Nurse-Midwifery at Columbia BY

Mary 1. Crawford'

Oraduate piwrarn In Matenlty NurslnK, DeparLmenl of Nursing-Faculty or Medlelne. Columhla Unlver%ltY

Historical Development

The first seed was sown in the development of the Graduate Program in Maternity Nursing at Columbia University in 1951 when Maternity Center Association loaned one of the nurse-mid- wives on its staff to Presbyterian Hospital in order to develop classes for parents in preparation for childbearing. Since parent education is an integral part of any program of graduate education in ma- ternity nursing, the first step was to find out whether this kind of maternity care could gain the backing of the medical and nursing staff of the Department of Obstetrics and Gynecology.

By 1953, the parent education program had gained acceptance and the Presbyterian Hospital assumed the responsibility for the salary of the nurse-midwife instructor. The time was now at hand to explore further, and the Columbia Presbyterian Medical Center and Maternity Center Association agreed to pool their resources in an experiment for the development of a graduate program in maternity nursing. Before establishing a program of this nature in the complicated framework of a university hospital, it was felt that a preliminary observation of the available clinical resources was desirable.

In January, 1954, two additional clinic sessions were set up in the antepartal clinic of Presbyterian Hospital for continuous individual- ized care. About 25 mothers were selected to open the clinic; 90 were cared for during the year. Only those mothers were selected whose prognosis was normal and whose transfer to this service was approved by an attending or resident obstetrician. Primiparas were referred after the second visit to the clinic, multiparas after the initial visits. Medical responsibility was vested in a member of the attending staff of the Department of Obstetrics and Gynecology. Every mother was seen by an obstetrician in the sixth and ninth months of pregnancy and at any time evidence of deviation from normal was apparent. At other times the mother was seen by the nurse-midwife. Appointments were scheduled to allow for teaching and answering questions as well as the routine physical check-up. The clinic was staffed by the instructor in parent education and two other nurse-midwives loaned on a part time basis from Ma- ternity Center Association. Experience showed that these clinics fitted in well with the hospital's clinic and educational program, and that medical results were comparable to those in the rest of

'Mary I. Crawford, R.N., M.A., C.N.M., is an Associate Professor of Nursing, Department of Nursing-Faculty of Medicine, Columbia University.

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thr service. An important criterion in evaluation of the program was its acceptance by the mothers. I t was noteworthy that once the program was explained, not one mother refused it. Only seven required any special reassurance. Many who were passive at the start evinced interest and satisfaction as their care progressed.

The last area to be explored was that of labor and delivery. This proved to be the area which required the greatest amount of interpretation, where the need for good communication was of para- mount importance, and whcre the highest degree of res' *stance was encountered. Nevertheless during the fall of 1954 it was finally decided that 12 mothers would be registered by Maternity Center Association for hospital delivery by the nurse-midwife. The nurse- midwife worked with the resident in the management of labor although the resident assumed full responsibility, wrote all the orders, and scrubbed in with the nurse-midwife for delivery. During the spring of 1955 the various hurdles encountered were surmounted and ten of the twelve mothers registered were delivered by the nurse-midwives in the hospital setting.

Four years had been spent in exploration but with this back- ground behind us we knew what the educational opportunitiej were in the hospital setting and we had also explored the different courses being offered in public health and hospital administration in the School of Public Health and Administrative Medicine.

Obiactives The objective in the development of the Graduate Program in

Maternity Nursins leading to an M.S. degree was primarily to help the graduate nurse develop depth as well as breadth of understand- ing and a degree of clinical skill in the field of maternity care which would enable her to participate most effectively in programs of maternity care, to accept her full responsibility for service to families and to respect her own contribution as well as that of other dis- ciplines tQ the changing patterns of maternity care. This means that the graduate nurse needs to:

1. master the basic scientific skills of midwifery 2. develop a philosophy which understands the significance of the pregnancy

experience and its relationship to family living 3. have sufficient background to be able to study the needs of families and how

these needs can be met 4. be able to conduct research 5. be able to teach 6. be able to work with and contribute to the work of other disciplines in

maternity care 7 . understand the community in which she works 8. have confidence in her own ideas and ability to interpret these ideas to

others

The Graduate Program is based on a concept of maternity care as a continuous, integrated service starting with the first awareness of pregnancy and continuing throughout the puerperium. The complete service (envisaged) includes not only obstetric care, but education of the expectant parents for their role, preparation of

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the mother for the labor experience, skilled attendance and emo- tional support throughout labor, and integration of maternity care with good family living. As the graduate student assumes more and more responsibiity for this kind of care she cannot help but take advantage of the vast resources available to her. Through repeated experience under supervision she gains confidence in herself and improves her judgement concerning the individual problems, and need of mothers and their families.

Plans developed and the first applicants were registered for the Graduate Program in Maternity Nursing to begin in September 1955. The program is offered by the Department of Nursing, Faculty of Medicine, Columbia University, in cooperation with the School of Public Health and Administrative Medicine, and Maternity Center Association. The School of Public Health and Administrative Medicine is also under the Faculty of Medicine of Columbia Uni- versity. The program is under the direction of the Associate Pro- fessor of Nursing in charge of Obstetrics and supports one full time instructor, part of whose salary is paid by Columbia University and part by Maternity Center Association. Another instructor will be joining the staff in June, 1959. The program is eleven months in length and leads to a Master of Science degree from Columbia University and a Certificate of Nurse-Midwifery from Maternity Center Association. The course is planned around preparation in the clinical specialty. A minimum of sixteen credits are required in maternity nursing, including field experience. The first unit of field experience provides an opportunity for students to learn how to teach and supervise selected mothers throughout pregnancy, to manage normal labor and delivery, and to follow through on the teaching of mothers in the puerperium. Blocks of experience in the Rooming-In Unit, Premature Nursery, and in other areas related to the student’s particular interest are included.

The second unit provides experience in the continuous care and supervision of mothers throughout the maternity cycle and is de- signed to test the student’s knowledge of theory and practice in nurse-midwifery. Opportunity is also provided for students to gain experience in teaching Preparation for Childbearing classes.

A minimum of not less than thirty-two credits must be completed in order to meet the requirements for the degree. Since students come to the program with widely varied preparation and experi- ence, and with different interests and aims, every effort is made to help them select additional courses which will meet individual needs and provide as much flexibility as possible. Many of the courses in hospital administration and in public health offered by the School of Public Health and Administrative Medicine, as well as courses offered by other schools in the University, are available to students in this program. Functional preparation for specific jobs however, may require more than the eleven months included in this program.

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Each student is required to investigate and prepare a report on a particular area of interest in maternity nursing. This project is accepted in lieu of a thesis and carries two credits.

Evaluation of the Program

A. Strengths of the Program: 1. Position of the program within the University offering acceea to courses

in all schools and departments in the University. 2. Support of the program by administration of The Presbyterian Hospital in

the City of New York The College of Physicians and Surgeons. The School of Public Health 'and Administrative Medicine, and The Department of Nursing.

3. Support of the program by the Medical Director of the Department of Obstetrics and G y n e c o l o ~ ~ .

4. Dual administration in nursing providing for the development of the same philosophy in nursing service and nursing education.

5 . The fact that by October, 1969. the Assistant Director of Nursing in charge of Obstetrics. the Supervisor in charge of the Labor and Delivery Room. the Supervisor in charge of the Obstetric Clinic, the Instructor in Parent Education as well as the Instructors in the Graduate Program and one Instructo; in the Basic Program will be nurse-midwives themselves with masters degrees and able to assist in the education of the nurse-midwife.

6. Wealth of clinical experience available in the Department of Obstetrics and GynecoloKY.

7 . Nurse-midwifery clinic developed within the regular obstetric clinic in which students gain experience in the supervision and teaching of mothers during pregnancy under the guidance of the nurse-midwifery instructor with one of the residents responsible for consultation.

8. Active participation of designated members of the resident and attending medical staff in the clinical teaching and supervision of students.

9. Opportunity for students to supplement clinical experience through affilia- tion in a different kind of clinical setting.

10. Limitation in number of students enrolled in the program which provides for a more individualized type of teaching and supervision by the nurse- midwife instructors.

B. Weaknesses in the program which still need to be resolved: 1. Limitations placed on the degree of responsihility students and instructors

may assume in the management of labor and delivery. 2. Frequent turnover of resident staff in each area of the service requiring

constant reorientation and reinterpretation. 3. Organized lines of rommunication between nursing and medical staffs within

the Department of Obstetrics and Gynecology still not fully developed. 4. Limited time available for clinical experience during the academic year. 5. Lack of opportunity to get to know the mother and her family in the home

setting.

Johns Hopkins (continued from Page 46) I t is believed that the program does not provide time enough to

include the kind of preparation in public health which is desirable. Psychological consultative service for the nurse-midwifery faculty

for the guidance of students needs further development. The present staffing by nurse-midwife instructors does not permit

their 24 hour supervision of students and makes planning for time off, vacations, illness, etc., exceedingly difficult. The shortage of staff also precludes experimentation with the educational program, both for students and patients.

If more students are enrolled in the program, additional re- sources for scholarship aid need to be found.

Even with these limitations, it is believed that the program is meeting the objectives.

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