceptions of mid-level providers, and midwives’ satisfaction with collaboration with a variety of obstetric care providers.

The Google Scholar search produced one meta-analysis examining the effectiveness of internet-based education (Cook et al., 2008) using the term "meta-analysis online continuing education health professionals." Further exploration with, “physicians’ perceptions of advance practice nurses” identified a descriptive study that surveyed physicians’ perceptions of the APRN roles (Burgess et al., 2003).

An ancestry search via Warmelink et al. (2017) yielded one pertinent qualitative work,

(Munro, Kornelson, & Gryzybowski, 2013) which considered barriers and facilitators of interprofessional models of maternity care.

In total, 11 pieces of literature were retained as the final sample for consideration. The supportive literature incorporated a wide range of designs including quasi-experimental, cross- sectional, qualitative, and descriptive. The studies included four relating to online education

(Bergman et al., 2016; Cook et al., 2008; Curran et al., 2006; Wang & Luque, 2016). two that pertained to models of care (Munro et al., 2013; Warmelink et al., 2016), and five that studied perceptions and opinions of physicians about other team members (Burgess et al., 2003; Pino-

Jones et al., 2019; Good, 1995; Murray-Davis et al., 2011; Perdok et al., 2016). This broad review not only created direction for this study but revealed gaps in existing literature.

Critique and Synthesis of the Evidence

Evaluation of each research study and meta-analysis was completed using the Strength of

Recommendation Taxonomy (SORT) scale (Ebell et al., 2004). This taxonomy is used to rate the study based upon its quality, quantity, and consistency and provides a simple algorithm for rating individual research articles into recommendations of 1, 2, or 3; with 1 being the strongest, and 3 being the weakest based upon an objective algorithm that considers both the quality of the evidence and the degree to which it is patient-oriented (Ebell et al., 2004). The body of evidence is also assessed based on the quality of the evidence and is assigned a letter: A, B, or C. Level A is assigned if the quality is good and the evidence is patient oriented. Level B denotes either limited-quality or inconsistent evidence. Level C includes other data such as usual practice, opinions, or case series studies (Ebell et al., 2004). An A-level recommendation, for instance may be a single, large, well-designed randomized controlled study with a diverse population, while a C-level recommendation may only reveal disease-oriented evidence (Ebell et al., 2004).

From the 11 retained research articles, three distinctive concepts emerged from the evidence: online clinician education, models of care, and interprofessional perceptions. One approach to improving interprofessional relationships includes educating each team member about the various roles in the collaborative group. Consideration of the articles both individually and collectively informed this project, though gaps in the knowledge are present.

Online Clinician Education

Bergman et al. (2016) conducted a quasi-experimental study that involved an online education module for clinicians regarding end of life care. The convenience sample of 114 participants from two facilities included a range of participants: medical students, physicians-in training, and attending physicians. Their focus was on engaging the learners with embedded hyperlinks within a web-based education module. The study also explored whether personal experience with end-of-life care impacted participant learning. A pre-intervention test, a self- study module, and post-intervention test were utilized, though no appendices with these tools were provided. Utilizing a forward selection model and regression analysis, the researchers found that most learners (79%) did not use the hyperlinks. Findings suggested that accessing additional embedded information significantly improved attitude and knowledge (4.21 both links v. 2.30, no links, p<0.01). The researchers also indicated that participants with personal experience with end-of-life care were more likely to access additional information (26% vs. 4%,

N=114). The small number of trainees (n=16) who utilized the embedded information limits the usefulness of this strategy in the future development of online education but encourages ongoing exploration of auxiliary resources to engage the learner. The overall SORT score for this study was 2 (Ebell et al., 2004).

A meta-analysis by Cook et al. (2008) examined data from 201 studies on learning models between 1990 and 2007. A search of nine databases was performed, and a comparison between web-based education, traditional education, and no education was made. The authors hypothesized that cognitive interactivity, peer discussion, ongoing access to instructional materials, and practice exercises would improve learning outcomes. Inclusion criteria focused on relevance, single group, 2-group, parallel, and crossover designs. Studies that did not compare

the experimental group with a non-intervention group were excluded. Studies were individually assessed for quality and comparability and were graded based upon a point system. Standardized data-extraction forms were utilized and analyzed by two reviewers and variances between studies were evaluated separately. Outcome measures included satisfaction, knowledge, skills, and behaviors and were subsequently converted to standardized mean differences. Overall findings suggested that internet-based learning, compared to no intervention, demonstrated a positive effect on knowledge (pooled effect of 1.0) and consistently indicated that internet courses were useful across a wide variety of learners, topics, and learning outcomes. Other results, such as skills outcomes and effects on patient care, were limited due to small subgroups. Their findings revealed that internet-based learning was just as effective as traditional face-to-face learning and is also associated with large positive effects. This study was graded with a SORT score of level 1

(Ebell et al., 2004) because it was a high-quality meta-analysis.

Curran, Lockyer, Sargeant, and Fleet (2006) also considered the value of online continuing medical education in their quasi-experimental study. A convenience sample of 146 learners provided evaluations of 14 different online continuing medical education (CME) courses offered in a Canadian, not-for-profit consortium. Pre- and post-surveys were used to measure changes in knowledge, confidence, and practice change and explored physician satisfaction with online CME activities over two years. The overall pre to post knowledge scores revealed overall effect size of 2.2 and confidence scores with an overall effect size of 2.7. Scores were analyzed using paired sample t-test, and the effect size was calculated for each course. Practice change was reported in 11 of the 14 courses evaluated. A high level of satisfaction (93.5%) was expressed by the participants in terms of gaining new knowledge, ease of use, and applicability to their practice. Effect sizes were not calculated for courses with few attendants (n<5). A level 2

SORT grade was assigned to this study because it was a quasi-experimental study. Other limitations included the voluntary nature of the sampling, a small number of participants, and possible self-reporting bias.

Wang and Luque (2016) considered a variety of clinicians' satisfaction with a web-based statewide education program. They collected feedback over three months from a variety of healthcare clinicians, including physicians, nurse practitioners, nurses, counselors, pharmacists, and case managers. This descriptive survey polled clinicians who had completed an online course and measured items of interest such as usefulness or relevance, format, and knowledge increase. Variables were applied to the evaluation feedback from the learners. For knowledge measurement, participants identified themselves as a novice, not deeply knowledgeable, knowledgeable, very knowledgeable, or expert. Chi-square test was used to examine the statistical significance of the differences measured before and after the training. A total of 1, 558 online evaluations were completed and revealed positive feedback (usefulness and relevance,

92%, easy comprehension 91%, knowledgeable trainer 92%, and appropriate format 86%).

Differences were discovered among clinician groups, with physicians and nurse practitioners providing the most positive evaluations compared to the other disciplines, suggesting that these clinicians were most satisfied with online learning. A Level 2 SORT (Ebell et al., 2004) score was assigned to this research because of the narrow subgroups and variations between the groups that were under-evaluated (Table 1).

Table 1

Studies Considering Online Education

Author/Title Type of Findings/Aims Implications for SORT Study/description Project Score Bergman et al. Quasi Evaluated Slight improvement Level 2 (2016) experimental, embedded links for in scores if online education improved learning embedded links for EOL care and if personal were used; may experience with consider for my on- EOL care engaged line education learners module Cook et al. Meta-analysis In favor of online Reinforces the Level 1 (2008) considered studies education; usefulness of that looked at comparable to online education online, traditional traditional and far education and better than none compared to each other and no education Curran et al. Quasi- Used pre and post- Reinforces that Level 2 (2006) experimental surveys, showed online education looked at that doing online satisfaction with education online education improved modules, varied knowledge and courses, confidence as well physicians/CMEs as sig practice online change. Physicians appreciated this format for CMEs Wang & Luque Survey over 3 Overwhelmingly Categories of Level 2 (2016) months, positive reviews of usefulness, considered online learning comprehension satisfaction with and format were online learning for identified; may a statewide consider education program incorporating these features

Models of Care

Using the snowball technique, Munro et al. (2013) conducted a qualitative study to investigate the barriers and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in four rural communities in British Columbia, Canada. Fifty- five participants, over a third of whom were physicians, were interviewed and 18 focus groups were conducted in four rural communities. Interviews and focus groups lasted between 60-90 minutes and were conducted until no new themes emerged. While each of the four communities identified different barriers, common challenges emerged, including lack of interprofessional support and perceived inequities of remuneration. Useful information regarding attributes of collaboration was also revealed, but some participants had difficulty defining the specific needs.

Implications for practice suggest that there is a wide variety of challenges when creating supportive, respectful interprofessional relationships. A Level 2 SORT (Ebell et al., 2004) was assigned because of the qualitative study design.

A descriptive, cross-sectional study was completed by Warmelink et al. (2016) to learn about midwife job satisfaction under the influence of collaborative care between midwives and other maternity care providers including obstetricians and family practice physicians in the

Netherlands in early 2010. A survey was distributed to 20 primary care midwifery practices in the country, which yielded 99 completed questionnaires. Practice type, level of urbanization, and region were used to stratify the sample. Findings revealed that midwife interactions with their non-physician colleagues (i.e., NPs), were more favorable than those interactions with physicians. Midwives had the least positive interactions with obstetricians. In nearly 50% of encounters, midwives indicated experiencing a power imbalance and a lack of trust by their OB counterparts. Overall, the research highlighted significant room for improvement within the

collaborative care model and suggested strategies originate from the involved professional bodies. A Friedman ANOVA test assessed differences in satisfaction with interdisciplinary collaboration. Bivariate analyses were performed, assessing the attitudes towards both midwives’work and their interprofessional collaboration and revealed differences between rural and urban environments as well as interactions between general practice doctors, obstetricians and pediatricians. This study earned a Level 2 SORT (Ebell et al., 2004) score due to the descriptive, cross-sectional design (x).

Table 2

Models of care

Author Study Findings Implications Sort Description Score Munro et al. Qualitative, Small study (55 Has limited Level (2013) snowball surveyed) identified application because 2 technique lack of this project is more considered interprofessional considering the interprofessional support and physician models of perceived inequities perspective but can maternity care in pay as barriers consider these in rural British identified obstacles Columbia Warmelink Descriptive Midwives found it Limited implications Level et al (2016) cross-sectional easier to for this but can 2 study, done in collaborate with provide insight for the professionals other possible areas for Netherlands, than Obstetricians, interprofessional survey room for development and distributed to improvement as improvement in midwives well as perceived terms of regarding power imbalance communication interdisciplinary relations, returned 99 surveys

Interprofessional Perceptions

Physicians’ perceptions were the focus of a 2001 descriptive study conducted in South

Carolina by Burgess et al. (2003). Physicians from specific regions of the state were polled (via mailed survey) to explore both the differences between urban and rural practitioners and the differences in their level of comfort with other types of providers. A total of 681 surveys comprised the completed sample, producing a 15% response rate. A five-point Likert-type scale was developed and piloted tested by the authors prior to this study. A variety of physicians participated with backgrounds in family practice, general medicine, internal medicine, pediatrics, and women's health. Less than half of the respondents had worked with NPs, a fifth had worked with PAs, and only 8% had worked with midwives. Using independent-sample t-tests for analysis of physicians’ perceptions 86% of the physicians surveyed reported that non-physician providers should not care for patients with unstable health conditions. Forty percent thought that this group should care for patients with stable health conditions. Only 16% of the physicians surveyed felt that patients would be attracted to their clinic if NPs, PAs, and nurse-midwives were providing care and the physicians also felt that there were both legislative and payment barriers to incorporating these clinicians into their clinics. The low response rate negatively impacted the validity of the research but did shed light on some probable areas of concern within the collaborative model. A SORT Level 2 was assigned to this study (Ebell et al., 2004).

A descriptive, mixed methods study in a California academic center in 2013 investigated hospitalist physicians’ perceptions of NPs and PAs on their teams and considered factors that impact these perceptions (Pino-Jones et al., 2019). A convenience sample of 25 academic hospitalists who had previously worked with PAs and NPs was surveyed, representing an overall response rate of 28%. The researcher created an online survey which was reviewed by several

experts to enhance the content validity of the tool. Ninety-six percent of the respondents agreed that having NPs and PAs improved patient care, reduced their workload, and improved their job satisfaction. Those surveyed expressed a preference for working with NPs and PAs who had either additional training or who were experienced. Free text responses revealed positive interpersonal interactions and the benefits of a shared workload. A small sample size limits the strength of the findings, and a Level 2 SORT score was assigned (Ebell et al., 2004). These widely varied perceptions suggest geography and access to collaborative care models are contributory.

Good (1995) surveyed Kansas physicians to examine the level of awareness and interest in collaboration with nurse-midwives. This descriptive study used an 11-item questionnaire that was mailed to every 10th obstetrician and family practitioner on the Kansas Medical Society list of physicians. Forty completed surveys were returned (30 family practice physicians, eight obstetricians, and two unidentified specialties). Answers were noted as "yes," "no," or

"undecided". Results were noted as simple percentages. Findings showed that 100% of obstetricians (n = 8) felt nurse-midwives were qualified to attend low-risk births in the hospital, while only 63% of family practice physicians endorsed this statement (n = 19). While randomization strengthened the findings, sample size was small which limits generalizability.

Further, the total, accessible obstetrician population was not reported. The author suggested a readiness for midwives to be integrated into healthcare reform and offers encouragement to midwives practicing in Kansas at the time. A SORT level of 2 was assigned (Ebell et al., 2004).

Murray-Davis, Marshall, and Gordon (2011) conducted a qualitative study using semi- structured interviews to explore the views of midwives and educators regarding interprofessional working and learning within midwifery. The sample was derived from four university sites

within the United Kingdom and consisted of both midwives and educators (N = 39). Using a constant comparative analysis, transcripts were coded and then clustered to form categories then further grouped to form broader themes. Analysis of midwife perspectives on collaboration was presented. Three interprofessional themes emerged: relationships, skills, and education. The respondents felt that these areas of interprofessional education were important but remained skeptical that this style of education would produce practice change. Greater optimism for improved interprofessional collaboration through education was expressed by midwife educators than by clinical midwives. Issues surrounding power structure, hierarchy, and philosophical approaches to care emerged as barriers to collaboration. All participants shared experiences of both effective and ineffective interprofessional behaviors, from devaluation of the midwife due to level of training to encouraging midwives to create networks with physician team members. A

SORT Level 3 was assigned. Limitations of the study included that data saturation was not described and using a small homogenous sample limited a broader application of the findings

(Ebell et al., 2004). This research suggests that there is a myriad of challenges to overcome when fostering collaborative relationships and creation of respectful, supportive relationships is paramount.

In 2016, a mixed-methods study was conducted to gain insight into the challenges and facilitators of integrating midwives and obstetricians within the maternity care model in the

Netherlands (Perdok et al., 2016). A convenience sample of participants was identified by the

Netherlands Institute for Health Services Research and reached via email. The final sample (N =

424) was comprised of ‘primary care’ or full-scope practice midwives (n = 131), ‘clinical’ or midwives with additional training for moderate risk patient management (n=51), and obstetricians (n =242). This descriptive study utilized a 48-question survey with a free text

section to promote additional sharing of participants' opinions. The questionnaire was developed and revised by a multidisciplinary group. Clinicians were asked whether they thought various styles of care provision, organizational characteristics, and continuity of care were facilitators or barriers to the process of collaborative management. Outcomes measured facilitators and barriers to the integration of midwifery and obstetric services. Analysis of the responses calculated the proportion of professionals who indicated a determinant as influential, and to what degree. Results revealed that while over 80% of obstetricians and midwives agreed that all professionals should work within one organization of care delivery, the specific characteristics of a system did not reach consensus and there was an apparent reluctance to change. The option of

‘neutral' was selected in approximately 13% of the questions, which may indicate a lack of opinion and indicates the need for further exploration. Specific areas of neutrality were not identified but could be reduced by using forced answer selections. This large-scale study reached a high number of professionals and fostered returns of 44%. The work emphasized the need for additional preparation of midwives and physicians for successful integration of multidisciplinary care. Analyses were completed for the different groups of respondents, including primary care midwives, clinical midwives, and obstetricians. Obstetricians largely felt that individual provider responsibility, an integrated care system, shared electronic records, and structured communication with care team members all facilitated interprofessional care.

Conversely, obstetricians identified patient risk management, midwives and obstetricians working autonomously, and the interference of financial motives in care provision as barriers to interprofessional care. A multidisciplinary project group did consult on the survey, adding additional value to the conclusions. However, generalizability may be limited given the specific healthcare model and context of a national healthcare delivery system. Also, the sampling was

one of convenience which could lead to sampling error and a non-representative sample. A

SORT Level of 2 was assigned to this study (Ebell et al., 2004) (Table 3).

Table 3

Interprofessional Perceptions

Author Study Description Finding Implications Sort score Burgess et al. (2003) Descriptive study Only ½ had worked with This is a 16-yr old study Level 2 mailed a survey to APRNs, only 40% felt does illuminate the fact physicians, APRNs should be caring for that many doctors did not conducted in South patients with stable want APRNs in their Carolina conditions and only 16% felt clinics/working with them that patients would be and did not feel as though inclined to attend with they should be caring for APRNs working with them patients Pino-Jones et al. Convenience sample Overwhelmingly feel that Consider in the education Level 2 (2019) of 25 hospitalists APRNs help improve pt module how midwives may physicians outcomes but prefer those actually help reduce their Descriptive, mixed with either advanced workload, improve their job methodology training and/or more satisfaction and improve Considered attitudes experience patient outcomes about working with APRNs Good (1995) Survey of Kansas 40 completed surveys found Should consider the past Level 2 physicians with an that most OBs felt CNMs exposure the physician 11-item could attend low-risk has had to midwives when questionnaire deliveries but fewer FP conducting the survey physicians felt this way Murray-Davis et al. Qualitative study in Three themes emerged: Limited application Level 2 (2011) the UK to explore relationships, skills and because this project is views of midwives education; important for considering the physician and interprofessional CNMs KA&Ps, but helpful from working and learning an interdisciplinary point environments Perdok et al. (2016) Convenience Considered a variety of Considered professional Level 2 sample, Mixed items and described it as vision, organizational methodology either a barrier or a characteristics and regarding integration facilitator education of midwives into the Completed by 424 providers May incorporate these Netherlands ob ideas into the study system

Synthesis of Evidence

Although Bergman et al. (2016) and Cook’s (2004) works reinforce the idea that web- based education is not only feasible but also practical, neither study delved deeply into the format nor the outcomes of learning. Their findings support the delivery of an online education module but lack relevance to the topic for this project. The meta-analysis performed by Cook et

al. (2004) provides greater depth and explores the usefulness and applicability of web-based learning and emphasizes the positive reception, retention, and willingness of providers to participate in this convenient format. Curran (2006) strongly supports this platform for education and helps to guide the method of assessment for this DNP project. Wang and Luque (2016) also inform this doctoral project as it reinforced physician satisfaction with web-based education.

Relative to models of care, reports by Warmelink et al. (2016) and Munro et al. (2013), highlight opportunities for improvements in collaborative care, even in environments that boast long histories of successful interprofessional relations. Inquiry about respect and support will be incorporated into the assessment of perception in this project.

While opinions and perceptions may be a key determinant of successful or unsuccessful collaborative models, there is a paucity of research done in this area. Burgess et al. (2003) and

Good (1995) both identify a reluctance of physicians to support other clinician’s independence surrounding care management and diagnosis of patients. Pino-Jones et al. (2019) suggest improvement in perceptions more recently and indicate a readiness in many physicians to work collaboratively. Perdok et al. (2016) also illuminate the need for reform to improve relations, satisfaction, and patient care surrounding collaborative care management: opportunities abound in all three areas of consideration for this doctoral project.

Based upon the examination of literature on this topic, an overall B recommendation is assigned for the body of evidence related to the impact of web-based physician education related to knowledge, perceptions, attitudes of the midwife role. Lack of consistency, randomization, and at least two good-quality meta-analyses limits the overall strengths (Ebell et al., 2004).

Project Rationale

Few studies have examined a collaborative obstetric hospitalist care model that includes obstetricians and midwives. This lack of research may be not only because the concept of hospitalists is so recent, but also because midwives are scarce and underutilized in the inpatient hospitalist setting. Improvement of interprofessional understanding and team building can improve outcomes, reduce cost, and enhance patient care experiences (Berwick, Nolan, &

Whittington, 2008). This gap creates an exciting opportunity to investigate a fledgling field that shows tremendous promise, not only for the midwifery profession, but for other clinicians, and for the women and families served.

Garvey (2011) suggests that when both midwives and obstetricians engage collaboratively within their full scope, three areas show improvement: patient outcomes, efficient care, and improved provider satisfaction. Smith (2014) suggests that matching the needs of the patient with that of the provider is both fundamental and straightforward. Despite the evidence suggesting team-based models offer gains in all aspects of care delivery, (Branch-Mays & Mays,

2013; Reeves et al., 2017; Renfrew et al., 2015) the inpatient collaborative obstetric hospitalists continue to struggle to actualize the full potential of this model. Online education has been shown to be an effective platform for professional education and with recent global implications of the COVID-19 pandemic, innovative web-based strategies are likely to increase (George et al.,

2019; Dedeilia et al., 2020).

CHAPTER III

Methodology

This chapter describes the methods used to deliver education to the physicians at the project site and explains the means used to collect, synthesize, and interpret the impact of the intervention. Project type and design, purpose and aims, protection of subjects, data analysis and management of data are described. Further step-by-step mapping of the project plan ensured progression and completeness. Using a presurvey, educational module, and a post-survey, the

Principal Investigator (PI) assessed the impact of the intervention in influencing knowledge and attitudes of obstetric hospitalist physicians about the midwife scope of practice.

Project Type and Design

This translational research project used a quasi-experimental, single group, pre-test/post- test design. According to Moran, et al (2017), a DNP project represents research if it systematically investigates, tests, and evaluates a phenomenon. In this approach, data collection often incorporates surveys, and the analysis is focused on a specific hypothesis. In this project, an online educational intervention was developed to provide information that was intended to expand knowledge and influence hospitalists’ attitudes toward midwives.

Purpose and Aims

The purpose of this project was to determine if an online educational intervention changed obstetric hospitalists’ knowledge and attitudes about midwives. Administration of a pre- survey, educational intervention, and post-survey was intended to reveal changes in interprofessional role understanding.

By developing and evaluating an online education intervention describing midwives’ scope of care and training, greater understanding of the midwifery role may consequently improve collaborative teamwork within this inpatient setting. Utilization of a conceptual framework that specifically considered the dynamics between obstetricians and midwives, may enhance this collaborative model in the inpatient setting (Smith, 2014). The clinical question was: In obstetric hospitalist physicians, does the completion of an online education module change their knowledge and attitudes toward the midwife role? The primary aim was to impact knowledge and attitudes with a longer-range goal of improving collaboration between hospitalist physicians and midwives. The secondary aim was to compare various demographic characteristics of participants to increase understanding of features that impact collaborative practice.

Setting, Sampling, and Population

The setting was a large hospitalist company with multiple locations across the United

States. Convenience sampling was used, and targeted physicians employed by this company at the time of the survey. The sample included physicians who consented and voluntarily completed an online demographic form, a pre-survey, an education module, and a post-survey. The accessible population was approximately 1230 physicians, companywide. Physicians included in this study were health professionals who have earned a degree of Doctor or Medicine (MDs) or

Doctor of Osteopathic Medicine (DOs) who were employed full-time, part-time, or per diem, and working as OB hospitalists. Physicians who did not wish to participate were excluded. With limitations on time, and with consideration of how physicians engage in learning, web-based education in a convenient, modular format tends to be a platform that physicians find acceptable for learning (Cook et al., 2008; Wang & Luque, 2016).The minimum sample size was

determined using a power analysis in G*Power 3.1.9.7. (Faul et al, 2007). A minimum sample size of 71 was required to obtain a power of .80, for a paired samples t-test with an alpha of .05, and small to medium effect size (d=0.3).

Plan and Implementation

Planning and implementation of the study involved ongoing multi-directional communication with the scholarly team, and with the site stakeholders to clarify the process and mitigate obstacles. A validated survey tool was modified as needed and underwent final approved by the instrument developers. Recruitment began in June of 2020 and lasted for three weeks. The online survey deployment was initiated by a company-wide email invitation (APPENDIX B).

Recruitment was voluntary and incentivized by the raffling of an $100 Amazon© gift card for participants. Pit, Vo, and Pykurel (2014) indicate that using a monetary incentive is more effective than either no incentive or a nonmonetary incentive. The survey was administered through Qualtrics© and remained accessible for three weeks. Two email reminders were sent to physicians at day 7 and day 14 after the initial recruitment email. The module included a demographic survey, an embedded consent, a pre-survey, narrated educational slides, and post- survey. Pre- and post-surveys were linked to each participant and completed in one session.

Human Subject Review

Research involving human subjects for this project warranted careful consideration and was guided by ethical considerations, Georgetown University’s Institutional Review Board

(IRB), and the DNP committee. The company’s research department did not require a separate

IRB process and issued a letter of approval for the project. The project mentor and the PI had current training regarding human research subject through the Collaborative Institutional

Training Program (2019). This study met criteria for expedited review as there was minimal risk

to the participants completing the survey (Moran et al., 2017). Once IRB approval was secured, the study moved into the implementation stage.

An embedded consent was incorporated in the beginning of the demographic survey and participants demonstrated consent by proceeding to complete the remaining sections. During the study, participants had the opportunity to complete the surveys and the education module but were able to stop the process at any time without negative consequences. Participants interested in the gift card raffle, voluntarily provided their email address to the company’s research department, which was not shared with the PI. All data remained confidential and demographics were collected by regions to help protect participant anonymity

Data Management

The project proposal and approval were accomplished during the third quarter of 2019 with IRB submission and subsequent approval in early 2020. Data collection was completed by the end of the second quarter of 2020 and data analysis was performed during the summer of

2020.

The survey was administered using Qualtrics™, a Georgetown University-approved survey platform, utilizing enterprise-grade security features that include data encryption, redundancy, and continuous network monitoring (Qualtrics, 2019). Security of the collected data was supported using Georgetown University Box which protected access and infiltration through numerous security layers. Access to the information in Box was limited to the PI and the statistician engaged in the project.

Educational Intervention

The online educational intervention was comprised of a PowerPoint presentation that was manually initiated and then automatically advanced. This compilation of information for the

educational module was developed through a project supported by the American College of

Nurse-Midwives and the American College of Obstetricians and Gynecologists to improve collaborative practice, encourage patient-centered care, and promote team-based care (ACNM-

ACOG, 2019). These two well-established and highly respected national organizations identified strategies to improve maternity care in the U.S. A narrated slide presentation provided information regarding collaborative team approach, midwifery training and scope of practice information. A reference list was included in the educational slides for interested participants.

Completion of the module took approximately 20 minutes and incorporated forced viewing, in that the participants could not advance to the post-test without viewing the module.

Measurement Tools and Questionnaires

Three measurement tools used in the project included a demographic questionnaire and a pre- and post- survey, using a previously validated tool used to measure physicians’ attitudes and knowledge about nurse practitioners (Forbes, Cardin, & Whelan, 2008). The demographic survey consisted of eight items that provided data that were analyzed with the survey results and was preceded by a consent document. Items such as gender, location of practice, years in obstetrics, and familiarity with working with midwives were included. The demographic survey was comprised of eight items and was completed by participants as part of the pre-survey. See

APPENDIX C for demographic questionnaire.

Pre- and Post-Survey Tool

Validity of this tool was established by expert reviewers and was also reflected by significant differences (p < .05) in nearly all of the relevant items between NPs and physicians

(Forbes, Cardin, & Whelan, 2008). The survey tool, developed in the U.S., is composed of 20 five-point questions, and used a Likert-type scale that evaluate various components of physician

knowledge and attitudes regarding midwives. The final segment of the survey was comprised of seven short-answer, true/false and open-ended questions intended to gather additional information regarding knowledge and attitudes of obstetric hospitalists. The final component of the survey was comprised of seven short-answer, true/false, and open-ended questions.

Data Collection Procedures

The demographic survey, pre-survey, online education module, and post-survey were distributed via company e-mail. Participants moved through the demographic survey, pre- survey, education module, and post-survey during one single session. The collected survey data were anonymous and stored within the account of the PI and was protected by both high-end firewall systems, routine scanning, and encryption for transmission (Qualtrics, 2019). If the participants chose to be entered into the raffle for the gift card, they provided a contact email at the conclusion of the survey.

Data Analysis Plan

The nominal data collected from the demographic survey was reported using percentages and frequencies. The pre- and post-surveys were reviewed for normal distributions and parametric tests could be applied, including paired t-tests with a Likert-type scale (Sylvia, &

Tehaar, 2018). The bulk of the survey data were collected at the ordinal level. Statistics used in this study included measures of frequency and percentage distributions, central tendency and dispersion, and skewness and kurtosis. Data analyses were conducted using IBM® SPSS

(Version 25). Statistical significance was determined setting alpha for the project at 0.05.

Dissemination of findings included the obstetric hospitalists and midwives who are currently employed at this nation-wide hospitalist company. With the anticipated growth of this maternity care model, a podium presentation at the ACNM annual convention has been pursued.

Demonstration of improved interprofessional understanding will encourage innovation in maternity care delivery. A manuscript of this project will be developed for submission to the

Journal of Midwifery and Women’s Health for publication of the findings.

Conclusion

Assigning the appropriate design, using an appropriate tool, and collating data in a comprehensive, complete manner required careful consideration to protect academic rigor in the

DNP project. Using a quasi-experimental design aligned effectively with the intention of this scholarly project.

CHAPTER IV

Results

This chapter describes the results of data analysis of the demographic survey and the pre and post-survey to evaluate physician learning after completion of an online education module. Descriptive statistics showed a demographic profile and professional characteristics of the participants. Presentation of the findings identified demographic associations related to participation and completion, as well as familiarity with the midwife role, education, and scope of practice. The influence of physician online education on knowledge and attitudes about midwives was evaluated.

Participants

Physicians employed within one national obstetric hospitalist company were recruited by email invitation, sent from within the organization’s research department. Two reminder emails were sent at one-week intervals to increase response rate (Edwards et al., 2009). A total of 1260 physicians employed within the organization received the email invitations regarding this project. The minimum sample size was determined using a power analysis in G*Power 3.1.9.7.

A minimum sample size of 71 was required to obtain a power of .80, for a paired samples t test with an alpha of.05, and small to medium effect size (d=.3) (Faul et al., 2007). Of 107 people who opened the survey, 65 (60.7%) completed it. Of the 42 people who did not complete the survey, 39 answered the demographics and pre-training questions; three did not answer any questions (see Figure 2).

Figure 2 Flow Diagram of Survey Respondents

Characteristics of the Provider Sample

Nearly two-thirds of the participating physicians were female and most (greater than

89%) had at least 11 or more years of clinical experience (see Table 4). Nearly half of the survey respondents indicated they worked with midwives in their clinical sites and nearly 85% of physicians indicated they had experience collaborating with midwives. Those in the Midwest were significantly less likely to complete the survey than those in any other region, X² (3) = 9.51, p = .023.

Table 4

Participant Characteristics (N=65)

n % Region Northeast 11 16.9 Midwest 3 4.6 South 31 47.7 West 20 30.8 Gender Male 24 36.9 Female 40 61.5 Years in Obstetrics 0-5 3 4.6 6-10 4 6.2 11-20 24 36.9 Over 20 34 52.3 Currently work with midwives in 34 52.3 clinical site Years working with midwives Never 5 7.7 5 or fewer 20 30.8 6-10 15 23.1 11-20 15 23.1 Over 20 10 15.4 Years working with other types of midwives Never 25 38.5 5 or fewer 14 21.5 6-10 10 15.4 11-20 10 15.4 Over 20 6 9.2 Had interprofessional education 31 47.7 experiences with midwives

Figure 3 Work Relationship with Midwives (n=34)

Analysis

Survey Results

Respondents were asked to rate their level of agreement with a series of 20 questions about midwives on a scale of 1 to 5, with 1 = Strongly agree, 2 = Agree, 3 = Neither agree nor disagree, 4 = Disagree, and 5 = Strongly Disagree. Ten questions were reverse coded (see R notation in. (APPENDIX D) so that a lower score indicated a more positive attitude toward midwives on all questions. After reverse coding, Cronbach’s alpha was computed for the full 20- item post-survey. Results exceeded the benchmark of .7 to confirm good internal reliability (α =

.88); that is, the questions appear to be measuring one underlying construct (Tavakol & Dennick,

2011). Scores for all items were averaged to create a composite score indicating level of positive attitude toward midwives, with lower scores indicating more positive attitudes (Forbes, Cardin,

& Whelan, 2008). APPENDIX E shows the distribution of scores pre-intervention while

APPENDIX F shows the distribution post-educational intervention. The mean scores pre- intervention on the 20 item attitudes toward midwives’ questions, rated on a 1-5 agreement scale, were compared using paired samples t tests.

Pre- and Post-Educational Intervention Comparisons

Significant differences were seen for all attitude-related items as well as for the overall score and a positive shift in attitude was noted post-intervention. In terms of secondary aims, however, total attitude scores did not differ by region, gender, or years in obstetrics. There was a small but significant difference in total attitude scores pre-intervention between those who currently worked with midwives (M = 2.49 SD = .51) and those who did not (M = 2.72 SD =

0.46), t(63) = 1.95, p = .056. The difference disappeared post-intervention with mean of 2.31 (SD

= .50) for those who currently work with midwives and 2.47 (SD = .51) for those who did not, t(63) = 1.21, p = .233. Respondents were asked the minimum degree required for a midwife to enter practice (see Table 5). There was a significant difference in responses pre-educational intervention, X2(9) = 36.01, p < .001, using the chi square likelihood ratio because the number of small cell counts did not meet assumptions for Pearson’s chi square. The biggest difference appeared to be a reduction in the percent of physicians who were unsure before the education module and changed to bachelors or master’s post-educational intervention.

Table 5

Comparison of Minimum Degree Required, Pre-Educational Intervention

Pre Post n (%) n (%) Bachelors 12 (18.5) 10 (15.4) Masters 35 (53.8) 50 (76.9) Doctorate 1 (1.5) 1 (1.5) Unsure 17 (26.2) 4 (6.2)

Further addressing the primary aim, six true/false questions about midwife training and skills were asked both pre and post the education intervention (see Table 6).

There were statistically significant increases in the percentage of “true” responses from pre- to post-educational intervention for all items except one. The item related to knowing that midwives can prescribe medications like other advanced practice registered nurses had no appreciable improvement since nearly all respondents answered correctly (as true) in the pre- educational intervention survey.

Table 6

Comparison of Training and Skills, Pre-Educational Intervention, Percentage of “True” (N=65)

When participants were asked if they would be comfortable working with midwives in their current workplace, 63 (96.9%) indicated yes both pre- and post-educational intervention.

Physicians were also able to comment on whether they would support a midwife attending them or their family member, to which three respondents noted they would not. Nine participants clarified their response with caveats such as “it depends” or “CNM only”. Most participants did not offer additional comments in either the pre- or post-survey.

CHAPTER V

Discussion

Interprofessional collaboration between midwives and obstetricians is essential in a successful hospitalist maternity care model that employs both midwives and obstetricians.

Efforts to cultivate team-based care can improve outcomes and patient experiences (Reeves et al., 2013). The purpose of this project was to provide education about the role of the midwife to physician members of the maternity care team and to assess its impact on knowledge and attitude. Overall, the results indicated that an online module can be an effective tool to enhance physician knowledge about midwives. There were no significant differences between those who finished the education module and those who did not by gender, working with midwives in their hospitalist site, years in obstetrics, or having interprofessional educational experiences with midwives. Nor was there any difference in their level of agreement with statements about midwives in the pre-survey. So other than region, there were no differences between those who completed the survey and those who dropped out.

Attitude changes were significant in selected areas such as quality of care and scope of practice. Physicians experienced an improved understanding certain aspect of the midwifery role, as well as greater awareness of midwife skills following module completion. Most physicians felt that midwives could manage low-risk pregnancies independently and high-risk pregnancies in collaboration prior to the education module. Just over half of the physician participants indicated that they were currently working with midwives as colleagues. Few physicians had never worked with midwives during their career and the vast majority indicated that they felt comfortable working with midwives in their workplaces both pre- and post-training. In

collaborative practice, education may enhance knowledge and improve interprofessional relationships; shared visions and understanding of training and background have been shown to enhance collaborative relationships (Perdok et al., 2016).

Strengths

Utilization of an online education module in the setting of a national hospitalist program providing labor and birth care is convenient and focused. This population is accustomed to accessing information and education through online mechanisms for ongoing learning, credentialing, and employee engagement. The PI, who is a company employee, could communicate easily and openly with the stakeholders and garner preparatory feedback to further customize the learning module. Administrative support and the utilization of an internal email invitation promoted trust and interprofessional support. The survey was formatted in a way that was accessible via computer, tablet, or mobile device, using both a traditional hyperlink and a scannable QR code.

Convenience may have also played a favorable role in engaging physicians in the survey.

Given the national attention to improving maternity care, this project was of interest to obstetric hospitalists as programs continue to integrate midwives into their teams. Online education appeals to medical professionals and has been shown to be as effective as traditional learning modes (Cook et al. ,2006; Curran et al., 2006; and Wang and Luque, 2016). The PI gathered opinions from both physicians and project team members and constructed the surveys and module to take 20 minutes or less to complete. Evidence is scarce, but one RCT by

McCambridge et al. (2011) suggests that length of a survey may not significantly impact participation rates. A chance to win a gift card incentivized some participants, which is consistent with other studies (Turnbull et al., 2015). Larger potential compensations or multiple

chances to win a gift card may have improved recruitment (Turnbull et al., 2015). Both the use of incentives and convenient study design are shown to improve response rate in healthcare professional online surveys (Cho et al., 2013).

Nearly 90% of participants had more than 11 years of obstetric experience and over half of the sample had greater than 20 years. Often, obstetric hospitalists have had years in private practice and seek alternative employment solutions, such as hospitalist shift work, to improve work-life balance and reduce burnout (Allen & Caughey, 2017; Nelson, 2011). While extensive clinical experience may be favorable for the hospitalist model of staffing, it does not address the possible lack of interprofessional role awareness in the greater obstetric community as more midwives are also being employed in this model (DeJoy et al., 2015). Study results suggest it is likely that obstetricians will interface with midwives over their careers. Ensuring accurate knowledge about the midwifery education and scope of practice needs recognition and attention for smooth interprofessional team functioning.

Limitations

While the target sample size reached 92% of the goal (participants=65, goal = 71), sample size was a limitation. With approximately 5% of the eligible physicians participating, an increased number of participants may have provided additional information or altered the outcomes. Nonresponse bias, or the possibility that the participants are not representative of the population, makes it difficult to generalize findings (Phillips et al., 2016). The survey and education module were launched amidst a surge of email and online educational traffic related to the SARS-COVID 19 pandemic and may have reduced the number of participants, in spite of the support of online education noted in the literature review. Surveys have traditionally yielded low response rates but offering varied options for completion, as well a more reminders to

participants has been shown to improve participation (Brtnikova, et al., 2018). Email and information overload may also pose a barrier to both physician education and research (Sbaffi et al., 2020).

Knowledge dissemination and acquisition are also facilitated via a web-based platform, particularly in organizations such as the one involved in this project who are familiar with this educational format, but low return rates should be explored. Research indicates that web-based education has been both acceptable to the users and is comparable to face-to-face learning

(Bergman et al, 2016; Wang & Luque, 2019); however, participation in education alone does not ensure changes in physician’s approach to care (Pollard, Bansback, & Bryan, 2015). RCTs should be conducted to assess outcomes such as retention of knowledge and behavior (Liossi et al., 2018).

Ongoing feedback and improvements with online learning is important as the world incorporates social distancing amidst the COVID-19 pandemic. Also, follow-up assessment of knowledge or attitude changes was not performed outside of the study survey. Although anonymity and confidentiality were addressed, participants may have been less forthright if they felt their responses could be discovered. It is unclear why completion rates for those participants located in the Midwest were lower; possibilities might include unfamiliarity with midwives, or a surge in information or case numbers related to the pandemic.

While the number of female participants was nearly double that of their male colleagues, it was not greater than the company ratio of just over two thirds female to male (68% female to32% male, Personal communication, N. Keely, Human Resource Analyst, October, 2020;

Smith, 2008). Participants who had midwives working in their hospitalist programs were also

more inclined to participate in the survey, potentially impacting the generalizability of the findings.

Implications for Practice

Collaborative hospitalist models of care that combine midwives and obstetricians demonstrate improved outcomes in key variables such as reduced cesarean rates (Angelini et al.,

2019; DeJoy, et al., 2015; Nijagal et al., 2015). Midwives are emerging as effective hospitalist team members and provide yet another avenue to apply the midwifery model of care. Midwives may also consider this new role as another employment option that could mitigate the stress of traditional work environments with long periods of on call responsibilities (DeJoy et al., 2015).

Opportunities for increasing awareness of the midwifery role may be accomplished through a variety of mechanisms including interprofessional education (Avery, Jennings, et al., 2020) and ongoing medical education.

Until fundamental changes are fully incorporated into resident training or practicing physician education, alternative options, and opportunities to improve knowledge and attitudes about midwives should be considered. As midwives continue to expand their participation within the healthcare delivery system, dissemination of information regarding their training and scope of practice will be essential. Distribution of a voluntary, free, online educational offering as used in this project may be one effective tool to support improved interprofessional understanding.

Tracking the hiring of midwives within the hospitalist model may also reveal trends that suggest acceptance.

Mandatory education of practicing obstetricians could significantly magnify the impact of this new understanding of the education and professional role of the midwife. Most professional healthcare organizations including the ACNM, ACOG and American Medical Association not

only endorse, but also mandate ongoing professional education to ensure clinicians serve patients to the best of their abilities and maintain professional standards (ACNM, 2020; ACOG, 2020;

AMA, 2020). Within the hospitalist organizations and trainings, such education could become associated with new employee education. Educational offerings through ACOG should include information about midwifery education, scope of practice and collaborative hospitalist roles. A smaller summary of the key points that made the most significant impact, such as the training requirements to become a midwife, or the possible skill set that the midwife possesses could be instrumental in expanding acceptance of midwives as hospitalists in labor and birth units.

Further Study

Understanding all roles of interprofessional team members is paramount to effective collaboration. Research suggests that follow-up interval assessments should also be considered to assess for long-term change in knowledge and attitudes about midwives, from their obstetrician colleagues (Sinclair, Kable & Levell-Jones, 2015). Other mechanisms of education could also be considered for research as well as follow-up interval assessments to ascertain knowledge retention or application of this knowledge in the workplace. Future research could also include the impact of interprofessional role understanding and education of all team members including

RNs, APRNs and physicians (O’Reilly et al., 2017).

While this project demonstrates that online education can be an effective intervention to influence physician knowledge and attitudes, other study approaches should be considered.

Using open-ended comments or mixed methods for further exploration of perceptions and attitudes following an educational intervention may provide depth to the ongoing evolution of the collaborative hospitalist maternity care model (Perdok et al., 2016).

Conclusions

The purpose of this project was to explore the effectiveness of a hospitalist physician online learning module to improve knowledge and attitudes about their midwife colleagues’ education and scope of practice. Approaches to effective collaboration entail accurate knowledge acquisition both for resident and practicing physicians alike. Lack of interdisciplinary understanding may create barriers to quality care and the achievement of positive patient outcomes. As U.S. maternity care outcomes continue to lag other high-resource countries, strategies including large-scale midwifery-led maternity care, and collaborative hospitalist models should be supported.

Online education has been shown to be acceptable to physicians, convenient, cost- effective, and feasible. A literature review revealed that there is sparse data regarding this specific collaborative maternity model and this lack of data supported the use of an educational intervention to educate physicians with the opportunity to impact collaborative hospitalist practice between obstetricians and midwives. Through this online education module, physicians gained information that impacted both their knowledge and their attitude regarding midwives.

This web-based educational intervention had a positive influence on the participants’ attitudes of midwifery care, level of training, and improved their knowledge of midwifery education. While most hospitalist physicians surveyed had worked with midwives in their career, their responses revealed opportunities for improvement and gaps in their understanding about midwives’ education and scope of practice. As the United States continues to strive to improve maternity care, opportunities to improve interprofessional collaboration should be actualized.

APPENDICES

APPENDIX A PERMISSION LETTER

APPENDIX B EMAIL INVITATION

APPENDIX C DEMOGRAPHIC QUESTIONNAIRE

APPENDIX D COMPARISON OF ATTITUDES PRE- AND POST-TRAINING

APPENDIX E ATTITUDES ABOUT MIDWIVES PRE-TRAINING

APPENDIX F ATTITUDES ABOUT MIDWIVES POST-TRAINING

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