As health care organizations look for new ways to meet consumer needs and control costs, RNs are being asked to take a more active role in patient-centered health care delivery models, both in the United States and in many other countries.1, 2 The benefits of RN-led interventions have been shown to include increased patient satisfaction, reduced hospital readmission rates, and improved patient outcomes,2-5 as well as better adherence to medication regimens.6 It's worth noting that increased patient satisfaction and improved patient outcomes are values incorporated into the American Nurses Credentialing Center's Magnet Recognition Program, which recognizes organizations noted for nursing excellence.7
Research suggests that, in general, there is a positive relationship between the higher quality of nursing care at Magnet-designated facilities and improved patient safety.8, 9 That said, to date, most studies of nursing involvement in prenatal care have focused primarily on certified nurse midwife (CNM) models, including individual face-to-face and group-based care. Although some studies have demonstrated the effectiveness of such models,10, 11 they haven't addressed the potential of care models that involve RNs.
Moreover, studies have found that frequent obstetric clinic visits don't necessarily translate into improved patient care12, 13 or increased patient satisfaction.14-18 Reducing the required number of clinic visits has shown mixed results with regard to patient satisfaction; for example, one study found that women who had fewer visits expressed greater dissatisfaction and “were less likely to feel listened to.”19 It's possible that models of care that promote flexible appointment scheduling and easier access to prenatal care could lead to improved outcomes and patient satisfaction. Although one study found that flexible scheduling was associated with increased dissatisfaction,20 a more recent literature review found that difficulty scheduling appointments and accessing on-site care were common barriers for many women.21
Our institution, a Magnet facility, developed a new prenatal care model (called OB Nest) for low-risk expectant mothers. The model, which decreased the number of scheduled in-office visits and provided opportunities for patients to have virtual connections (via telephone or online portal) with RNs, was formally evaluated in a randomized controlled trial.22 Compared with patients receiving usual care, those receiving care under this model required fewer office visits and reported decreased pregnancy-related stress and improved patient satisfaction. They also connected with RNs more often. These quantitative findings suggest that the model was effective in achieving key outcomes. A qualitative evaluation was also embedded in the parent trial to assess patient, physician, and CNM and RN perceptions of the model and its implementation. In this article, we discuss findings from the qualitative evaluation, which offers a fuller understanding of whether this model of care can be effective in achieving outcomes and whether a nurse-led model can be accepted.
Design. Qualitative methods are increasingly being embedded in randomized controlled trials to study implementation processes and aid in interpretation of quantitative data. In this case, we sought an in-depth understanding of how various stakeholders viewed the role of RNs in a new, patient-centered prenatal care model. Such understanding facilitates the identification of factors critical to the successful implementation of this and similar models. The protocol for the parent trial, including details about study design, data collection, and analysis, has been described in a previous article.23
Setting and sample. This qualitative study took place in the obstetric division of the Department of Obstetrics and Gynecology at our institution between March 11, 2014, and November 18, 2015. A total of 300 low-risk patients were initially enrolled, with random assignment of 150 patients to the new prenatal care model and 150 patients to usual care at their initial eight-week prenatal appointment with an RN. Physicians further screened patients for eligibility at the first provider visit. Of the 150 patients assigned to the new care model, 16 were subsequently excluded from the study (two transferred care, five withdrew, and nine were deemed ineligible), leaving 134 patients available for analysis.
During the consent process and before randomization, patients were asked whether they would be willing to participate in an interview or a focus group; 114 indicated they would be willing to be interviewed, and 98 said they would be willing to participate in a focus group. A subset of patients in the intervention arm was subsequently sampled for qualitative data collection. Recruitment for interviews and focus groups was aimed at balance by parity, because we hypothesized that nulliparous and multiparous women might have different experiences or expectations related to prenatal care.
All physicians and CNMs who were available to see the intervention patients in the clinic, as well as all unit RNs and those whose work was dedicated to the new prenatal care model, were invited to participate in either interviews or focus groups.
Intervention. Usual care consisted of 12 scheduled office visits with a physician or a CNM. The RN role in usual care consisted of meeting with patients at their clinic intake appointments and again at 19 weeks’ gestation.
Patients in the new care model were assigned to a dedicated nursing care team consisting of three part-time RNs with expertise in the ambulatory obstetric area. These RNs directed care, scheduling visits and ordering laboratory work based on a visit template (see Table 1). They also connected with pregnant patients during four care visits conducted by telephone or via an online patient portal; these visits replaced four of the 12 regularly scheduled office visits. Two additional connected care visits were added at 16 weeks’ gestation and at one week postpartum. Patients also received home monitoring equipment. The connected care visits included education appropriate for the patient's gestational period (information on what to expect and upcoming tests, for example), but the primary aim was to make each visit patient centered to ensure a high quality of care. Visit content varied among patients in response to their questions and home monitoring readings. Patients were also directed to contact a connected care model RN by telephone or online portal between visits with any additional questions or concerns. Further details on the intervention, including visit schedules and content, have been described in a previous article.23
Data collection. Institutional review board approval for the study was obtained before data collection commenced. Qualitative data were obtained through face-to-face interviews and in-person and online focus groups.
Patients. Individual patient interviews took place between August 21 and November 5, 2014. Patients were purposefully recruited based on parity at approximately 28 to 32 weeks’ gestation, and recruitment was continued until 26 patients (12 nulliparous and 14 multiparous) agreed to participate. Data collection was obtained at 28 to 32 weeks’ gestation because participants had enough exposure to the care model to report their experiences. The semistructured interview guide included questions related to patient interest in the prenatal care model, experience with the intervention components, relationships with the care team, and educational needs and satisfaction. Interviews were conducted by experienced qualitative interviewers who weren't involved in clinical care (three of us, JLR, MAM, and DMF) and were audio recorded with the patient's permission. Interviews and data analysis were conducted concurrently. The study team reviewed cases that did not conform to emerging themes to further explore patterns in the data.
Two asynchronous online patient focus groups were also conducted to explore preliminary findings from the patient interviews, including positive and negative perceptions of the model and specific questions related to the nurse–patient relationship. These groups were hosted on a secure website; participants logged in at their convenience to answer questions posed by the moderators (JLR and MAM), as well as to respond to comments from other focus group participants. A total of 15 patients participated in the focus groups; one focus group was conducted with seven nulliparous patients, and another was conducted with eight multiparous patients. The moderator posted new questions every two or three days, and each group remained open for 10 days. (See Table 2 for the patients’ demographic data.)
Providers. Data were collected from providers between March 11, 2014, and November 18, 2015, specifically at the study's launch (baseline), midpoint, and completion. At baseline, individual interviews were conducted with six physicians. One focus group was conducted with eight CNMs; another focus group was conducted with two of the connected care model RNs and seven unit RNs. Midpoint data collection included interviews with eight physicians, one focus group of eight CNMs, and one focus group of three connected care RNs, six unit nurses, and one nursing supervisor. At study completion, interviews were conducted with six physicians and one focus group each was held with nine CNMs and with two of the connected care RNs. No unit RNs participated in the last focus group, as most were not actively engaged with the new care model and we felt that their baseline and midpoint feedback yielded sufficient information about how the new model affected unit workflow and other aspects.
The semistructured interview guides were based on the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework described by Glasgow and colleagues.24 The guides were supported by normalization process theory, which focuses on the implementation and integration of innovations in complex conditions.25, 26 The interview questions concerned providers’ understanding and appraisal of the new prenatal care model and its effect on their work over the study period.
Audio recordings of all individual interviews were transcribed verbatim; the in-person focus groups were moderated by two researchers (JLR and MAM). The online focus group transcripts were captured electronically.
Data analysis. The methods of qualitative thematic analysis were used, involving initial familiarization with the data and then development of an inductive thematic framework, which was applied to the data along with descriptive annotations. To increase the trustworthiness of the findings, all data were coded by at least two of us (JLR, MAM, and DMF). Any coding discrepancies were reconciled by consensus, and codes were entered into qualitative analysis software (NVivo version 10.1, QSR International Pty Ltd). To offset potential bias, we also asked quantitative researchers and clinical team members from the larger study team (including the connected care model RNs) for their input on data interpretation. Data were analyzed within and across the groups of patients, physicians, CNMs, and RNs at the study's launch, midpoint, and completion.
Two overarching themes emerged from the participants’ reported perceptions: ongoing relationships, including support; and autonomy and scope of practice.
Ongoing relationships and support. Participants in all groups stressed the importance of relationships, whether patient–nurse, patient–physician or CNM, or nurse–physician or CNM. Regarding patient–nurse relationships, the connected care model RNs reported high satisfaction with the connectedness they developed with many of their patients. They contrasted these relationships with those developed in usual care, in which pregnant patients met with nurses just twice for the purpose of education, often with different nurses each time. The connected care RNs reported developing stronger relationships with their patients, based on having more interactions, and felt they were able to give better personalized care. Relationship building also increased the efficiency and effectiveness of nurse–patient communications. As one connected care RN said,
“I enjoy it…. I feel like I know them when I see them. I know in the back of my head that I kind of have an idea of what's going on with them because I've read their chart, I've seen them at either 12 weeks or 18—now 24 weeks…. And I just feel that they have more of a connection. And even when you talk with them on the phone, you know what's going on. As opposed to usual care where you see them once and you never see them again.”
Unit RNs also spoke to the potential for the new care model to increase both patient and nurse satisfaction. One said, “I think it is going to use the nurse's scope of practice, which is satisfying. We're looking at patients and patient outcomes and how this will affect that, but we need to look at staff satisfaction as well. I think it really would provide a great satisfaction there.” Another said,
“I think it has the potential to increase workload, but I also think it will give nurses a really great sense of responsibility over their patients, and I think that's really good…. It's just nice to really follow through and I think it's great for patients. There are so many providers in their picture and they get that one solid nurse, and I think that's really helpful.”
Many patients expressed appreciation for working with a small number of dedicated connected care RNs, especially since they had fewer in-person office visits with other providers. Some said they appreciated that the connected care nurses were readily available whenever they had questions or wanted more information. Although the nurses valued their connections with patients, it was the patients who determined how much connectivity was needed. One multiparous patient said,
“I feel very connected with the nurses. They're the ones that I talk to mostly; certainly, I talk to both of them. And when I go into my in-person appointments, I see them as well, so I feel like I've had a lot of ongoing regular contact with them. And the nice thing about that, compared to the regular model of care… is I would see a different nurse every time during that care, and so it's nice to have a continuation or continued relationship with a couple of people.”
While many patients valued their relationships with the connected care model RNs, they also wanted connection with their physician or CNM (ideally, the person who would be present at delivery). Some indicated that they valued their relationships with such providers and with the connected care RNs differently. Failures in continuity of care with physicians or CNMs were more dissatisfying for some patients. One nulliparous patient said that, at first, her relationship with the connected care RN was
“a little bit less important to me than [my relationship with] the midwives, because you know the midwives are the ones who are there, and especially with [my clinician] having a team of midwives… it is not just one person that you know is going to be there. So I guess having the relationship with the nurses is just a little bit less important to me. Still nice to have the familiarity there, but it is not… a deal breaker or anything like that.”
CNMs in particular spoke of the importance of their relationships with patients, and expressed concerns about losing connectivity under the new care model. For the CNMs, this was compounded by a study-specific requirement that patients see a physician at the first visit to verify low-risk eligibility criteria. CNMs described the new care model as unsatisfactory from that standpoint, although they acknowledged that it might be satisfying to some patients. One CNM said, “I do worry about this model. In midwifery, one of the things we think is important is getting to know the patients and developing a relationship with the patients.” The CNMs suggested assigning one CNM to a patient's care as much as possible, to increase continuity of care and strengthen that relationship.
Relationships between the connected care nurses and other providers were generally seen as favorable. The physicians and CNMs reported hearing good things about the nurses from the new care model patients. But the CNMs and physicians reported wanting better ongoing face-to-face communication with both unit and connected care RNs. Most such communication occurred via notes in the electronic health record (EHR), and many providers expressed frustration at the effort required to sift through copious notes in order to locate important patient information. Some physicians and CNMs suggested that assigning each patient to one connected care RN (rather than to a team of three part-time RNs) would enhance patient care and aid them in communicating with the designated nurse. As one CNM stated, “It might be beneficial to have the patient be connected to just one OB Nest nurse and have [that] continuity [be] part of it… that could be helpful because if you needed to know something about the patient… you could connect with the nurse who had that patient on her caseload.” The connected care RNs suggested that partnering with particular providers to care for a group of patients could help foster team care. One connected care RN said,
“I think [OB] Nest would work really with a team approach… so you have [a physician] and two nurses are assigned to [that physician]. Those nurses deal with her Nest patients…. If you have concerns, you always have that same doc to go to. You can have a better bonding relationship with that provider and maybe the trust would build better.”
Autonomy and scope of practice. Enhanced autonomy and scope of practice were inherent in the prenatal care model. The addition of home monitoring and the reduction in the number of scheduled office visits were intended to shift the locus of control from providers to patients. The shift in responsibility for directing care from other providers to RNs was intended to give the nurses greater responsibility for prenatal education and help lower costs. Indeed, some patients did perceive having more control over their care. Patient education included helping patients understand normal blood pressure and weight ranges and fetal heart zone rates; and patients could add additional office visits if they wanted to. One nulliparous patient said,
“I thought it was… giving me a little bit more sense of control over my care. Instead of just having an appointment once a month and between appointments not really having any idea what was going on. To be able to listen to the heartbeat and keep an eye on my own weight and blood pressure and everything.”
Both the connected care RNs and the other providers requested more nurse-led protocols and educational materials for the nurses. These were requested in addition to existing order sets, protocols, and access to on-site providers. Several physicians noted that the nurses were well qualified to provide patient education, and felt that their own time was better spent on higher-risk cases. As one physician said, “I think probably the biggest impact is just efficiency and letting us see more of the patients that need to be seen by a physician, opening up our schedules… if somebody has a… complicated pregnancy.” Some physicians and CNMs had concerns about changes to the RN's scope of practice that might require practice changes to ensure patient safety and efficiency. But many physicians and CNMs believed that adding more order sets and protocols could solve these issues. One CNM offered this example:
“Some years ago we developed some talking points to make sure [pregnant patients] understood the risks of not receiving the influenza vaccination. And it seems like when the nurses were offering the flu shots, when they were declined, it was just documented “patient declined.” So that's something that I feel pretty strongly, that we need to either have the nurses participate in the template or make that the job of the midwife to double-check all of that if [a patient] declines.”
Some providers also noted that continuing education for the connected care RNs could improve their understanding of some clinical practice guidelines. For example, one patient refused a nurse's recommendation that she get the tetanus–diphtheria–pertussis vaccine. The nurse directed her to discuss the vaccination with her provider at her next office visit. Some providers stated that RNs could be counseled to provide more in-depth education to the patient themselves.
The connected care model RNs expressed interest in the new care model in relation to their autonomy. They cited the ability to use their clinical knowledge and judgment in caring for a core group of patients as falling within the full scope of their practice and increasing their job satisfaction. They spoke to how the new care model allowed them to direct and manage patient care by ordering tests and appointments, provide patient education, triage symptom-related telephone calls, and connect with patients in person and by telephone or online portal. One connected care RN said,
“Autonomy—being able to order things, take care of the patients, not having to seek provider input, having protocols that I could work off of. Loved, loved, loved that piece.”
Both the connected care RNs and the other providers commented on the cumbersome nature of the notes template in the EHR. These participants generally agreed that expanding RNs’ access so that they could record more patient data in key areas would give them greater responsibility and would facilitate the sharing of up-to-date information, making other providers’ jobs easier. As one physician stated,
“Now, for the whole clinic, the nurses are allowed to put a few restricted things on the problem list, but it's really, really hard because [the] nursing [staff] charts in a different way than we do. And what I noticed with a lot of the templated notes… [was that] I'd have to read through them all to see what the key things were.”
By reducing the number of scheduled in-office visits and increasing the RN's role in patient management and education, the new prenatal care model sought to make more efficient use of the health care team and provide patients with greater flexibility and control of their care. Results from the parent trial showed that this approach was effective in increasing patient satisfaction and reducing stress and health care utilization without adversely affecting maternal or fetal outcomes.22 Findings from the embedded qualitative evaluation indicated that patients appreciated the dedicated connected care RNs and the education, availability, and connectedness they provided. Many patients reported that these RNs were skilled and helpful. The connected care RNs reported that they were able to get to know their patients better, and to tailor their education accordingly.
In the current health care environment, maintaining continuity of care is often challenging. At our institution, patients in both study arms were unlikely to see the same physician or CNM throughout a pregnancy. Assigning each patient to the dedicated connected care RNs provided better continuity, although patients still expressed a desire for continuous connection with their physician or CNM.
The connected care RNs in particular were keenly interested in the new model's potential for building stronger patient connections through relationship-based care. The other providers expressed similar interest, especially the CNMs, who were increasingly asked to direct prenatal care for low-risk patients in this practice. Simply reducing the number of scheduled visits would mean seeing patients less often, and this could threaten the robustness of patient–provider relationships. The new care model allows for some substitution of in-person visits via telephone or online portals, and it also affords patients ways to connect at will with RNs between visits. Better patient–provider continuity and a more integrated team approach to patient care management could improve relationship building among patients, RNs, and other providers. Our findings are consistent with other research findings demonstrating that patients desire continuity of care in nurse-led clinics27, 28 and ongoing relationships with their health care providers.29
Several aspects of the RN's role in the new care model are consistent with characteristics of Magnet facilities, including better nurse–physician relationships and greater nurse autonomy. Nurse autonomy can be defined as the nurse's ability to use her or his independent nursing judgment and knowledge to provide patient-focused care within the full scope of RN licensure and institutional rules.30-32 Our results indicate that the connected care RNs did have greater autonomy and worked closer to the full scope of their practice. That said, the results also suggested room for improvement through continuing education and more nurse-led protocols.
Kramer and colleagues explored nurse autonomy at several Magnet facilities where staff rated nurse autonomy as high and where care models based on overlapping RN and physician scopes of practice were used.33 They found that nurse autonomy and overlapping scopes of practice were supported best when protocols were evidence based, were designed for specific patient populations, and allowed RNs to use their judgment in decision making. They also found that mutual respect between physicians and nurses was an important factor in helping providers negotiate their scopes of practice and make fluid changes as needed. Indeed, adapting to changes of responsibility, knowing when to consult another provider, respecting other team members’ professions, and being able to collaborate are supported in the American Nurses Association's Nursing: Scope and Standards of Practice.34 In our study, the connected care nurses reported having good relationships with other providers. But they also believed that trust would be improved if more nurse-led protocols were created for this patient population and if they had more freedom in updating patients’ EHRs.
Limitations. This study was conducted within a highly educated community. Of the 41 participants in patient interviews and focus groups, the majority (73.2%) had at least a four-year college degree; very few (4.8%) had no postsecondary-level education. Several patients either had spouses who were health care providers or were themselves nurses or other providers. These patients often used their personal professional connections when they had questions or wanted more information. A second limitation was that the group of dedicated connected care RNs in this study consisted of three part-time nurses, rather than one full-time nurse. Models of care that incorporate greater patient access and RN availability in relationship building, like this one, would likely benefit from having full-time or nearly full-time staff to promote continuity of care.
Practice recommendations. Our institution's new prenatal care model positively affected several patient and health system outcomes. Participants in all groups offered positive opinions on an RN-led model of care. Future implementations would likely benefit from the following considerations. First, patient and clinician satisfaction could be increased by assigning patients to specific connected care RNs and other providers. This would foster greater continuity of care at all points of contact, whether via face-to-face clinic visits, electronic messaging, or telephone calls. Second, changing the study-specific requirement such that all patients see a CNM rather than a physician at their first visit (to verify low-risk status) would allow patients in the midwifery service to receive better continuity of care.
Our findings underscored the importance of RN expertise and communication skills in obstetric care. Nurses need to be supported with evidence-based institutional policies and protocols that allow nurses to use their judgment. Nurses also need access to important areas of the EHR, thus enhancing communication with other providers. The physicians and CNMs in this study also expressed interest in systems that improved patient safety, regardless of the number of in-person visits. Development of a system for regular collaborative chart reviews could serve as both a safety check and an opportunity for providers to communicate care expectations and recommendations.
Policy recommendations. The new prenatal care model provides ongoing connected care with an RN while reducing both patients’ travel time and their scheduled clinic visits. The use of virtual visits offers greater opportunities for care delivery to patients living farther away or across state lines. Proven, successful models of care require clear and expanded policies, including those related to scope of practice and state regulations.1 Changes in policies at the national level are thus recommended.
Research implications. Further research exploring similar prenatal care models in more demographically diverse populations is warranted. For example, different populations may have different levels of knowledge and expectations with regard to prenatal care and patient–provider relationships. Studies in rural communities or other settings where the existing staffing models vary would be useful. Additional research comparing the cost savings of a nurse-led prenatal care model with those of other models could also be illuminating.
As more organizations look to RNs to lead models of care that increase patient satisfaction and improve patient outcomes, it's ever more vital that we understand how to best create and develop such models. Most studies thus far have involved care models led by advanced practice nurses; but there is a clear potential and need for RN-led models. Our institution's new prenatal care model allowed patients to decrease the number of scheduled in-person clinic visits with physicians or CNMs while building stronger nurse–patient relationships through virtual connected care visits with an RN. The results included increased patient satisfaction and greater autonomy for RNs, allowing them to make better use of their knowledge and expertise. Although the new model gave physicians more time in which to see higher-risk patients, CNM–patient relationships may have been limited. While more research is warranted, it's likely that creating new RN-led protocols, adding more continuing education, creating or amending the chart review process, and addressing institutional limitations could further enhance patient care and increase the RN's ability to work to a full scope of practice.