Journal of Midwifery & Women’s Health
www.jmwh.org
Original Review
A Mini-Midwifery Business Institute in a Midwifery Professional Roles Course: An Innovative Teaching Strategy for Successful Career Planning and Business Management of Practice D. Elizabeth Jesse, CNM, PhD, Connie Dewees, CNM, DrPH, William C. McDowell, PhD It is essential to include teaching strategies in midwifery education that address career planning and the business aspects of practice. This article presents the Mini-Midwifery Business Institute (M-MBI), an innovative teaching strategy for midwives that can also be applied to other advanced practice professions. The M-MBI can be integrated into a professional roles course. Before and after graduation, midwifery students and other advanced practice professionals can use the information to gain confidence and skills for successful career planning and the business management of practice. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:75–82 Keywords: business, career planning, midwifery students
INTRODUCTION
The professional responsibilities of certified nurse-midwives (CNMs) and certified midwives (CMs), as defined in the core competencies for basic midwifery practice,1 require the knowledge of practice management and finances. Further, before or soon after graduation, midwifery students and other advanced practice professionals are confronted with finding a job, negotiating contracts, salary and benefit packages, and making other complex business decisions requiring a set of business and career planning skills that can lead to success.2 However, midwifery students and recent graduates often lack knowledge about important business concepts. In an early study published in 1998, 33 midwifery program directors rated “business management of practice” as one of the top 4 areas that needed substantially more emphasis in midwifery curricula.3 Learning the business management of practice is even more important for midwives and other health care providers since the US Patient Protection and Affordable Care Act of 2010 (ACA) was established.4–6 Midwives and other advanced practice nurses will have additional opportunities for leadership and management of innovative health care delivery systems with this expansion of insurance coverage that will reach more vulnerable individuals.5 For example, the ACA included $50 million in funding for proposals to develop and support nurse-managed health clinics and authorized Medicaid reimbursement to freestanding birth centers (Section 2301).4,5,7–10 With the current and potential expansions in health care delivery, there is an even greater need for additional knowledge about how to establish independent practices or primary care health centers. Introducing these principles during their formal education can help students learn how to begin
and/or maintain a productive, financially sound, and successful practice.2 Yet, it can be challenging for faculty to offer principles of career planning and successful business management for students in an already crowded curriculum.3 To enhance the likelihood that midwifery graduates will be successful, we developed an innovative interdisciplinary Mini-Midwifery Business Institute (M-MBI), a 2-day oncampus intensive. This article describes the implementation of the M-MBI activities for nurse-midwifery students enrolled in a distance education program at East Carolina University College (ECU), College of Nursing and summarizes the students’ evaluations. BACKGROUND
Address correspondence to D. Elizabeth Jesse, CNM, PhD, Graduate Nursing Science, 3160 Health Sciences Bldg., East Carolina University College of Nursing, 600 Moye Blvd., Greenville, NC 27858. E-mail: [email protected]
The objectives of the midwifery concentration curriculum at ECU’s College of Nursing include preparing students to work in rural and underserved communities. The program has graduated 4 to 11 students per year. All midwifery courses are offered online, and most have an on-campus intensive component at the beginning of the semester. The program offers 2 online professional roles courses, each 2 semester hours: 1) Introductory Nurse-Midwifery Professional Roles and Issues, which introduces the students to the historical, theoretical, and scientific foundations of the nurse-midwifery role; and 2) Integration of Nurse-Midwifery Professional Roles and Issues, which focuses on issues relevant to the assumption of the role and responsibilities inherent in professional nurse-midwifery and the development of career skills. The professional roles courses were the only formal teaching in this area delivered prior to the development of the M-MBI. The M-MBI intensive is offered on campus during orientation week in the fall semester of the students’ senior year, which coincides with students’ need to seek postgraduation employment. In real time, the students prepare their professional portfolio for interviews with potential employers and use skills gained from practice interviews to prepare questions.
1526-9523/09/$36.00 doi:10.1111/jmwh.12201
c 2014 by the American College of Nurse-Midwives
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✦ The Mini-Midwifery Business Institute (M-MBI) is an innovative, interdisciplinary 2-day on-campus intensive to enhance the likelihood that midwifery graduates will be successful in managing the business aspects of clinical practice. ✦ A variety of successful midwife guests who own or direct midwife practices bring unique perspectives on the business aspects of operating a midwifery practice. ✦ The students rated the “best thing about the M-MBI” as the experience of midwives and recent graduates sharing their wisdom and knowledge. ✦ In midwifery education, it is vital that programs such as the one described here ensure that students are prepared with skills to enhance their professional success.
MINI-MIDWIFERY BUSINESS INSTITUTE
Curriculum and Guest Speakers
Theory
Several weeks before the M-MBI is held, the faculty send the students a welcome letter, agenda, and reading assignments to complete. Students are also asked to bring their current r´esum´e to the M-MBI. Course texts include Slager’s Business Concepts for Healthcare Providers 2 and Ament’s12 Professional Issues of Midwifery. Students focus on Ament’s chapter, “Practice Structure,” and are also assigned journal articles and Web resources on M-MBI topics. In addition to organizing the event, the ECU course faculty invite the guest speakers, host the event, introduce speakers, facilitate discussion, and prepare an evaluation tool for the students to give feedback after the M-MBI. They also send a follow-up letter to thank the guest speakers, and as a token of their appreciation, the course faculty offer the guests a small remuneration for their presentation and/or travel expenses. Each time the M-MBI is presented, the mix of professional speakers varies. The students’ interests, as expressed in previous courses and the speakers’ availability, influence the final speaker roster. Table 1 presents the variety of midwife and physician guest speakers and a summary of their lecture topics that are pertinent to the M-MBI goals. Each speaker shares a unique perspective on finding a fit between one’s philosophy and a practice model. In addition to the midwifery service director who has presented during the first 2-day campus intensive, other presenters have included local, regional, and national midwifery leaders with a broad range of expertise. In addition, practice directors, midwife administrators, midwifery practice business managers, recent graduates, and expert nurse-midwives are invited who represent the wide scope of midwifery practices, as described by Schuiling et al in their findings from the ACNM membership surveys.11 For example, in 2011 the largest percentage of nurse-midwives were employed by hospital/medical centers (29.1%), followed by physician-owned practices (20.4%); private CNM/CM practices, including freestanding birth centers or home birth practices (7.3%); educational institutions (11.9%); community health/nonprofit health agencies (11.1%); and the military/federal government (3.5%). Midwives who are drawn to more entrepreneurial or private practice positions may desire more independence, less bureaucracy,
The development of the M-MBI was guided by Bandura’s theory of self-efficacy,4 defined as “a belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations”.4 Based on this theory, we anticipated that learning job seeking and business management skills in a safe environment would increase students’ confidence and abilities to succeed in an existing midwifery or physician obstetrics and/or gynecology practice, or to plan and develop a midwifery practice of their own. The 3 broad goals of the focused MMBI are: 1) develop confidence, skills, and knowledge for establishing a practice or for joining an existing practice; 2) practice techniques for the interviewing and negotiation process; and 3) develop productive and financially sound business practices within the health care delivery system. Overview and Historical Development
A faculty member’s idea for the development and integration of the M-MBI in the professional roles course began after listening to student feedback about the need for more career planning and practice management skills. Following this initial idea, all midwifery faculty met to develop the M-MBI program. To explore these ideas further, the faculty of the professional roles course contacted a midwife who was the service director and president of a midwifery practice. Their discussions led to the development of the first M-MBI 2-day intensive that was placed as the on-campus portion of the professional roles online course. The midwife service director shared her experiences from nearly 20 years of practice; almost 10 years of those experiences were developing and managing a private midwifery practice. Her topics included: 1) developing your vision and confidence; 2) networking; 3) negotiating a contract; 4) American College of Nurse-Midwives (ACNM) benchmarking and Medical Group Management Association practice data; 5) malpractice insurance; 6) hospital credentialing; 7) planning for self employment or partnership; and 8) advertising and billing. She also shared knowledge from her activities with the Nurse-Midwifery Service Directors Network and the Midwifery Business Institute. 76
Volume 60, No. 1, January/February 2015
Table 1. Midwifery, Physician, and Other Speakers and Topics
M-MBI Goals/Objectives Speakers Midwives and physicians in collaborative practices
Topics Introducing midwifery into an established practice:
Addressed in This Topica 1, 3
Practice adaptations when adding midwives to an established obstetric practice Impact of physician workload and patient mix Collaboration patterns between midwives and physicians Organizational structure and desirable reporting hierarchy for midwives Financial implications of adding midwifery and tracking productivity Practice purchase by a health care corporation Implications for midwife-physician collaboration and control of clinical practice decisions and patterns
Midwives who own their practices
Developing a midwifery practice:
1, 3
Incorporation and business planning Capitalization (startup funding) Identifying collaborating physicians; maintaining sound relationships Obtaining hospital privileges Marketing to potential clients Getting paid (credentialing with third-party payers) Financial management Physical space (type; location re: hospital; use; layout; flow) Midwifery support staffing and scheduling for in-hospital and out-of-hospital practices (birth center and home birth). Narratives about successful practices that thrived and then failed; lessons learned
Not-for-profit birth center
History of development as a not-for-profit corporation:
professionals: midwife director,
Philosophy of care and how that affects business strategies
business manager, physician
Getting paid and credentialing with third-party payers
medical director/
Collaborative relationships with family
consultant/supervisor
Medical director and consultants
1, 3
Consultation with obstetric physicians for high-risk developments Marketing and orientation of new clients Success (impact of growth on the practice) Midwives representing military, Negotiating a position within a complex system government clinics, and
1, 2
Precepting learners of obstetrics (medical students and residents)
universities Professionalism in practice
ACNM President; national issues that affect midwifery practice and business
1, 3
State affiliate leaders How to become involved with state professional organization Networking Finding “your fit” and practice
Finding a practice that fits one’s individual philosophy and life needs
issues
Negotiating a midwifery position
1, 2
What the practice wants from you Duties, scheduling, and call schedule What you want from the practice Salary, benefits, vacation, and educational leave; additional prerequisites Continued Journal of Midwifery & Women’s Health r www.jmwh.org
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Table 1. Midwifery, Physician, and Other Speakers and Topics
M-MBI Goals/Objectives Speakers
Addressed in This Topica
Topics Contract issues: Contract vs letter Legal advice Confronting non-compete clauses
National midwifery expert in
Billing and coding for midwifery services
financial issues
Doing business with third-party payers (private and governmental)
3
Abbreviation: M-MBI, Mini-Midwifery Business Institute. a M-MBI goals/objectives: For the student to: 1) develop confidence, skills, and knowledge for establishing a practice or for joining an existing practice; 2) practice techniques for the interviewing and negotiation process; and 3) develop productive and financially sound business practices within the health-care delivery system.
and fewer institutional rules, or to remain in their respective communities. Most guest speakers and faculty come to campus to facilitate live interactions with students. Technological methods, including Skype (Microsoft Skype Division, Luxembourg City, Luxenbourg), Saba (Saba Software, Redwood Shores, CA), and teleconferences are employed for guests who live at a distance. Over the 2 days, speakers are scheduled for presentations lasting one to 3 hours. After an introduction to the M-MBI by the course faculty, there are approximately 5 sessions. The University Career Center counselors review the center’s resources and Web site with students and assist them to write professional cover letters and r´esum´es. Students work in pairs with the career center counselor to update and develop their professional cover/query letter and r´esum´e. They also field common interview questions and learn when and how to discuss salaries, effective methods for searching for a job, and interviewing skills. The career counselors continue to be available to students after the M-MBI. Students can schedule a mock interview for a hypothetical or real midwifery job for which they desire to interview. A week after the M-MBI, students e-mail their query letter and an updated r´esum´e to the career center counselor for additional feedback and post a final copy of their cover letter and r´esum´e to the professional roles course online grade book. Students also post the draft that includes comments from the career center counselor so that the course faculty can determine how students addressed the counselor’s suggestions.
College of Business Guest Speaker
A faculty member in the College of Business at ECU—an expert on entrepreneurship, not-for-profit organizations, and interorganizational relationships—prepares the midwifery students to write a business plan for setting up a midwifery clinical practice and serves as a consultant to students as they apply business management concepts to their business plan for a clinical practice. The session begins with an overview of what starting a business is all about for a midwifery practice, or in this case, midwifery entrepreneurship. The content addresses all of the major areas of the group assignment that the students will be responsible for at the end of the semester. 78
The topics covered during the College of Business faculty presentation include the generation of business plan ideas for a midwifery practice and how to identify practice/business opportunities. Other topics are: understanding environmental research; describing venture and plans for marketing; and the importance of organization, operations, and finances. The process of learning about and creating a business plan for a midwifery practice allows the students to gain hands-on, real world experience for what starting a business or joining a practice/business will be like. They not only get to do their own research and writing, but also have the College of Business professor accessible throughout the semester to help them along the way. Table 2 describes the categories that are included in the students’ Midwifery Practice Plan Group assignment. Assignments
Students have the opportunity to apply what they learned from the M-MBI and other learning activities in the professional roles course in 3 assignments. In addition, there are 2 ungraded synchronous chats, which are followed by quizzes that include information from the chats. There is one asynchronous chat in the course wherein the students give each other feedback on their practice plans. Students are graded on their level of participation in the chat within the practice plan rubric. Billing and Coding
The director of a large midwifery service in Michigan and a certified specialist in billing and coding presents information on billing and coding in an online format. Students continue the discussion with this guest in a synchronous chat that is followed by an online quiz to ascertain if students acquired key concepts and topics covered in the guest’s online presentation and readings. Midwifery Practice Plan Group Assignment
In groups of 2 to 4 and with guidance from midwifery faculty, the College of Business faculty, and a midwifery mentor, the students develop a business plan for a hypothetical new midwifery practice or midwifery service that will be added to an existing practice in a rural or urban setting. When the students Volume 60, No. 1, January/February 2015
Table 2. Criteria of the Midwifery Practice Plan Group Assignment PowerPoint Presentation
Practice Plan Criteria and Details Introduction Cover page Table of contents Executive summary Business concepts What midwifery practice model are you in? What services will you provide? Mission, vision, goals Market research/analysis Community assessment (demographics and statistics to support need) Who are the current providers of care for your target population? What are community preferences and attitudes toward midwives/midwifery care? Marketing plan Objectives Strategies Activities Organization Legal form of ownership Organizational structure Management, reporting ladder Operations Flow of services to clients/patients Communications Facility layout and location Technology necessary to provide services and do business Staff (professional, business) Scheduling Contracts/relationships with consultants Financials Forecast of patients (number by type of service, mix of third-party payer) by month, operating costs, capital budget Pro forma (projected income minus costs and expenses) Projected growth over time; cash flow by month Break-even analysis Financing the practice Funding sources Timeline Overall schedule Action calendar
do their practice plan assignment, they plan a complete practice model that includes philosophy, specific clinical services, quality assurance, and business components such as financial projections and marketing. As much as possible, they choose a real community location with a site selected from available real estate in the area. Student groups develop their practice plans throughout the semester, and the faculty member from ECU’s College of Business provides detailed feedback on the drafts of their Journal of Midwifery & Women’s Health r www.jmwh.org
plans. The College of Business faculty member also maintains a discussion board forum on the course Web site. Students are encouraged to contact the faculty member with questions or concerns in a specified area of the online discussion board. In addition, the students receive feedback and suggestions from the faculty members via Saba, an online voice and video conferencing technology. Students develop and present their practice plans orally in real time using the Saba synchronous chat format. Students review each group’s practice plan and 79
Table 3. Student Responses to the Open-Ended Evaluation Questions Following the Mini-Midwifery Business Institute
Top Rated Responses by Order of Frequency
Sample Student Response
What was the most useful thing you learned from the M-MBI? Setting up a practice and how to write a business plan
“I think the most informative piece for me this semester is learning the business side of midwifery.” “The mini-business institute was a great start, Slager’s books are great, and creating the budget for our group was eye opening.” “The information regarding setting up a practice or entering a practice, being aware of practice guidelines.”
Learning the realities of midwifery practice
“Listening to the practicing midwives, lectures about practicing in the real world.”
Interviews with prospective employers and
“Interviewing skills.”
negotiating a contract
“Interviews, planning/skills, r´esum´e prep, contract prep.” “Talking about contracts and explaining tail coverage.”
The clinical operations of out-of-hospital facilities
“Home birth and birth center discussions.”
and developing a Medicaid pregnancy home R´esum´e development, job search, interviewing skills, career resources, and developing a portfolio
“I am also enjoying compiling my professional portfolio. This is a time to think about my profession and the educational journey as a whole, while creating a useful document at the same time. I think that I will use this resource a lot through my first years as a quick reference.”
What was the best thing about the M-MBI? The top rated item was having experienced
“I enjoyed the panel of professionals put together (sic) and found having past
midwives share their wisdom and knowledge,
students most beneficial. I felt as students we were trying to relate to them,
including recent graduates.
since we would soon be in their shoes; looking for and being offered jobs.” “Having experienced midwives share their wisdom and knowledge.”
What did I do that facilitated your learning the most? A variety of guests, teaching techniques, and
“Had such a diverse line-up.”
comfortable room
“Had a comfortable room and food and drinks available.” “The Skype enhanced the program.” “Gave PowerPoint to make notes.” “Wow, this was an amazing M-MBI. Thank you [faculty] for all your time, patience, and hard work in recruiting and organizing all of the excellent speakers! I wish that every midwifery student in America could have the opportunity to attend [your] M-MBI prior to graduation (exactly as it was presented to us). I am appreciative and feel the information presented was highly applicable to where we are at this point in our “mission.” I could just go on and on with positive feedback. That was definitely a reflection of an excellent nurse-midwifery program.”
What did I do that facilitated your learning the least? Logistics of billing and coding presentation
“The billing and coding could have been done on a Saba chat to perhaps save time.” “Include billing and coding information a little prior to our first clinical.” “I wouldn’t change a thing.”
End M-MBI an hour earlier
“Stop at 4 pm (had to focus when tired).”
Offer a sample practice plan
“Maybe include a sample business plan to understand better about devising a business plan.”
Abbreviation: M-MBI, Mini-Midwifery Business Institute.
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offer suggestions, feedback, and evaluative comments in an asynchronous discussion thread in Blackboard (Washington, DC). Professional Portfolio
Every year, students complete a professional portfolio representing their professional development. In the first few years of the M-MBI, students included their documents in a leather binder portfolio that was organized with index tabs. They used this professional portfolio to enhance their interviews and to practice with their peers, who played the role of a potential employer. More recently, students have presented a professional e-portfolio in Blackboard using ECU’s template,13 which includes documents useful to potential employers or potential investors for a practice under development. The items that comprise the professional portfolio can be customized as appropriate for the position under consideration by choosing from the total portfolio package. For example, students desiring an out-of-hospital position may include the essential ACNM documents and criteria for provision of home birth services or the National Birth Center Standards. STUDENT FEEDBACK
Table 3 describes previous students’ feedback of the M-MBI. The feedback form includes a series of Likert-style questions with a 1 to 5 scale that addresses their satisfaction with the speaker and topics. Evaluation questions also address the deficiencies of the M-MBI. Students rarely described ways that the faculty could change anything. Sometimes, they described their dissatisfaction with unavoidable issues that occurred with the use of technology, such as a poor connection with a guest who presented live via Saba or Skype. To address the technology problems, before the M-MBI begins, faculty arrange for practice times with online guests with the information technology (IT) department present. We reserve a larger “smart” room during the on-campus institute that is more technology-friendly. IT staff are present during the start of all Skype sessions. The faculty teaching this course also review the evaluations to determine which topics and speakers have the most positive impact on student learning. These topics and guests are included the following year. In some instances, guests are rated highly by the students, but they cannot return due to the logistics of their practice or because the midwifery program may lack funds to support them. When possible, student evaluations are shared with the guest speakers, including positive feedback and areas for improvement. In addition to the MMBI evaluation, the students evaluate the professional roles course as part of the university’s evaluation program. For example, in 2012 the mean student evaluation of the course was 6.79 on a Likert scale of one to 7, with one being strongly disagree and 7 being strongly agree. FOLLOW-UP OF MIDWIFERY GRADUATES
Although no formal follow-up of midwifery graduates successes has been collected, anecdotally, our midwifery gradu-
Journal of Midwifery & Women’s Health r www.jmwh.org
ates have been very successful in gaining employment. Several graduates have joined the staff of existing birth centers, and as a result of their proposals, have joined existing physicianowned practices. Three students were hired by these practices. Two students initiated a birth center with the collaboration of the physician owner. Even those who have been hired into existing midwifery practices report that the business skills learned from this exercise have proven helpful in becoming successful in practice. For example, one student applied her vision and aspects of her student group business plan assignment to a real world situation. Portfolio in hand, she approached an existing obstetrics and gynecology practice in a rural area and proposed that they add midwifery services to their practice. As a result of her recommendations, they instituted a new midwifery practice. In turn, for several years this graduate returned as a guest who inspired students with her vision, plan, and successes. FUTURE PLANS FOR THE MINI-MIDWIFERY BUSINESS INSTITUTE
The midwifery faculty are participating in a recently awarded grant (Preparing a Diverse and Culturally Competent Nurse-Midwifery Workforce) from the Health Resources and Services Administration (Rockville, MA) that advances interprofessional education. In the future, faculty plan to include other professionals as participants in the M-MBI, such as obstetric and family medicine residents and nursepractitioner students. The goal of interprofessional participation in the M-MBI is to prepare students and providers to work within a health care team to deliver patient-centered care, monitor patient safety and quality assurance, and participate in the equitable distribution of resources within a collaborative practice. If faculty of midwifery or advanced practice nursing education programs wish to institute a program similar to the M-MBI within their curriculum, they can consult with our faculty to make individual arrangements. CONCLUSION
This article describes the M-MBI, an innovative model that facilitates new graduates’ successful career planning, and in which, they learned skills for practice business management. The M-MBI received very positive student feedback and can be replicated in other midwifery and advanced practice education programs so that more students are prepared with business skills to enhance their professional success. AUTHORS
D. Elizabeth Jesse, CNM, PhD, is Professor at the East Carolina University College of Nursing, Greenville, NC. She currently teaches in the doctoral program and was a Principal Investigator for a National Institute of Mental Health award. She taught the Professional Roles courses for 8 years and created the M-MBI. Connie Dewees, CNM, DrPH, is Clinical Assistant Professor at the East Carolina University College of Nursing, midwifery concentration. She is the clinical site director for the program.
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She also teaches the Professional Roles courses and the MMBI. William C. McDowell, PhD, is Associate Professor in the Department of Management at East Carolina University’s College of Business. He is the faculty business consultant for the M-MBI. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. ACKNOWLEDGMENTS
The authors are grateful for Elizabeth Tornquist’s (MA, FAAN) editorial support and critique of this article. REFERENCES 1.American College of Nurse Midwives. American College of Nurse-Midwives Core Competencies for Basic Midwifery Practice. Silver Springs, MD: American College of Nurse-Midwives. 2012. Available from: http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000050/Core%20 Comptencies%20Dec%202012.pdf. Accessed January 28, 2014. 2.Slager J. Business Concepts for Healthcare Providers: A Quick Reference for Midwives, PAs, NPs, CNSs, and other Disruptive Innovators. Boston, MA: Jones and Bartlett; 2004. 3.Bellack JP, Graber D, O’Neil EH, Musham C. Curriculum trends in nurse-midwifery education: Views of program directors. J Nurse Midwifery. 1998;43(5):341-350. 4.Bandura A. Self-Efficacy in Changing Societies. New York, NY: Cambridge University Press; 1995. 5.Tillett J. Practicing to the full extent of our ability: The role of nurses in healthcare reform. J Perinat Neonatal Nurs. 2011;25(2):9498. Available from: http://www.nursingcenter.com/lnc/journalarticle? Article ID=1165684 Accessed January, 28, 2014.
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6.Patient Protections and Affordable Care Act. P. L. 111–148. Sec. 3502. Patient Protection and Affordable Care Act (PPACA): S.3590, 111th Congress, 2nd Session. 2010. Available from: http://www.gpo.gov/ fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed January, 28, 2014. 7.Johnson KA. Women’s health and health reform: Implications of the Patient Protection and Affordable Care Act. Cur Opin Obstet Gynecol. 2010;22(6):492-497. 8.American Nursing Association (ANA). Issue Brief. Information and analysis on topics affecting nurses, the profession and health care. New Care Delivery Models in Health Care System Reform: Opportunities for nurses and their patients, 2010. Available from: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/HealthCareReform Resources/Care-Delivery-Models.pdf Accessed January 8, 2014. 9.American College of Nurse Midwives. ACNM Issue Brief NurseManaged Health Clinics – Health Care Reform Law (111-148) (nd). Available from: http://midwife.org/ACNM/files/ACNMLibraryData/ UPLOADFILENAME/000000000243/Nurse%20Managed% 20Hlth%20Clinics%20HCR%20111.148.May%202011.pdf Accessed January 8, 2014. 10.ACNM. Midwives and Medicare after Health Care Reform 2011. Available from: http://www.midwife.org/Midwives-and-Medicareafter-Health-Care-Reform Accessed January 8, 2014. 11.Schuiling KD, Sipe, TA, Fullerton, J. Findings from the analysis of the American College of Nurse-Midwives’ membership surveys: 2009 to 2011. JMWH 2013;58:404-415. 12.Ament L. Professional Issues in Midwifery. Sudbury, MA: Jones and Bartlett; 2007. 13.Coleman H, Kubasko D, Dickerson J. Web-Based Electronic Portfolio Systems: Asynchronous Assessment and Accountability, a Best Practices Presentation, East Carolina University. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1 &source=web&cd=4&cad=rja&ved=0CDkQFjAD&url=http%3A% 2F%2Feditlib.org%2Fd%2F29251&ei=jgdvUq2BIeza4AOpm4Co BQ&usg=AFQjCNF˙oJUruIE4qk5TRkjRaozUhLo53w Accessed October 28, 2013.
Volume 60, No. 1, January/February 2015
www.jmwh.org
Original Review
A Mini-Midwifery Business Institute in a Midwifery Professional Roles Course: An Innovative Teaching Strategy for Successful Career Planning and Business Management of Practice D. Elizabeth Jesse, CNM, PhD, Connie Dewees, CNM, DrPH, William C. McDowell, PhD It is essential to include teaching strategies in midwifery education that address career planning and the business aspects of practice. This article presents the Mini-Midwifery Business Institute (M-MBI), an innovative teaching strategy for midwives that can also be applied to other advanced practice professions. The M-MBI can be integrated into a professional roles course. Before and after graduation, midwifery students and other advanced practice professionals can use the information to gain confidence and skills for successful career planning and the business management of practice. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2015;60:75–82 Keywords: business, career planning, midwifery students
INTRODUCTION
The professional responsibilities of certified nurse-midwives (CNMs) and certified midwives (CMs), as defined in the core competencies for basic midwifery practice,1 require the knowledge of practice management and finances. Further, before or soon after graduation, midwifery students and other advanced practice professionals are confronted with finding a job, negotiating contracts, salary and benefit packages, and making other complex business decisions requiring a set of business and career planning skills that can lead to success.2 However, midwifery students and recent graduates often lack knowledge about important business concepts. In an early study published in 1998, 33 midwifery program directors rated “business management of practice” as one of the top 4 areas that needed substantially more emphasis in midwifery curricula.3 Learning the business management of practice is even more important for midwives and other health care providers since the US Patient Protection and Affordable Care Act of 2010 (ACA) was established.4–6 Midwives and other advanced practice nurses will have additional opportunities for leadership and management of innovative health care delivery systems with this expansion of insurance coverage that will reach more vulnerable individuals.5 For example, the ACA included $50 million in funding for proposals to develop and support nurse-managed health clinics and authorized Medicaid reimbursement to freestanding birth centers (Section 2301).4,5,7–10 With the current and potential expansions in health care delivery, there is an even greater need for additional knowledge about how to establish independent practices or primary care health centers. Introducing these principles during their formal education can help students learn how to begin
and/or maintain a productive, financially sound, and successful practice.2 Yet, it can be challenging for faculty to offer principles of career planning and successful business management for students in an already crowded curriculum.3 To enhance the likelihood that midwifery graduates will be successful, we developed an innovative interdisciplinary Mini-Midwifery Business Institute (M-MBI), a 2-day oncampus intensive. This article describes the implementation of the M-MBI activities for nurse-midwifery students enrolled in a distance education program at East Carolina University College (ECU), College of Nursing and summarizes the students’ evaluations. BACKGROUND
Address correspondence to D. Elizabeth Jesse, CNM, PhD, Graduate Nursing Science, 3160 Health Sciences Bldg., East Carolina University College of Nursing, 600 Moye Blvd., Greenville, NC 27858. E-mail: [email protected]
The objectives of the midwifery concentration curriculum at ECU’s College of Nursing include preparing students to work in rural and underserved communities. The program has graduated 4 to 11 students per year. All midwifery courses are offered online, and most have an on-campus intensive component at the beginning of the semester. The program offers 2 online professional roles courses, each 2 semester hours: 1) Introductory Nurse-Midwifery Professional Roles and Issues, which introduces the students to the historical, theoretical, and scientific foundations of the nurse-midwifery role; and 2) Integration of Nurse-Midwifery Professional Roles and Issues, which focuses on issues relevant to the assumption of the role and responsibilities inherent in professional nurse-midwifery and the development of career skills. The professional roles courses were the only formal teaching in this area delivered prior to the development of the M-MBI. The M-MBI intensive is offered on campus during orientation week in the fall semester of the students’ senior year, which coincides with students’ need to seek postgraduation employment. In real time, the students prepare their professional portfolio for interviews with potential employers and use skills gained from practice interviews to prepare questions.
1526-9523/09/$36.00 doi:10.1111/jmwh.12201
c 2014 by the American College of Nurse-Midwives
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✦ The Mini-Midwifery Business Institute (M-MBI) is an innovative, interdisciplinary 2-day on-campus intensive to enhance the likelihood that midwifery graduates will be successful in managing the business aspects of clinical practice. ✦ A variety of successful midwife guests who own or direct midwife practices bring unique perspectives on the business aspects of operating a midwifery practice. ✦ The students rated the “best thing about the M-MBI” as the experience of midwives and recent graduates sharing their wisdom and knowledge. ✦ In midwifery education, it is vital that programs such as the one described here ensure that students are prepared with skills to enhance their professional success.
MINI-MIDWIFERY BUSINESS INSTITUTE
Curriculum and Guest Speakers
Theory
Several weeks before the M-MBI is held, the faculty send the students a welcome letter, agenda, and reading assignments to complete. Students are also asked to bring their current r´esum´e to the M-MBI. Course texts include Slager’s Business Concepts for Healthcare Providers 2 and Ament’s12 Professional Issues of Midwifery. Students focus on Ament’s chapter, “Practice Structure,” and are also assigned journal articles and Web resources on M-MBI topics. In addition to organizing the event, the ECU course faculty invite the guest speakers, host the event, introduce speakers, facilitate discussion, and prepare an evaluation tool for the students to give feedback after the M-MBI. They also send a follow-up letter to thank the guest speakers, and as a token of their appreciation, the course faculty offer the guests a small remuneration for their presentation and/or travel expenses. Each time the M-MBI is presented, the mix of professional speakers varies. The students’ interests, as expressed in previous courses and the speakers’ availability, influence the final speaker roster. Table 1 presents the variety of midwife and physician guest speakers and a summary of their lecture topics that are pertinent to the M-MBI goals. Each speaker shares a unique perspective on finding a fit between one’s philosophy and a practice model. In addition to the midwifery service director who has presented during the first 2-day campus intensive, other presenters have included local, regional, and national midwifery leaders with a broad range of expertise. In addition, practice directors, midwife administrators, midwifery practice business managers, recent graduates, and expert nurse-midwives are invited who represent the wide scope of midwifery practices, as described by Schuiling et al in their findings from the ACNM membership surveys.11 For example, in 2011 the largest percentage of nurse-midwives were employed by hospital/medical centers (29.1%), followed by physician-owned practices (20.4%); private CNM/CM practices, including freestanding birth centers or home birth practices (7.3%); educational institutions (11.9%); community health/nonprofit health agencies (11.1%); and the military/federal government (3.5%). Midwives who are drawn to more entrepreneurial or private practice positions may desire more independence, less bureaucracy,
The development of the M-MBI was guided by Bandura’s theory of self-efficacy,4 defined as “a belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations”.4 Based on this theory, we anticipated that learning job seeking and business management skills in a safe environment would increase students’ confidence and abilities to succeed in an existing midwifery or physician obstetrics and/or gynecology practice, or to plan and develop a midwifery practice of their own. The 3 broad goals of the focused MMBI are: 1) develop confidence, skills, and knowledge for establishing a practice or for joining an existing practice; 2) practice techniques for the interviewing and negotiation process; and 3) develop productive and financially sound business practices within the health care delivery system. Overview and Historical Development
A faculty member’s idea for the development and integration of the M-MBI in the professional roles course began after listening to student feedback about the need for more career planning and practice management skills. Following this initial idea, all midwifery faculty met to develop the M-MBI program. To explore these ideas further, the faculty of the professional roles course contacted a midwife who was the service director and president of a midwifery practice. Their discussions led to the development of the first M-MBI 2-day intensive that was placed as the on-campus portion of the professional roles online course. The midwife service director shared her experiences from nearly 20 years of practice; almost 10 years of those experiences were developing and managing a private midwifery practice. Her topics included: 1) developing your vision and confidence; 2) networking; 3) negotiating a contract; 4) American College of Nurse-Midwives (ACNM) benchmarking and Medical Group Management Association practice data; 5) malpractice insurance; 6) hospital credentialing; 7) planning for self employment or partnership; and 8) advertising and billing. She also shared knowledge from her activities with the Nurse-Midwifery Service Directors Network and the Midwifery Business Institute. 76
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Table 1. Midwifery, Physician, and Other Speakers and Topics
M-MBI Goals/Objectives Speakers Midwives and physicians in collaborative practices
Topics Introducing midwifery into an established practice:
Addressed in This Topica 1, 3
Practice adaptations when adding midwives to an established obstetric practice Impact of physician workload and patient mix Collaboration patterns between midwives and physicians Organizational structure and desirable reporting hierarchy for midwives Financial implications of adding midwifery and tracking productivity Practice purchase by a health care corporation Implications for midwife-physician collaboration and control of clinical practice decisions and patterns
Midwives who own their practices
Developing a midwifery practice:
1, 3
Incorporation and business planning Capitalization (startup funding) Identifying collaborating physicians; maintaining sound relationships Obtaining hospital privileges Marketing to potential clients Getting paid (credentialing with third-party payers) Financial management Physical space (type; location re: hospital; use; layout; flow) Midwifery support staffing and scheduling for in-hospital and out-of-hospital practices (birth center and home birth). Narratives about successful practices that thrived and then failed; lessons learned
Not-for-profit birth center
History of development as a not-for-profit corporation:
professionals: midwife director,
Philosophy of care and how that affects business strategies
business manager, physician
Getting paid and credentialing with third-party payers
medical director/
Collaborative relationships with family
consultant/supervisor
Medical director and consultants
1, 3
Consultation with obstetric physicians for high-risk developments Marketing and orientation of new clients Success (impact of growth on the practice) Midwives representing military, Negotiating a position within a complex system government clinics, and
1, 2
Precepting learners of obstetrics (medical students and residents)
universities Professionalism in practice
ACNM President; national issues that affect midwifery practice and business
1, 3
State affiliate leaders How to become involved with state professional organization Networking Finding “your fit” and practice
Finding a practice that fits one’s individual philosophy and life needs
issues
Negotiating a midwifery position
1, 2
What the practice wants from you Duties, scheduling, and call schedule What you want from the practice Salary, benefits, vacation, and educational leave; additional prerequisites Continued Journal of Midwifery & Women’s Health r www.jmwh.org
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Table 1. Midwifery, Physician, and Other Speakers and Topics
M-MBI Goals/Objectives Speakers
Addressed in This Topica
Topics Contract issues: Contract vs letter Legal advice Confronting non-compete clauses
National midwifery expert in
Billing and coding for midwifery services
financial issues
Doing business with third-party payers (private and governmental)
3
Abbreviation: M-MBI, Mini-Midwifery Business Institute. a M-MBI goals/objectives: For the student to: 1) develop confidence, skills, and knowledge for establishing a practice or for joining an existing practice; 2) practice techniques for the interviewing and negotiation process; and 3) develop productive and financially sound business practices within the health-care delivery system.
and fewer institutional rules, or to remain in their respective communities. Most guest speakers and faculty come to campus to facilitate live interactions with students. Technological methods, including Skype (Microsoft Skype Division, Luxembourg City, Luxenbourg), Saba (Saba Software, Redwood Shores, CA), and teleconferences are employed for guests who live at a distance. Over the 2 days, speakers are scheduled for presentations lasting one to 3 hours. After an introduction to the M-MBI by the course faculty, there are approximately 5 sessions. The University Career Center counselors review the center’s resources and Web site with students and assist them to write professional cover letters and r´esum´es. Students work in pairs with the career center counselor to update and develop their professional cover/query letter and r´esum´e. They also field common interview questions and learn when and how to discuss salaries, effective methods for searching for a job, and interviewing skills. The career counselors continue to be available to students after the M-MBI. Students can schedule a mock interview for a hypothetical or real midwifery job for which they desire to interview. A week after the M-MBI, students e-mail their query letter and an updated r´esum´e to the career center counselor for additional feedback and post a final copy of their cover letter and r´esum´e to the professional roles course online grade book. Students also post the draft that includes comments from the career center counselor so that the course faculty can determine how students addressed the counselor’s suggestions.
College of Business Guest Speaker
A faculty member in the College of Business at ECU—an expert on entrepreneurship, not-for-profit organizations, and interorganizational relationships—prepares the midwifery students to write a business plan for setting up a midwifery clinical practice and serves as a consultant to students as they apply business management concepts to their business plan for a clinical practice. The session begins with an overview of what starting a business is all about for a midwifery practice, or in this case, midwifery entrepreneurship. The content addresses all of the major areas of the group assignment that the students will be responsible for at the end of the semester. 78
The topics covered during the College of Business faculty presentation include the generation of business plan ideas for a midwifery practice and how to identify practice/business opportunities. Other topics are: understanding environmental research; describing venture and plans for marketing; and the importance of organization, operations, and finances. The process of learning about and creating a business plan for a midwifery practice allows the students to gain hands-on, real world experience for what starting a business or joining a practice/business will be like. They not only get to do their own research and writing, but also have the College of Business professor accessible throughout the semester to help them along the way. Table 2 describes the categories that are included in the students’ Midwifery Practice Plan Group assignment. Assignments
Students have the opportunity to apply what they learned from the M-MBI and other learning activities in the professional roles course in 3 assignments. In addition, there are 2 ungraded synchronous chats, which are followed by quizzes that include information from the chats. There is one asynchronous chat in the course wherein the students give each other feedback on their practice plans. Students are graded on their level of participation in the chat within the practice plan rubric. Billing and Coding
The director of a large midwifery service in Michigan and a certified specialist in billing and coding presents information on billing and coding in an online format. Students continue the discussion with this guest in a synchronous chat that is followed by an online quiz to ascertain if students acquired key concepts and topics covered in the guest’s online presentation and readings. Midwifery Practice Plan Group Assignment
In groups of 2 to 4 and with guidance from midwifery faculty, the College of Business faculty, and a midwifery mentor, the students develop a business plan for a hypothetical new midwifery practice or midwifery service that will be added to an existing practice in a rural or urban setting. When the students Volume 60, No. 1, January/February 2015
Table 2. Criteria of the Midwifery Practice Plan Group Assignment PowerPoint Presentation
Practice Plan Criteria and Details Introduction Cover page Table of contents Executive summary Business concepts What midwifery practice model are you in? What services will you provide? Mission, vision, goals Market research/analysis Community assessment (demographics and statistics to support need) Who are the current providers of care for your target population? What are community preferences and attitudes toward midwives/midwifery care? Marketing plan Objectives Strategies Activities Organization Legal form of ownership Organizational structure Management, reporting ladder Operations Flow of services to clients/patients Communications Facility layout and location Technology necessary to provide services and do business Staff (professional, business) Scheduling Contracts/relationships with consultants Financials Forecast of patients (number by type of service, mix of third-party payer) by month, operating costs, capital budget Pro forma (projected income minus costs and expenses) Projected growth over time; cash flow by month Break-even analysis Financing the practice Funding sources Timeline Overall schedule Action calendar
do their practice plan assignment, they plan a complete practice model that includes philosophy, specific clinical services, quality assurance, and business components such as financial projections and marketing. As much as possible, they choose a real community location with a site selected from available real estate in the area. Student groups develop their practice plans throughout the semester, and the faculty member from ECU’s College of Business provides detailed feedback on the drafts of their Journal of Midwifery & Women’s Health r www.jmwh.org
plans. The College of Business faculty member also maintains a discussion board forum on the course Web site. Students are encouraged to contact the faculty member with questions or concerns in a specified area of the online discussion board. In addition, the students receive feedback and suggestions from the faculty members via Saba, an online voice and video conferencing technology. Students develop and present their practice plans orally in real time using the Saba synchronous chat format. Students review each group’s practice plan and 79
Table 3. Student Responses to the Open-Ended Evaluation Questions Following the Mini-Midwifery Business Institute
Top Rated Responses by Order of Frequency
Sample Student Response
What was the most useful thing you learned from the M-MBI? Setting up a practice and how to write a business plan
“I think the most informative piece for me this semester is learning the business side of midwifery.” “The mini-business institute was a great start, Slager’s books are great, and creating the budget for our group was eye opening.” “The information regarding setting up a practice or entering a practice, being aware of practice guidelines.”
Learning the realities of midwifery practice
“Listening to the practicing midwives, lectures about practicing in the real world.”
Interviews with prospective employers and
“Interviewing skills.”
negotiating a contract
“Interviews, planning/skills, r´esum´e prep, contract prep.” “Talking about contracts and explaining tail coverage.”
The clinical operations of out-of-hospital facilities
“Home birth and birth center discussions.”
and developing a Medicaid pregnancy home R´esum´e development, job search, interviewing skills, career resources, and developing a portfolio
“I am also enjoying compiling my professional portfolio. This is a time to think about my profession and the educational journey as a whole, while creating a useful document at the same time. I think that I will use this resource a lot through my first years as a quick reference.”
What was the best thing about the M-MBI? The top rated item was having experienced
“I enjoyed the panel of professionals put together (sic) and found having past
midwives share their wisdom and knowledge,
students most beneficial. I felt as students we were trying to relate to them,
including recent graduates.
since we would soon be in their shoes; looking for and being offered jobs.” “Having experienced midwives share their wisdom and knowledge.”
What did I do that facilitated your learning the most? A variety of guests, teaching techniques, and
“Had such a diverse line-up.”
comfortable room
“Had a comfortable room and food and drinks available.” “The Skype enhanced the program.” “Gave PowerPoint to make notes.” “Wow, this was an amazing M-MBI. Thank you [faculty] for all your time, patience, and hard work in recruiting and organizing all of the excellent speakers! I wish that every midwifery student in America could have the opportunity to attend [your] M-MBI prior to graduation (exactly as it was presented to us). I am appreciative and feel the information presented was highly applicable to where we are at this point in our “mission.” I could just go on and on with positive feedback. That was definitely a reflection of an excellent nurse-midwifery program.”
What did I do that facilitated your learning the least? Logistics of billing and coding presentation
“The billing and coding could have been done on a Saba chat to perhaps save time.” “Include billing and coding information a little prior to our first clinical.” “I wouldn’t change a thing.”
End M-MBI an hour earlier
“Stop at 4 pm (had to focus when tired).”
Offer a sample practice plan
“Maybe include a sample business plan to understand better about devising a business plan.”
Abbreviation: M-MBI, Mini-Midwifery Business Institute.
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offer suggestions, feedback, and evaluative comments in an asynchronous discussion thread in Blackboard (Washington, DC). Professional Portfolio
Every year, students complete a professional portfolio representing their professional development. In the first few years of the M-MBI, students included their documents in a leather binder portfolio that was organized with index tabs. They used this professional portfolio to enhance their interviews and to practice with their peers, who played the role of a potential employer. More recently, students have presented a professional e-portfolio in Blackboard using ECU’s template,13 which includes documents useful to potential employers or potential investors for a practice under development. The items that comprise the professional portfolio can be customized as appropriate for the position under consideration by choosing from the total portfolio package. For example, students desiring an out-of-hospital position may include the essential ACNM documents and criteria for provision of home birth services or the National Birth Center Standards. STUDENT FEEDBACK
Table 3 describes previous students’ feedback of the M-MBI. The feedback form includes a series of Likert-style questions with a 1 to 5 scale that addresses their satisfaction with the speaker and topics. Evaluation questions also address the deficiencies of the M-MBI. Students rarely described ways that the faculty could change anything. Sometimes, they described their dissatisfaction with unavoidable issues that occurred with the use of technology, such as a poor connection with a guest who presented live via Saba or Skype. To address the technology problems, before the M-MBI begins, faculty arrange for practice times with online guests with the information technology (IT) department present. We reserve a larger “smart” room during the on-campus institute that is more technology-friendly. IT staff are present during the start of all Skype sessions. The faculty teaching this course also review the evaluations to determine which topics and speakers have the most positive impact on student learning. These topics and guests are included the following year. In some instances, guests are rated highly by the students, but they cannot return due to the logistics of their practice or because the midwifery program may lack funds to support them. When possible, student evaluations are shared with the guest speakers, including positive feedback and areas for improvement. In addition to the MMBI evaluation, the students evaluate the professional roles course as part of the university’s evaluation program. For example, in 2012 the mean student evaluation of the course was 6.79 on a Likert scale of one to 7, with one being strongly disagree and 7 being strongly agree. FOLLOW-UP OF MIDWIFERY GRADUATES
Although no formal follow-up of midwifery graduates successes has been collected, anecdotally, our midwifery gradu-
Journal of Midwifery & Women’s Health r www.jmwh.org
ates have been very successful in gaining employment. Several graduates have joined the staff of existing birth centers, and as a result of their proposals, have joined existing physicianowned practices. Three students were hired by these practices. Two students initiated a birth center with the collaboration of the physician owner. Even those who have been hired into existing midwifery practices report that the business skills learned from this exercise have proven helpful in becoming successful in practice. For example, one student applied her vision and aspects of her student group business plan assignment to a real world situation. Portfolio in hand, she approached an existing obstetrics and gynecology practice in a rural area and proposed that they add midwifery services to their practice. As a result of her recommendations, they instituted a new midwifery practice. In turn, for several years this graduate returned as a guest who inspired students with her vision, plan, and successes. FUTURE PLANS FOR THE MINI-MIDWIFERY BUSINESS INSTITUTE
The midwifery faculty are participating in a recently awarded grant (Preparing a Diverse and Culturally Competent Nurse-Midwifery Workforce) from the Health Resources and Services Administration (Rockville, MA) that advances interprofessional education. In the future, faculty plan to include other professionals as participants in the M-MBI, such as obstetric and family medicine residents and nursepractitioner students. The goal of interprofessional participation in the M-MBI is to prepare students and providers to work within a health care team to deliver patient-centered care, monitor patient safety and quality assurance, and participate in the equitable distribution of resources within a collaborative practice. If faculty of midwifery or advanced practice nursing education programs wish to institute a program similar to the M-MBI within their curriculum, they can consult with our faculty to make individual arrangements. CONCLUSION
This article describes the M-MBI, an innovative model that facilitates new graduates’ successful career planning, and in which, they learned skills for practice business management. The M-MBI received very positive student feedback and can be replicated in other midwifery and advanced practice education programs so that more students are prepared with business skills to enhance their professional success. AUTHORS
D. Elizabeth Jesse, CNM, PhD, is Professor at the East Carolina University College of Nursing, Greenville, NC. She currently teaches in the doctoral program and was a Principal Investigator for a National Institute of Mental Health award. She taught the Professional Roles courses for 8 years and created the M-MBI. Connie Dewees, CNM, DrPH, is Clinical Assistant Professor at the East Carolina University College of Nursing, midwifery concentration. She is the clinical site director for the program.
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She also teaches the Professional Roles courses and the MMBI. William C. McDowell, PhD, is Associate Professor in the Department of Management at East Carolina University’s College of Business. He is the faculty business consultant for the M-MBI. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. ACKNOWLEDGMENTS
The authors are grateful for Elizabeth Tornquist’s (MA, FAAN) editorial support and critique of this article. REFERENCES 1.American College of Nurse Midwives. American College of Nurse-Midwives Core Competencies for Basic Midwifery Practice. Silver Springs, MD: American College of Nurse-Midwives. 2012. Available from: http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000050/Core%20 Comptencies%20Dec%202012.pdf. Accessed January 28, 2014. 2.Slager J. Business Concepts for Healthcare Providers: A Quick Reference for Midwives, PAs, NPs, CNSs, and other Disruptive Innovators. Boston, MA: Jones and Bartlett; 2004. 3.Bellack JP, Graber D, O’Neil EH, Musham C. Curriculum trends in nurse-midwifery education: Views of program directors. J Nurse Midwifery. 1998;43(5):341-350. 4.Bandura A. Self-Efficacy in Changing Societies. New York, NY: Cambridge University Press; 1995. 5.Tillett J. Practicing to the full extent of our ability: The role of nurses in healthcare reform. J Perinat Neonatal Nurs. 2011;25(2):9498. Available from: http://www.nursingcenter.com/lnc/journalarticle? Article ID=1165684 Accessed January, 28, 2014.
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6.Patient Protections and Affordable Care Act. P. L. 111–148. Sec. 3502. Patient Protection and Affordable Care Act (PPACA): S.3590, 111th Congress, 2nd Session. 2010. Available from: http://www.gpo.gov/ fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed January, 28, 2014. 7.Johnson KA. Women’s health and health reform: Implications of the Patient Protection and Affordable Care Act. Cur Opin Obstet Gynecol. 2010;22(6):492-497. 8.American Nursing Association (ANA). Issue Brief. Information and analysis on topics affecting nurses, the profession and health care. New Care Delivery Models in Health Care System Reform: Opportunities for nurses and their patients, 2010. Available from: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/HealthCareReform Resources/Care-Delivery-Models.pdf Accessed January 8, 2014. 9.American College of Nurse Midwives. ACNM Issue Brief NurseManaged Health Clinics – Health Care Reform Law (111-148) (nd). Available from: http://midwife.org/ACNM/files/ACNMLibraryData/ UPLOADFILENAME/000000000243/Nurse%20Managed% 20Hlth%20Clinics%20HCR%20111.148.May%202011.pdf Accessed January 8, 2014. 10.ACNM. Midwives and Medicare after Health Care Reform 2011. Available from: http://www.midwife.org/Midwives-and-Medicareafter-Health-Care-Reform Accessed January 8, 2014. 11.Schuiling KD, Sipe, TA, Fullerton, J. Findings from the analysis of the American College of Nurse-Midwives’ membership surveys: 2009 to 2011. JMWH 2013;58:404-415. 12.Ament L. Professional Issues in Midwifery. Sudbury, MA: Jones and Bartlett; 2007. 13.Coleman H, Kubasko D, Dickerson J. Web-Based Electronic Portfolio Systems: Asynchronous Assessment and Accountability, a Best Practices Presentation, East Carolina University. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1 &source=web&cd=4&cad=rja&ved=0CDkQFjAD&url=http%3A% 2F%2Feditlib.org%2Fd%2F29251&ei=jgdvUq2BIeza4AOpm4Co BQ&usg=AFQjCNF˙oJUruIE4qk5TRkjRaozUhLo53w Accessed October 28, 2013.
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