professional maturity or independence?

PROFESSIONAL MATURITY OR INDEPENDENCE?

Joyce E. Thompson, CNM, DPH, FAAN

ABSTRACT

This paper discusses the thesis that nurse-midwifery will grow and flourish in a climate of economic cons~'aint and competition if every nurse-midwife assumes both the responsibilities and privileges of professional maturity. This maturity is based on the concept of interdependence in relationships with clients, physicians, and nurses, and other nurse-midwives. These relationships are also built upon mutual respect and trust. Concerns for client self-determination at the expense of safety, paternalism/maternalism at the expense of client autonomy, expansion of midwifery practice into medicine, and the extension of professional limits of practice beyond one's level of competence are discussed. The final goal of healthier mothers and babies with access to care for all women requires nurse-midwifery care in cooperation with other health professionals. No one professional group can meet this goal alone.

The preceding papers by Rooks, Ernst, and Rothman comprehen - sively address nurse-midwifery--its past, its present , and its future. ACNM President Judith Rooks con- tends that the survival and success of nurse-midwifery depends upon the building of an institutionalized support system that is based on inter- dependen t relationships with other groups. Renowned nurse-midwifery spokesperson Eunice Ernst chal- lenges us to look at what we can do as a group of nurse-midwives if we work t o g e t h e r - - coopera t ive ly seeking the common goal of healthy women, babies, and families. Sociol- ogist Barbara Katz Ro thman con- t inues the chal lenge to us by sug- gesting that we have yet to reach full

This article is based on the closing address given at the 29th Annual Meeting of the Amer- ican College of Nurse-Midwives, Philadelphia, PA, May 17, 1984.

Address correspondence to Joyce E. Thompson, Director, Nurse-Midwifery Pro- gram, University of Pennsylvania School of Nursing, 420 Service Drive $2, Philadelphia, PA 19104.

professional status (in sociological terms of control of the workplace) and why that should be important to us individually and collectively. Each in her own way is raising our con- sciousness abou t the n e e d for re- maining sensitive to the special needs of women and families as well as to those nurses and midwives who need to be educated to help with the tasks ahead. We are, indeed, building for the future with recognition that much remains to be done to assure each and every woman and family access to quality health care.

THE CHALLENGE

I offer yet another challenge, or at least a slightly different perspective. My thesis is that nurse-midwifery will grow and flourish in a climate of economic constraint and friendly competition if and only if every nurse- midwife and nurse-midwifery collectively assumes both the responsibilities and privileges of professional maturity based on interdependence in relationships with clients, physi-

clans, and other health professionals, and other nurse-midwives.

We have lived through several years of a d o l e s c e n c e - - t h e time of demanding privilege but not always being sure of wanting or accepting the inherent responsibilities of those privileges. We wanted to be accepted as full members of the health care team caring for mothers and babies, but somet imes without any visible concern for what our participation might mean to physicians or nurses. Remnants of that adolescence still are evident today. Some remain un- willing to carry the full responsibility of nurse-midwifery care during childbearing due to the constant nature of on-call status. We want the privilege of caring for laboring families, but only on our terms or if they happen to fall on our "shift." We want to do "our thing" without interference, un- aware of the responsibilities and im- practicality of doing "one ' s thing" in a pluralistic, interdependent society.

We want the economic security of salaried positions, even as we enter private practices with physician col-

Journal of Nurse-Midwifery • Voi. 29, No. 5, September/October 1984

Copyright © 1984 by the American College of Nurse-Midwives

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0091-2182/84/$03.00

leagues. Yet we complain when those same employers control our practice patterns. We fought hard for direct reimbursement of services without being aware of some of the many ramifications of such an action. And even when reimbursement passed, many were content to continue prior arrangements of having the physician bill so that the reimbursement would be higher than what would be given to the CNM. Do our services really cost as much as those of the physician? Now we find ourselves in the position of possibly refusing to care for those who cannot pay. Are we in danger of replacing the goal of care with the goal of economic gain? I suggest that we, as CNMs, can never afford to refuse to care for the poor if we remain truly committed to healthy mothers and babies, for it is lack of prenatal care that guarantees unhealthy outcomes for families.

These and other concerns ex- pressed by the membership, individually and collectively, have rein- forced my objective for focusing this paper on the subject of professional maturity in relationships. Now is the time to grow further as a profession and take our rightful place among the responsible professionals who provide health care in this country.

DEFINITIONS

Dr. Rothman describes the sociological definition of professional as

Dr. Thompson is Associate Professor and Director of the Nurse-Midwifery master's program at the University of Pennsylvania School of Nursing. She received her nurse-midwifery education at Maternity Center Association in 1966 and has been in active practice since that time in Chile, New York, and now Pennsylvania. She is also Director of Nurse-Midwifery at Pennsylvania Hospital and maintains a small private practice there. Dr. Thompson has taught in certificate and master's basic nurse-midwifery educational programs since 1971.

being in control of one's workplace. ! would add that to be professional is to be ethical, with all that entails in today's pluralistic society. And the common grounds for ethical practice is knowledge and understanding of self and of others. To the ongoing debate of whether nursing and nurse-midwifery are professions, I would respond that both are professions but not all members are professional.

Professional maturity, as it is being used in the context of this paper, implies knowledge and acceptance of all the responsibilities inherent in nurse-midwifery practice and education. These include such concepts as mutual respect and trust in relationships, maintenance of competence and ongoing learning, knowledge of history (lest we are doomed to repeat the mistakes of the past), risk-taking with responsibility for outcomes, and reasoned decision making in all aspects of professional life. Maturity also implies the ability to live with uncertainty. And, indeed, our future is not crystal clear. All these aspects of maturity are needed for the growth of nurse-midwifery practice.

It is time we talked less of the privileges of being a nurse-midwife (power and prestige) and talked more of the responsibilities (what we can reasonably accept and imple- ment) inherent in such a role. We can no longer remain ignorant of what our statements of philosophy, Functions, Standards and Qualifica- tions (FS & Qs), and new Joint State- ment on Maternity Care imply in terms of individual and collective responsibility. One of the phrases most often misinterpreted is that nurse- midwives support client autonomy in order to provide satisfying care without recognition that the word "safe" precedes satisfaction, and should always come first in our caring for others. I will come back to this point later.

I believe the bottom line in main- taining professional viability is recognition that there is no way nurse-

midwives can carry out our philosophy of care alone. Let's give up the adolescent cry of "we can do it better ourselves" and responsibly accept the adult version, "we can only suc- ceed by working in cooperative part- nership with clients, physicians, and nurses, and other CNMs." And I add that the key to cooperative partner- ship is good communication based on mutual respect and trust.

I would like to briefly explore some of the implications of communication based on mutual respect and trust within three major relationships. The first is nurse-midwife with client; the second is nurse-midwife with physi- clan and other health care team members; and the last is nurse-midwife with nurse-midwife. I need to preface these remarks by stating that trust takes time and effort to develop between and among individuals. It is not automatic in any relationship. Mutual respect should be a given by the very nature of the value of human beings. Yet, we must first value ourselves and know what we have to offer others as nurse-midwives as well as individuals. That is, only if we value ourselves can we also value others. Such respect implies time given to attentive listening and dialogue. Respect implies a willingness to try to understand others that reinforces their intrinsic value as a person. We do not, however, need to agree with others in order to respect their positions. Respect also implies a willingness to share one's own thoughts and beliefs openly as two or more search for a reasoned solu~ tion or decision.

CNM-CLIENTS

One area of great concern to me that is echoed by several of my colleagues is the concept of patient's rights or self-determination, l am concerned that new practitioners as well as experienced ones may be misinformed about the meaning of self-determination. It does not imply that the client always decides what

308 Journal of Nurse-Midwifery • Vol. 29, No. 5, September/October 1984

the professional will do. Rather, self- determination is based on two inter- related concepts--capaci ty to decide and informed decision making. If we simply replace physician authority with client authority in our clinical practice, we do not change the de- pendent nature of such practice. Per- sonal authori ty in negotiat ion is closer to mature re la t ionsh ips - - nurse-midwives have an ethical responsibility to provide complete in- formation to clients so that informed choice is possible, but they also re- tain the responsibility to know what is safe care as well. I suggest we may not wish to cont inue the t rend of client decisions at all c o s t - - w e have a professional responsibility to provide care that is also safe and competent. We also need to remember that part of our responsibility in caring for clients is a clear understanding of client responsibility for decisions. Just as mature CNMs take full responsibility for their actions, clients likewise must be willing to take full responsibility for their decisions and the resultant conse- quences.

I would also like to mention the misuse of "clinical judgment" that may thwart client se l f -determina- t i on - - the other side of the coin, if you will. We need to be conscious of the use of clinical judgment as a cover-up for personal or professional values that the client may not share. Once again, we are called upon as mature professionals to know ourselves and what we value. Only then can we share appropr ia te ly with clients in nonemergency situations where time for discussion and client input is available. Making decisions for others in situations in which they are capable of making their own decisions is commonly called "maternalism" or "paternalism." Both are sometimes seen as unethical, similar to situations of suppor t ing clients who select unsafe actions during their childbearing because that 's what the client wants to do. There is an important balance of professional competence and informed client de-

cision making needed in providing care that is both safe and satisfying.

CNM-PHYSICIAN-NURSE

l have long believed that the success of nurse-midwifery in this count ry has been roo ted in the understanding and acceptance that we are the experts in the care of normal or healthy women and pregnancies and that obstetricians are the experts in the care of women with medical or obstetrical complications. Many of us have been successful in establishing and expanding nurse-midwifery practice because of the mutual respect and unders tanding of these roles from CNMs and physicians. We have learned to trust each other as well as respect the areas of expertise each has to offer the childbearing family.

There is concern, however, that this clarity of role responsibilities is blurring. I caution each of us to understand what we are doing when we expand our scope of practice. It is a given that each of us, being highly educated and extremely intelligent, is capable of learning almost anything. Likewise, we could learn and practice medicine. The more important issue-, I think, is should we be doing that and still call ourselves nurse- midwives? I choose to remain a competent , safe nurse-midwife. If I wanted to expand further into medicine, I would have gone to medical school. I suggest that we recognize that our success as nurse-midwives has been our ability to remain experts in midwifery. Let us be careful lest we lose that expertise because of the thrill of expanding our role into medicine or the misguided notion that if we won' t do something for a client, no one else wil l - -a t least not as well.

One of my concerns in relationships with o ther health care team members, notably nurses, is that we may forget our nursing base and ex- pect the staff nurse to "nurse" our clients. We have for years tolerated two major types of midwifery prac-

tice in our profession, that of "nurse"-midwife and that of "physician"-midwife. Maybe it is unreal- istic to care for a large caseload of women and still provide the bulk of labor support, but I wonder if it is fair to call ourselves "midwives" if we only show up for the delivery? I have also witnessed CNMs calling for a nurse to clean up their client who has just vomited in labor while the CNM looks on. Is it any wonder we continue to have difficulty in nursing relationships when we treat our nursing colleagues as less than person or col- league? Mutual respect and maturity in relationships calls for interdependence and cooperative team efforts, not passing one 's work onto others.

CNM-CNM

A final note of concern for professional maturity is in our relationships with each other. Constructive support and critique were vital to the early growth of nurse-midwifery. At times I wonder whether we have lost that vital concern for each other. Peer review, informal consultation, and o p en critique of ques t ionable practice seem more threatening than constructive these days. Why is this so? Why do some of our colleagues feel so isolated? Have we misused our concern for excellence in practice and differing interpretation of scope of practice to witch hunt each other? I certainly hope not! Professional maturity calls for continued concern for excellence in practice from all of us as well as respect for differences in practice that are safe.

During the past 14 years, I have been privileged to participate in the education of many nurse-midwives. I have watched them learn and heard of their ongoing professional growth years afterward. I am beginning to think that there are at least three levels of clinical judgment evident in our profession. All are learned. None are inherited or intuitive. The first level of clinical judgment is achieved by all learners prior to graduat ion and involves the ability to recognize

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problems or minor deviat ions in clients' health status and treat them correctly. The second level of clinical judgment occurs when one can an- ticipate a potential problem and pre- pare to handle it ahead of time. This level of judgment is crucial to safe practice in settings where backup or referral sources require some time and/or distance. This level of judgment may also develop during the basic midwifery education program, but it is not guaranteed. Because of the need for such judgment in certain practice settings, new graduates without this level of clinical judgment should be counsel led accordingly. The third level of clinical judgment requires time and experience. It occurs when the nurse-midwife antici- pates a potential p rob lem early enough to work with the client to prevent it actually occurring.

Although I am a believer that standards of nurse-midwifery practice must be dearly written irrespective of the place of practice, I do believe it takes a more advanced level of clinical judgment to practice in some settings. I worry when our current stu- dents report that "standards limit cre- ativity and that each individual must be allowed to set their own circle of safety." (See the 1983 ACNM Stu- dent Report, published under the Is- sues and Opinions column in this issue.) New practitioners may lack the knowledge and experience to set s tandards of safe midwifery care. Well-written professional standards serve as both guidelines and protec-

tion for the practitioner as well as the clients we serve. We each have an ethical obligation to maintain competence (including safety) in practice and education. This means recog- nizing our own limits of knowledge and practice expertise. Even more importantly, competence requires an unwillingness to be pushed beyond these limits no matter what the cir- cumstance or reason.

Once again our common goal of healthy mothers and babies directs our relationships with each other. We must be willing to subject our practice and education to review and critique by o t h e r s - - w e must be willing to continue our learning and have that currency e v a l u a t e d - - w e must be willing to accept our ethical obligation to know our own limits and provide safe care for our clients. Professional maturi ty requires no less.

SUMMARY

I conclude by supporting what Judith Rooks stated in her Presidential address. Nurse-midwives are here to stay; there is a definite need for the type of well-woman and family-cen- tered childbearing services we provide, and our future is building and bright as long as we remain clear on our central purpose for b e i n g - - t h e provision of high quality, family-cen- tered care for healthy women and newborns. Our new joint statement on maternity care reiterates the need for both obstetricians (specialists in

high-risk pregnancy care) and nurse- midwives (specialists in healthy pregnancy care) working as a team to provide competent, acceptable, and available services for all women and families. I think our continued success as par tners in the delivery of midwifery and obstetrical services will d e p e n d on our willingness to trust each other, to recognize those unique areas of expertise that each of us has to offer clients, and to work together so that women, all women, will benefit from the composite skill and expertise of both professionals.

I further believe that only through maturity in relationships with clients and professionals can we hope to continue to improve maternity care for all women in this country. If our direction as a Col lege and as a profession is the guarantee of access to health care for all w o m e n and families by 2000 (as I bel ieve it should be), then we have much building to do. No one can do it alone. The benefi ts of caring and providing compassionate and competent care across the childbearing cycle as a team far outweigh the neg- ative aspects of adolescent competition. We will survive in an era of fi- nancial restraint when we learn that independence gives way to interdependence, competition gives way to constructive and cooperative caring, and we neve r lose sight of our c o m m o n goal of providing health care for all. We are well on our way and we unite in our commitment to healthier mothers and babies.

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professional maturity or independence?

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