Certified Nurse Midwife First Assisting: Benefits, Barriers and Future Education

Many Certified Nurse Midwives (CNMs) in the United States have expanded their practice as surgical first assistant beyond their basic midwifery education. In February 2012, the Association of periOperative Registered Nurses (AORN) issued a proposal statement change regarding the Advanced Practice Registered Nurse (APRN) as surgical first assistant. Purpose: The purpose of this project was to explore the potential effect of the proposed APRN guidelines on CNMs who practice first assisting, and what benefits or barriers arise in general for CNMs when they add the role of first assistant to practice. This project also reviewed and compared educational programs available for the advanced practice nurse who wishes to expand practice to include first assisting. Aims: The aim of the questionnaire was to identify the benefits and barriers of the expanded practice of first assisting. Questions focused on the perceived effect of AORN's proposed APRN position statement on current and future practice of CNMs. Methods: An extensive literature review was completed regarding the history of nurses as first assistants and the previous and current position statements from the AORN and ACNM were reviewed. First assisting and formal RN first assistant (RNFA) educational courses available to APRNs/CNMs were identified and reviewed. The Framework for effective management of change in clinical practice: Dissemination and implementation of clinical practice guidelines was chosen as the theoretical framework for this project (Moulding, Silagy, & Weller, 1999). A pilot questionnaire was developed to explore CNM first assist issues. The questionnaire, conducted using Survey Monkey, was distributed November 11-October 4, 2012. Outcomes: Descriptive statistics and qualitative data were reported. There was a 36% response rate from Utah CNMs and 38% response rate from Utah student nurse midwives (SNMs). 47% of Utah CNMs are currently first assisting. 16% have past experience and 4.5% want to add first assisting to practice. 86% are assisting in cesarean section with 14% assisting in cesarean and gynecological surgeries. CNMs reported how they obtained training in first assisting as follows: 24% took continuing education courses, 4.8% reported taking a continuing education course at the national ACNM convention. The majority (90.5%) trained on the job with local surgeons. One respondent (4.8%) reported taking an RNFA course. The majority (95%) reported not having first assistant training in their midwifery practicum and 4.5% did. 79% of those currently assisting report that if a separate credential was required to practice, it would affect their current practice. 80% reported they would be willing to take a course to continue first assisting. 86% of those currently assisting and 75% of SNMs would like an RNFA program incorporated into the core midwifery program. Only 47% of CNMs currently assisting would be interested in a post-master's RNFA program, while 75% of SNMs would be interested depending on cost, location, and/or hours of study. Regarding reimbursement and billing, 86% reported being reimbursed for surgical first assisting. 62% reported that their practice was billing under their unique provider number (UPIN) with 33% unknown. Recommendations: Consider replication of the questionnaire to the national ACNM. Continue future research regarding reimbursement for CNM first assist through insurance and Medicaid. Add an elective course for RNFA didactic completion at the University of Utah for CNMs, APRNs, student NPs, SNMs and post-baccalaureate RNs who hold certification in the OR. Conclusions: Extra education in the RNFA role is important to consider when expanding practice as a CNM or APRN.