Professional Liability Section Survey

Certified Nurse Midwives (CNMs) and Certified Midwives (CMs) face litigation and liability in their clinical practice. The Professional Liability Section (PLS) of the American College of Nurse Midwives (ACNM) has conducted surveys in the past to understand the issues surrounding litigation in CNM and CM practice. The last liability and litigation survey distributed by the PLS was in 2009. Litigation data in midwifery practice is currently outdated, leaving a knowledge gap about multiple issues connected to litigation. The purpose of this project is to make revisions to the current survey, create a draft of the new version, and pilot the draft. The revised survey will be given to ACNM to use nationally. The objectives of this project included, 1) evaluation of previous surveys and current literature regarding CNM litigation and liability, 2) revision of the latest PLS survey for ACNM and pilot the survey, 3) analysis of the feedback from the piloted survey and discussion of needed changes with ACNM, and 4) submission of the revised survey to ACNM for national member distribution. Two previous PLS surveys have been conducted in 2005 and 2009. The 2009 survey concluded that there is a need for regular surveys to track litigation frequency and outcomes noting that new data will help to clarify professional roles in litigation for midwives, to justly distribute responsibility and thereby will improve relationships between midwifery practice and physicians. This project was implemented through discussion of the previous surveys with ACNM PLS personnel, revision of the survey with a content expert, and a review of current trends in obstetric litigation, all of which informed the revision of a new survey. The revised survey was piloted among CNM members of the Region VI ACNM affiliate in Utah who gave feedback which was as analyzed and discussed with the content expert. Revisions were made to the final survey which will be submitted to ACNM to be distributed nationally to ACNM members. The goal of this DNP project was to revise and pilot the next ACNM professional liability survey. The survey will inform stakeholders about midwifery practice trends and include the frequency and reasoning for litigation in midwifery practice. National results will provide information on changes that have occurred in liability over the last seven years. It will also highlight practice areas that are linked most frequently with litigation. The future goal of this project is to initiate a process of obtaining increased frequency of cyclic survey information.

Running head: PROFESSIONAL LIABILITY SECTION SURVEY Professional Liability Section Survey Melissa R. House Cardeña In Partial Fulfillment of the Doctor of Nursing Scholarly Project College of Nursing University of Utah 1 PROFESSIONAL LIABILITY SECTION SURVEY 2 Table of Contents Executive Summary 3 Problem Statement 4 Clinical Significance and Policy Implications 5 Objectives 7 Literature Search Strategy 7 Review of the Literature 7 Theoretical Framework Implementation and Evaluation 17 Error! Bookmark not defined. Implementation 18 Evaluation 19 Results 20 Recommendations 22 DNP Essentials 22 Conclusion 23 References 24 Appendix A: Original Survey 27 Appendix B: Suggested Edits from May 2016 PLS Meeting 50 Appendix C: Pilot Version of Survey 51 Appendix D: Survey Feedback 81 PROFESSIONAL LIABILITY SECTION SURVEY 3 Executive Summary Certified Nurse Midwives (CNMs) and Certified Midwives (CMs) face litigation and liability in their clinical practice. The Professional Liability Section (PLS) of the American College of Nurse Midwives (ACNM) has conducted surveys in the past to understand the issues surrounding litigation in CNM and CM practice. The last liability and litigation survey distributed by the PLS was in 2009. Litigation data in midwifery practice is currently outdated, leaving a knowledge gap about multiple issues connected to litigation. The purpose of this project is to make revisions to the current survey, create a draft of the new version, and pilot the draft. The revised survey will be given to ACNM to use nationally. The objectives of this project included, 1) evaluation of previous surveys and current literature regarding CNM litigation and liability, 2) revision of the latest PLS survey for ACNM and pilot the survey, 3) analysis of the feedback from the piloted survey and discussion of needed changes with ACNM, and 4) submission of the revised survey to ACNM for national member distribution. Two previous PLS surveys have been conducted in 2005 and 2009. The 2009 survey concluded that there is a need for regular surveys to track litigation frequency and outcomes noting that new data will help to clarify professional roles in litigation for midwives, to justly distribute responsibility and thereby will improve relationships between midwifery practice and physicians. This project was implemented through discussion of the previous surveys with ACNM PLS personnel, revision of the survey with a content expert, and a review of current trends in obstetric litigation, all of which informed the revision of a new survey. The revised survey was piloted among CNM members of the Region VI ACNM affiliate in Utah who gave feedback which was as analyzed and discussed with the content expert. Revisions were made to the final survey which will be submitted to ACNM to be distributed nationally to ACNM members. The goal of this DNP project was to revise and pilot the next ACNM professional liability survey. The survey will inform stakeholders about midwifery practice trends and include the frequency and reasoning for litigation in midwifery practice. National results will provide information on changes that have occurred in liability over the last seven years. It will also highlight practice areas that are linked most frequently with litigation. The future goal of this project is to initiate a process of obtaining increased frequency of cyclic survey information. Committee members included, Dr. Deb Penney CNM, MPH, PhD: DNP Project Chair, Dr. Gwen Latendresse, PhD, CNM, FACNM, CNM Specialty Track Director, Dr. Pam Hardin, PhD, RN Assistant Dean of MS and DNP Programs. Content Experts: Mary "Mamie" Guidera, CNM, MSN, FACNM - Advanced Senior Lecturer, University of Pennsylvania, Expert Witness, Chairperson of the ACNM PLS. Angela Deneris, CNM, PhD, FACNM - Professor University of Utah, Midwifery Malpractice Case Reviewer and Expert Witness. PROFESSIONAL LIABILITY SECTION SURVEY 4 Problem Statement Certified Nurse Midwives (CNMs) and Certified Midwives (CMs) face litigation and liability in their clinical practice. The Professional Liability Section (PLS) of the American College of Nurse Midwives (ACNM) has conducted surveys in the past to understand the situations, circumstances, and frequency of litigation in midwifery practice. There has not been a liability and litigation survey distributed by the PLS since 2009 (Guidera, McCool, Hanlon, Schuiling & Smith, 2012). A new survey is needed to capture current trends in litigation for CMs and CNMs and to identify areas in current CNM and CM practice that lead to litigation. In addition, according to the results of the 2009 survey (Guidera, et al., 2012), revisions are needed in the survey in order to improve data collection. This project will focus on making revisions to the a new PLS survey by creating a draft of the new version, piloting the draft, and eventually sending out the new survey to members of ACNM. The information gained from the survey is important to midwifery practice because it presents an opportunity to dispel myths about nurse-midwifery practice while shedding light on misconceptions surrounding liability. In addition, the survey will inform the leadership of PLS and ACNM of areas of areas of practice that may need attention or change. The last two survey results (2005 and 2009) have been shared at ACNM annual conference presentations and have been published (McCool, Guidera, Hakala & Delaney, 2007; Guidera, et al.,2012; McCool, Guidera, Reale, Smith & Koucoi, 2013). Development and implementation of a new survey will capture significant changes in midwifery practice that include birth settings and professional trends of new CNMs who have entered practice over the past seven years. There is a need to collect current and expanded information and to tailor questions for analysis. In particular, there is need for additional questions that will provide data about litigation outcomes, the practices PROFESSIONAL LIABILITY SECTION SURVEY 5 most frequently associated with litigation, and how litigation has affected the CNM workforce (Guidera, et al., 2012). The scope of this project will be to design and implement a new survey for CNMs/CMs with ACNM membership. It will be piloted to ACNM members in Utah. The participants will give useful feedback on the survey and after revisions are made, the survey will then be distributed to CNM/CM members of ACNM nation-wide through an online link that members will receive via email. Clinical Significance and Policy Implications The results of the 2009 ACNM PLS survey were important because they led to the debunking of myths about nurse-midwifery practice. According to M. Guidera who is the Chairperson of the PLS committee of ACNM, (personal communication, June 21, 2016), one popular myth is that it is not cost effective to hire new graduate CNMs/CMs, because they are more likely to get sued. According to Guidera, et al., (2012), this was not confirmed by the 2009 survey which found that new graduate CNM/CMs were actually the least expensive to hire and the least likely to be sued the average time of practice when litigation occurred was at 6 years. Employers who know this fact may be more likely to hire a new graduate, thus facilitating hires for new graduates. The stakeholders that are affected by the results of the survey are ACNM leadership, members of ACNM, practicing CNMs/CMs, obstetric/gynecologic (OB/GYN) physicians, CNM/CM educators, licensing boards, hospital administrators and patients. Survey results can potentially inform all stakeholders by giving information about CNM/CM practice safety and litigation. ACNM leadership and midwifery educators can learn about common areas of litigation and develop plans to make changes in practice to avoid litigation. To avoid litigation, it PROFESSIONAL LIABILITY SECTION SURVEY 6 is necessary for CNMs/CMs to practice from evidence and best standards of care, and thereby avoid fear based practice, which is linked to instances of litigation (Guidera, et al., 2012). Members of ACNM including CNMs/CMs and other midwives can use the results of the survey to critically review their practice for areas where vulnerabilities may exist for litigation and change their practice as needed. A current survey can also inform State licensing boards about areas of liability and common litigation or professional consequences of malpractice suits occurring in other states. Patients are affected by survey results in the way that results are received, interpreted, and applied by other stakeholders mentioned above. If the survey is not revised and redistributed, then practices and beliefs about litigation are limited to the results of the last two surveys leaving stakeholders with outdated information. There are many new CNMs/CMs that have entered the field since 2009, and without the insights and contributions of new practitioners, the results from seven years ago remain incomplete and outdated. Without an additional survey, misconceptions and myths will persist. The response rate in past surveys has generally been low. In 2005, the rate was 18% and 23% in 2009 (McCool, et al., 2007; Guidera, et al., 2012). One goal of this project is to increase response rates by offering an incentive to participants, with a random drawing from survey respondents for a ticket to the next annual ACNM conference. In addition, the plan is to increase the frequency of the survey distribution, and notifications of the survey. The 2009 survey results reflected the "general membership of ACNM" (Guidera et al., 2012, p. 351) by age, distribution and region and may be reflective of litigation in these general terms but the authors also noted that it is uncertain if trends in litigation are due to a significant rise in the number of midwives involved in lawsuits or a due to increased chances of this over time. This survey is valuable to various stakeholders and it has the potential to greatly impact midwifery practice. PROFESSIONAL LIABILITY SECTION SURVEY 7 Objectives The purpose of this scholarly project is to revise and distribute a new Professional Liability Section (PLS) survey to members of ACNM in order to understand current litigation and liability issues in midwifery practice. The objectives are listed below. 1. Evaluation of previous surveys, and identifying key issues regarding CNM/CM litigation and liability. 2. Creation of 2016 PLS survey for ACNM 3. Distribution/dissemination of pilot survey 4. Submission of the final version of survey to ACNM for distribution to members Literature Search Strategy The articles by authors Guidera and McCool (McCool, et al., 2007; McCool, Guidera, Stenson & Dauphinee, 2009; Guidera, et al., 2012; McCool, et al., 2013; McCool, et al., 2015). were initially surveyed as these reported directly on the PLS surveys. The literature review was then expanded by conducting a search to find additional articles relevant to midwifery litigation, and surveys involving midwives. The search terms used `were: "midwifery, litigation, and survey." These search terms were entered into Google Scholar, CINAHL and PubMed. Between these sites, these terms initially returned 11,300 results. After narrowing results down to the last 10 years, there were 6,390 results. The search results were further narrowed by changing the order of articles by most recently published, to last published. Review of the Literature The Litigious Environment In the U.S., it is common for litigation to follow after some type of adverse clinical event. When comparing previous PLS surveys, CNMs and CMs have reported an increased PROFESSIONAL LIABILITY SECTION SURVEY 8 involvement in lawsuits with more than 25% of respondents indicating their involvement in one lawsuit in 2005 (Mc Cool et al., 2007) and 32% in 2009 (Guidera et al., 2012). A survey of practicing midwives in Michigan reported that 35% of respondents had been named in one malpractice claim in their career. The American College of Obstetrics and Gynecology (ACOG) have conducted surveys on its members to track malpractice lawsuits periodically over the last 30 years (McCool, et al., 2007; Guidera, et al., 2012; McCool, et al., 2015). The incidence of malpractice lawsuits in obstetrics/gynecology clinical practice has markedly increased since these surveys initially began (McCool, et al., 2015). Additionally, these recent surveys also included an increase in midwives being named as co-defendants from 2.6% (2006-2008) as compared to 2.6% in earlier surveys (McCool et al., 2015). The litigious environment for CNM/CMs has remained awkward and antagonistic and characterized by practicing on a basis of fear rather than evidence-based strategies that could counter the chance of litigation (Greer, 2010). Fear of litigation has several implications for CNM/CM practice. As in the case of an ACOG survey on professional liability, fear may move obstetric practitioners to accept fewer high risk patients and many stopped offering trials of labor for women with a previous cesarean section (Klagholz & Strunk, 2009). Fear-based practice limits the opportunity for a variety of higher risk patients to be cared for by CNM/CMs as well. Fear of litigation negatively affects midwives' confidence and can alter decision making (Symon, 2000). A culture of fear is disempowering to competent providers (Guidera, et al., 2012). In the Michigan survey 69% of midwives reported that liability concerns had affected their practice by increasing their use of diagnostic testing beyond what might be medically indicated, using interventions earlier than before, and referring to specialists more often than in their early practice (Xu. Seifert, Jacobsen, & Ransom, 2008). PROFESSIONAL LIABILITY SECTION SURVEY 9 Results of the 2005 PLS Survey The purpose of the 2005 survey was to determine approximately how often midwives are named in malpractice lawsuits, how many years of practice, on average, take place prior to an outcome that results in litigation, and what are the practice settings where events that lead to lawsuits (McCool, et al., 2007). The survey showed that midwives were named in malpractice lawsuits approximately 16.8% of the time (McCool, et al., 2007). This same survey noted that the average years of practice prior to an outcome resulting in litigation and the first lawsuit was 6.5 years. The survey also revealed that the practice setting where the most lawsuits occur correlates to the practice setting where most midwives practice; and this was the hospital setting (86%). The 2005 survey response rate of CNMs/CMs was 17.5% and these authors concluded that responses were too small to be reflective of practices across the U.S. Also, the survey results were potentially bias as those who responded were more likely to be involved in some type of litigation. The 2005 survey represented the members of ACNM at the time, "the geographic distribution of respondents was closely representative of the distribution of ACNM registered CNMs/CMs across the country in 2004 at the time of the survey's distribution (Chi-square = 5.14; P = .40), (McCool, et al., 2007)" which means there were no significant differences between the distributions of the 2 samples - in other words, the survey sample matched the distribution of CNMs/CMs in general across the country, thus making the sample a valid one (W. F. McCool, personal communication, April, 3, Commented [MH1]: Direct quote from Bill McCool email on 04/03/2017 2017).. The main recommendation from the 2005 survey was to practice regular data collection regarding midwives' involvement in litigation (McCool, et al., 2007). These authors noted that many questions remained after analysis of the 2005 survey, for example, data did not reveal the Commented [MH2]: Direct quote from 04/03/2017 email from Bill McCool PROFESSIONAL LIABILITY SECTION SURVEY 10 number of CNM/CMs that were named in at least one lawsuit, and of these, were they more or less willing to respond to questions regarding their experiences. Also unanswered was the possible role of fear of judgment and the difficulty this may play in CNM/CMs ability to share their experiences within their community. In addition, the survey left a question about how CNM/CMs process the stressful experiences of their practice. Results of the 2009 PLS Survey Guidera, et al., (2012) reported the findings of the 2009 PLS survey which was aimed at examining the incidence of midwifery lawsuit involvement, identify the outcomes of litigation, and describe the coping mechanisms of CNM/CMs that had been involved in litigation. After analysis, these authors noted that incidence of lawsuits among midwives was significantly related to birth exposures overtime and that experience of a lawsuit did not greatly impact practice patterns or job security. They recommended that there was a need for future cyclic surveys to track litigation frequency and outcomes that result in lawsuits, to ultimately improve and establish correlations between midwifery practice and litigation in medical malpractice. "'Incorporating comments received anonymously from respondents to the 2005 Midwifery Litigation Survey and suggestions by a member of the ACOG Professional Liability section regarding the language of recent ACOG Surveys on Professional Liability (N. Wilson, oral communication, March 2008), a Web-based survey was created in 2009 to re-explore the extent to which adverse obstetric and gynecologic practice outcomes resulted in litigation proceedings for CNMs/CMs.' This speaks to "Content Validity," since we - the experts - adjusted the 2nd survey based on comments received from the 1st survey. It also hints at "Concurrent Criterion Validity" because we've compared our questions to those used by ACOG. However, I would not go as far as to say that ACOG's survey is the "gold standard" for PROFESSIONAL LIABILITY SECTION SURVEY 11 these litigation types of surveys. It's a similar one, but not the gold standard" (W. F. McCool, personal communication, April, 3, 2017). The survey by Guidera, et al., (2012) also found that CNMs/CMs know very little about their malpractice insurance coverage, and that counseling after involvement in an adverse event was greatly underused. These authors reported that fears of CNMs/CMS about malpractice and litigation are not supported by the findings of the survey, regarding frequency and actual occurrence of litigation. Strengths of the 2009 survey included its national coverage and respondents appropriately reflected the general membership of ACNM. Limitations of the 2009 survey included issues surrounding wording of questions, and answer choices that limited the potential for analysis. The questions on the survey could have included volunteer bias, by prompting or discouraging participation of CNMs/CMs who had or had not been previously involved in litigation. Areas of Litigation and Practice Deficits Major areas of litigation for CMs and CNMs have been reported by McCool et al. (2015) in their analysis of closed claims of medical malpractice lawsuits involving midwives who were insured by the American International Group from 2002-2012. These authors reported the main litigation cases included clinical situations of fetal/newborn complications or death, alleged provider negligence related to pregnancy care, shoulder dystocia, alleged negligence relating to gynecologic care, failure to assess need for a cesarean, genetic anomalies (undiagnosed during the antepartum period), and vaginal birth after a cesarean section (VBAC). In addition, the analysis mentioned practice details that led to litigation for each area. McCool, et al. (2015) found that the fetal/newborn area was the largest for risk of litigation. The majority of cases fell into subcategories of death of a newborn, stillborn, or fetal Commented [MH3]: Direct quote from Bill McCool email on 04/03/2017 PROFESSIONAL LIABILITY SECTION SURVEY 12 demise. The other cases in this category were "birth of a fetus with medical conditions, perinatal asphyxia, newborn burned by a heating pad, bleeding complications post-circumcision, and head laceration" (p. 440). In this report, antenatal and intrapartum deficits in documentation can affect the CM/CNM credibility in a legal case. Negligence is also cited as a reason for litigation. As a legal term these same authors refer to Black's Law Dictionary (Garner & Black, 2014) and defined negligence as "the failure to do what a reasonably prudent and careful clinician would do under similar circumstances, or it is the performing of some action that a person of ordinary prudence would not have done under the circumstances" (p. 440). In the analysis by McCool et al. (2015), negligence included management of cases that led to newborn death or injury, 2) maternal injury, 3) failure to diagnose, 4) substandard care (i.e., care that is considered below the standard for a particular type of care, or for the type of care typically practiced in a specific geographic area where the case originated), 5) complications with laceration repairs, and 6) negligent labor and birth management" (p. 440). The authors cited a case where negligence included the omission of documented collaboration, and consultation as standards of care when a pregnancy takes an abnormal physiologic course. Shoulder dystocia has no standard definition, but accepted definitions include: (1) impaction of the anterior or posterior shoulder, (2) failure to deliver the fetal shoulders by typical methods, (3) prolonged "head-to-body" delivery time (>60 seconds), and (4) the need for ancillary maneuvers (Hunter, 2015). These same authors reported shoulder dystocia to be the third most popular type of case reviewed (McCool, et al., 2015). In their analysis, 10 of 18 shoulder dystocia cases had an outcome of Erb's palsy (define) and some of these also included brain damage while other associated conditions included brachial plexus injury and PROFESSIONAL LIABILITY SECTION SURVEY 13 developmental delay. In their analysis, tailure to diagnose and poor management of shoulder dystocia pointed to midwifery care at the time that was substandard. This same analysis (McCool et al., 2015) reported that gynecological care negligence included 12 cases and the most common reason for these cases involved intra-uterine devices (IUDs) and failure to remove or properly place the device. The second most common area was the failure to manage and diagnose ectopic pregnancy. The authors pointed out that as CM/CNM gynecological scope of practice expands it is critically important that knowledge and skills match the care provided and that standards for care are followed. McCool et al. (2015) analyzed 12 cases where the midwife had initial care of the laboring woman and initiated a consult for a cesarean section. In these cases, failure was listed as "1) failure to perform a cesarean in a timely manner; 2) failure to perform a cesarean, resulting harm to the mother or newborn; or 3) failure to perform a cesarean, resulting in the death of the fetus" (p. 441). These failures resulted in traumatic birth, and in one case neonatal death. Three cases reviewed by McCool et al. (2015) involved genetics. Two cases involved wrongful life, referring to incidents in which a newborn has significant birth defect(s). These cases claimed that the CNM/CM had not offered sufficient counseling that would have provided the mother with an opportunity to decide about pregnancy continuation or adequate notice to prepare for caring with a newborn with special needs. There were also issues related to genetic testing failures and their relation to adverse newborn outcomes. Another theme in this category was failure of the provider to properly interpret genetic testing. According to AIG, there has been a slight increase in claims related to genetics. The increase in mothers of advanced maternal age, and increase in twin pregnancies and births, has led to increased midwifery exposure to claims in areas of genetics (McCool et al., 2015). PROFESSIONAL LIABILITY SECTION SURVEY 14 In the McCool et al., (2015) review there was only one case related to a woman attempting vaginal birth after cesarean (VBAC), which resulted in uterine rupture. Per AIG, there has been a decrease in claims related to VBAC over the past decade. It is difficult to make conclusions about VBAC claims at this time, because there was only one case in the review. The same review cited the most frequent area of litigation risk involved the well-being of the fetus and newborn (McCool et al., 2015). This was consistent with the findings of Angelini and Greenwald (2005). In cases with congenital causes, adverse outcomes are involving the fetus/newborn are an unfortunate inevitability. However, when viewing this from a clinical quality perspective, provider practice has contributed to adverse outcomes in some cases. From a risk management perspective, omissions in documentation negatively affected a midwife's testimonial credibility regarding the events that lead to adverse outcomes (McCool et al., 2015). In review of these cases, the authors (McCool et al., 2015) pointed out that a litigious environment has led to a practice based on fear where the normative practice is carried out as a standard of care without consideration for what is truly evidence-based. Additionally, fear of litigation has promoted a defensive practice characterized by the unnecessary use of technology and intervention (Greer, 2010) which can also alter decision-making (Symon, 2000). Effects of Adverse Events In a qualitative study (Robertson & Thompson, 2016) during 2006-2007, investigators interviewed 22 National Health Service (NHS) midwives in the United Kingdom after being involved in alleged negligence. The findings of this qualitative study confirmed the findings of previous studies (McCool et al., 2007; Guidera et al., 2012, Symon, 1998; Ball et al., 2002; Xu et al., 2008) conducted in the areas of midwifery practice and litigation. In the NHS study (Robertson & Thompson, 2016) the qualitative interviews of midwives who had been involved in PROFESSIONAL LIABILITY SECTION SURVEY 15 alleged negligence, showed that these midwives made several changes in their practice such as increased documentation, and an increase for some midwives in keeping personal records after adverse events. In this study the midwives also reported an increased use of electric fetal heart monitoring (EFM) in low risk cases, where continuous EFM would not be indicated. Several, of the midwives also reported an increase in defensive practice, and fear-based practice; they noted less confidence in practice and increased likelihood of medical consultation earlier in the birth process. The study found a repeated mention of "blame culture" that negatively impacted openness and ability to learn with a team approach after an adverse event. Overall, the researchers discovered that the quality of the midwife/patient relationship was negatively impacted in some instances, and some midwives felt like they couldn't establish the same rapport with their patients after alleged negligence. The study also found that some midwives lost confidence in their competence and skills; one midwife switched back to working in a nursing position, and another midwife actively sought to the leave the profession altogether. The researchers also reported that a few midwives stopped attending births after alleged negligence because of fear of litigation. In an international qualitative study, researchers (McCool, Guidera, Stenson & Dauphinee, 2009) explored experiences and coping methods of 22 midwives after involvement in an adverse perinatal outcome. The results of this study showed that in more developed nations, the main fear after involvement in some type of adverse event revolved around litigation. The study revealed that for midwives from developing nations, the fear of litigation was present, but the main fear for these midwives included loss of income and livelihood while emotional energy was focused on preventing future adverse outcomes. Midwives from developed nations who had PROFESSIONAL LIABILITY SECTION SURVEY 16 experienced an adverse outcome focused their emotional energy on personal healing, and coping with litigation. Litigation and Barriers to Practice At an International Confederation of Midwives (ICM) conference in 2010, a survey of midwives from the Americas was conducted to better understand barriers that limit midwifery practice (McCool, Guidera, Reale, Smith & Koucoi, 2013). The survey included 58 midwives from 12 different countries and was conducted in an effort to explore influences on work retention, and included encounters of adverse outcomes in clinical practice, work place empowerment for change, and migration. The findings of the survey showed that 60% of the responding midwives had encountered some type of maternal/newborn death or injury in their work and that 10% of them had considered leaving the field. There were three potential common results after encountering an adverse outcome in practice, these included (a) an investigation by a government agency; (b) complaints about the midwife in the media; (c) involvement in litigation. The results also showed that there were barriers to implementing EBP, usually in the form of resistance from obstetrical colleagues. Implications for Midwifery Practice Midwives across the globe experience common issues related to adverse perinatal outcomes (McCool et al., 2009; McCool et al., 2013). The support and the respect that the midwife receives in their workplace, and country of practice seem to have a big impact on midwifery workforce retention (McCool et al., 2013; Hildingsson et al., 2016). More support for midwives following litigation ideally would include a thorough assessment of poor outcomes, review of clinical practice standards in light of evidence-based practice and emotional support. It PROFESSIONAL LIABILITY SECTION SURVEY 17 is paramount to understand how to avoid adverse outcomes and litigation, and to promote professional resiliency. A professional liability survey is an initial step in this direction. Theoretical Framework The theoretical framework for this project is the Data, Information, Knowledge and Wisdom (DIKW) Model (Rowley, 2007). This theory has been used to explain the process of obtaining data, converting that data into understandable information, interpreting that information into knowledge, and turning that knowledge into wisdom (Baskarada & Koronios, 2013). The DIKW hierarchy began in 1987, and the current version used is taken from Rowley (2007) and referred to as the Wisdom Hierarchy. The theory includes four main ideas which are simply explained as data, information knowledge and wisdom. Application of the theory to this project is clear; data is collected and formed into relevant information then is disseminated as knowledge and then incorporated as wisdom. In this project, data was obtained through participant feedback and survey results after participants completed the piloted PLS survey. The survey was revised and will be distributed nation-wide by ACNM. The data from the revised survey will be interpreted into specific information about litigation in CM/CNM practice and disseminated nation-wide through future publications on the survey results. As CMs/CNMs read the information, they will gain knowledge about practice litigation and use this to reflect on their own practices, then hopefully, move toward needed changes in practice to prevent litigation. The translation of the information into practice is wisdom. Objectives, Implementation and Evaluation Objective 1) Identify needed changes in the previous ACNM survey Implementation 1) Discuss previous survey with key stakeholders Evaluation 1) Content expert contacted and survey revisions identified PROFESSIONAL LIABILITY SECTION SURVEY and trends in CM/CNM litigation 2) Create ACNM PLS survey 3) Test the effectiveness of the new survey through piloting with participants. 4) Dissemination of survey and survey results 2) Determine the time frame for survey revision with ACNM content expert 1) Incorporate suggested changes into the revised survey 1) Obtain permission to use list serve from affiliates' leadership. 2) Email the survey to PA and UT ACNM groups 3) Collect the responses and participant's feedback for analysis 1) Submit the revised survey to ACNM with a report of changes and responses 2) Submit an abstract for poster or podium presentation to the local ACNM affiliate for meeting in April 2017 meeting 18 2) Content expert sets time for revisions 1) Project chair and content experts review and approve revised survey 1) List serve obtained and emails sent. 2) Survey results collected and feedback from participants analyzed with content expert 3) Questions modified and survey revised with content expert 1) Completed survey is with ACNM leadership 2) Abstract and presentation reviewed and approved by content expert and project chair 3) Presentation given at April 2017 ACNM affiliate meeting. Implementation The first objective was to identify needed changes in the most recent PLS survey and gather information about litigation among CMs/CNMs. This was accomplished by conducting a through a literature review, evaluating previous surveys, identifying practice issues linked with litigation, and by having conversations with the content expert regarding the contents of the survey. The second objective was implemented by creating a new PLS survey. The University of Utah IRB office was contacted and informed regarding the nature of the pilot and the intended use of the collected data and it was concluded that IRB approval was not needed for the pilot or survey testing (See Appendix ??). The other members of the Professional Liability Section are in Commented [DP4]: Put the email you received in an appendix to show this result. Commented [MH5R4]: I never got an email from them. This was a phone conversation. I followed up but never got a response. PROFESSIONAL LIABILITY SECTION SURVEY 19 the process of obtaining IRB approval for the nationwide survey launch through the ACNM, which is separate from the pilot survey. The survey was put into a survey program (RedCap). Based on feedback from the 2005 and 2009 surveys the wording and logic of numerous questions on the survey were modified or added (See Appendix B). The third objective was to test the effectiveness and clarity of the survey questions through piloting the survey. The survey was distributed electronically to CNMs members of the Region VI ACNM affiliate in Utah through an email list serve. Permission was granted to use the list from the ACNM affiliate leadership. In preparation for the survey, in October, 2016 at a local ACNM affiliate meeting, the project was introduced and a question and answer period allowed attendees to discuss the nature of the survey and to be notified it was coming via email so members were encouraged to participate. Three days after the reminder email was sent out to the affiliate, a unique link by email was sent to each active member of the affiliate with an invitation to participate in the survey. A total of three emails were sent out to members during the course of the pilot testing period, an initial invitation email, and two additional reminder emails. Members had 2 weeks to take the survey starting on December 1, 2016 and ended on December 15th. The fourth objective was dissemination of the survey. The final revised survey and results from the pilot of the survey were submitted to ACNM national headquarters. An abstract was submitted to the local ACNM affiliate for a poster or podium presentation at a regional ACNM meeting in April of 2017. The abstract submission and presentation was reviewed by the project chair. Evaluation The objectives of this project have been achieved. Each project step for each objective was reviewed and approved by the content experts and the project chair. This was PROFESSIONAL LIABILITY SECTION SURVEY 20 evaluated as complete when and the project chair was informed that these steps had been performed. The steps included identifying the parameters and content of the project, putting the survey into a computer program (RedCap) after the wording and logic of numerous questions on the survey were modified, obtaining permission, announcing and then emailing the pilot survey to local affiliate members, obtaining feedback and discussing changes with the content experts, making revisions to the survey and submitting it to the PLS committee of ACNM. The results of the project consisted of the feedback received from participants following the pilot survey. The final form of the survey for the PLS section of ACNM has been developed and has been given to the PLS section for full ownership and use of the survey at their discretion. Results Results from piloting the survey was the focus of this project. There were two questions in the survey that allowed for written feedback, one for positive feedback, and another for recommendations for changes. Only four surveys out of all the completed surveys provided feedback with suggestions for changes. There were additionally two emails sent directly to the PI with feedback suggestions. Five specific questions were specifically mentioned in the feedback. Questions 14, 15, 17, 21, and 25 all received feedback. Feedback consisted of the need for clarity, and content revision. The feedback has been reviewed and discussed by the PLS committee and were considered before distribution to the ACNM. Questions 21 and 25, which both pertain to insurance coverage, received feedback from two participants, which both advised changing the information regarding professional liability insurance and tail. More clarity about insurance coverage and was needed, specifically who pays for these components of insurance. This question was discussed with the PLS committee and changed to reflect the suggestion based on the participant's feedback. Additionally, feedback from multiple participants was received PROFESSIONAL LIABILITY SECTION SURVEY 21 regarding the wording of the survey, pertaining to retirement and current practice status, and the need to include or modify the survey based on a CNM's/CM's retirement status. Based on this feedback, the introduction letter to was changed to clarify and promote inclusion of answers from midwives at any stage of their career, regardless of whether they are currently practicing. The logistical flow of questions was also modified to end the survey faster for midwives who are not currently in practice, and who have never been involved in litigation. One question was added to inquire about professional discipline at any time in clinical practice. Additional answers were added to questions to include data from retired CNMs/CMs. These suggestions will be reflected in the version of the survey that is submitted to the ACNM. Positive feedback about the survey length and content was received. The survey had 26 participants which represents an impressive 55% response rate. The main result of the pilot showed that the survey itself is a functioning tool that works well to collect the desired information regarding litigation and liability in midwives. The pilot showed a 6.5% rate of involvement in litigation, this closely mirrors the 7% involvement in litigation from previous surveys (McCool et al., 2007; Guidera et al., 2012). An original desire of this project was to gather sufficient feedback from participants to inform further changes to the national survey. Because only six separate suggestions were received, there was insufficient participant feedback on each individual question to merit a change to the survey itself, based on feedback alone. This was an unintended negative consequence that wasn't adequately considered prior to launching the pilot and represents the main limitation of the study. Yet, this did not prevent accomplishing the objective of the project and was not considered to sufficiently impact on the ability of the PLS committee to make informed decisions about changing the survey. These responses were considered and some of PROFESSIONAL LIABILITY SECTION SURVEY 22 them were incorporated based on PLS review of suggestions. Recommendations The project should be continued and carried out to the desired intention of a new national PLS survey for ACNM. It would be beneficial to pilot the survey to a broader audience to obtain greater clarity for questions. For the project to be continued, members of the PLS need to remain involved and new members of the PLS committee are needed to gather from the historical knowledge of those who have carried out this survey over several years. The survey revisions should involve students who can learn from this process. Local surveys could also be done by email or in person using some of the same questions to add to the knowledge on litigation among CMs and CNMs. The survey could also be given among CPMs and DEMs to compare data and practice issues. Results from the survey will be submitted by PLS members and published. Future students could use the results to assess clinical care for EBP, inform practices of areas of litigation, and foster support for midwives who have had poor outcomes. Teachers of midwives can use the information to inform students of the nature of litigation and its practice implications. DNP Essentials This project addresses DNP Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care (American Association of Colleges of Nursing [AACN], 2006). This project used technology to create and distribute a new Professional Liability Section (PLS) survey. Technology was also used to interpret the data received from participants. Essential IV is evident in this DNP project by through demonstration of technical abilities in information systems that ultimately benefit the profession of midwifery and the communities they serve. The survey demonstrates leadership in creating a national survey, management of aggregate level information, informs patient care, and PROFESSIONAL LIABILITY SECTION SURVEY 23 provides a means of applying new knowledge through the results which will ultimately impact midwifery practice and patient care. Conclusion The aim of this project was to analyze litigation information, to revise the existing national PLS survey, test the survey through a pilot distribution and modify it before national distribution. The updated survey will be used to collect data from active members of ACNM across the nation. This data will be collected and interpreted to inform practicing midwives about the litigious environment of practicing obstetrical and gynecologic midwifery care. The new data from the survey is needed and will inform midwives about areas of frequent litigation and reinforce the need for EBP so that midwives can maintain a practice of low litigation and that supports physiologic birth. PROFESSIONAL LIABILITY SECTION SURVEY 24 References Angelini, D. J., & Greenwald, L. (2005). Closed Claims Analysis of 65 Medical Malpractice Cases Involving Nurse‐Midwives. Journal of Midwifery & Women's Health, 50(6), 454460. Baskarada, S., & Koronios, A. (2013). Data, information, knowledge, wisdom (DIKW): a semiotic theoretical and empirical exploration of the hierarchy and its quality dimension. Australasian Journal of Information Systems, 18(1). Ball, L., Curtis, P., & Kirkham, M. (2002). Why Do Midwives Leave? Talking to Managers. Royal College of Midwives. Fealy, G. M., Rohde, D., Casey, M., Brady, A. M., Hegarty, J., Kennedy, C., & Prizeman, G. (2015). Facilitators and barriers in expanding scope of practice: findings from a national survey of Irish nurses and midwives. Journal of clinical nursing, 24(23-24), 3615-3626. doi: 10.1111/jocn.12980 Fullerton, J., Sipe, T. A., Hastings‐Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., ... & Krulewitch, C. J. (2015). The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data. Journal of Midwifery & Women's Health, 60(6), 751-761. doi 10.1111/jmwh.12405 Garner, B. & Black, H. (2014). Black's law dictionary. St. Paul, MN: Thomson Reuters. Greer, J. (2010). Are midwives irrational or afraid?. Evidence-Based Midwifery, 8(2), 47-53. Guidera, M. (2016, June 21). Personal phone interview Guidera, M., McCool, W., Hanlon, A., Schuiling, K., & Smith, A. (2012). Midwives and Liability: Results from the 2009 Nationwide Survey of Certified Nurse‐Midwives and PROFESSIONAL LIABILITY SECTION SURVEY 25 Certified Midwives in the United States. Journal of Midwifery & Women's Health, 57(4), 345-352.doi: 10.1111/j.1542-2011.2012. 00201.x Hildingsson, I., Gamble, J., Sidebotham, M., Creedy, D. K., Guilliland, K., Dixon, L., ... & Fenwick, J. (2016). Midwifery empowerment: National surveys of midwives from Australia, New Zealand and Sweden. Midwifery. http://dx.doi.org/10.1016/j.midw.2016.06.008 Hunter, L. A. (2015). Complications During Labor and Birth in King, T., Brucker, M.C., Kreibs, J.M., Fahey, J.O., Gegor, C.L. & Varney. H. (2015). Varney's Midwifery (5th Ed.). Burlington, MA: Jones & Bartlett Learning. McCool, W. F., Guidera, M., Griffinger, E., & Sacan, D. (2015). Closed Claims Analysis of Medical Malpractice Lawsuits Involving Midwives: Lessons Learned Regarding Safe Practices and the Avoidance of Litigation. Journal of Midwifery & Women's Health, 60(4), 437-444. doi: 10.1016/j.jmwh.2007.03.013 McCool, W. F., Guidera, M., Hakala, S., & Delaney, E. J. (2007). The Role of Litigation in Midwifery Practice in the United States: Results from a Nationwide Survey of Certified Nurse‐Midwives/Certified Midwives. Journal of Midwifery & Women's Health, 52(5), 458-464. doi: 10.1016/j.jmwh.2007.03.013 McCool, W., Guidera, M., Reale, B., Smith, A., & Koucoi, J. (2013). Professional issues related to obstacles to midwifery practice in the Americas: A pilot survey. Midwifery, 29(8), 838844. http://dx.doi.org/10.1016/j.midw.2012.08.007 McCool, W., Guidera, M., Stenson, M., & Dauphinee, L. (2009). The pain that binds us: midwives' experiences of loss and adverse outcomes around the world. Health care for women international, 30(11), 1003-1013. doi: 10.1080/07399330903134455 PROFESSIONAL LIABILITY SECTION SURVEY 26 Robertson, J. H., & Thomson, A. M. (2016). An exploration of the effects of clinical negligence litigation on the practice of midwives in England: A phenomenological study. Midwifery, 33, 55-63. http://dx.doi.org/10.1016/j.midw.2015.10.005 Rowley, J. E. (2007). The wisdom hierarchy: Representations of the DIKW hierarchy. Journal of Information Science. doi: 10.1177/0165551506070706 Symon, A. (1998). Litigation: the views of midwives and obstetricians. Who's accountable? Who's to blame? Hochland and Hochland. Symon, A. (2000). Litigation and changes in professional behaviour: a qualitative appraisal. Midwifery, 16(1), 15-21. Schuiling, K. D., Sipe, T. A., & Fullerton, J. (2013). Findings From the Analysis of the American College of Nurse‐Midwives' Membership Surveys: 2009 to 2011. Journal of Midwifery & Women's Health, 58(4), 404-415. doi:10.1111/jmwh.12064 Xu, X., Lori, J. R., Siefert, K. A., Jacobson, P. D., & Ransom, S. B. (2008). Malpractice Liability Burden in Midwifery: A Survey of Michigan Certified Nurse‐Midwives. Journal of Midwifery & Women's Health, 53(1), 19-27. PROFESSIONAL LIABILITY SECTION SURVEY 27 Appendix A: Original Survey Professional Liability Thank you for taking the time to respond to this important survey. Benefits and Risks For some individuals there may be a benefit to completing the survey. Reflecting upon stressful events or critical incidents in one's professional life may provide a means for healing. Toward this regard, participation in the survey may have some therapeutic value, although this is not the intent or goal of the investigation. Possible risk in responding to this survey is psychological distress due to rethinking an event(s) that could have caused emotional concerns at the time when the event occurred Voluntary and Confidential As with all research of this nature, participation is entirely voluntary, with absolutely no penalty or loss of ACNM benefits to anyone who decides not to participate. Confidentiality of all respondents will be maintained and all data collected de-identified. ACNM Statement on Confidentiality and De-Identification of Membership Data Membership information collected in this survey may be used in research describing membership and workforce characteristics of ACNM members. This information may be used to inform policy makers, legislatures, consumers and others. The information may be published on the ACNM website, in Quickening or professional journals. Data will be de-identified and analyzed in the aggregate to assure confidentiality and maintain anonymity of those responding. Responding to the survey is voluntary and implies consent. Demographics 1) What is your current age? ____________________________________________________________ 2) Please identify your gender. o Female o Male o I choose not to respond 3) Please select the PRIMARY state where you currently live. If you live in a territory, select 'other' and specify the territory in the box provided. PROFESSIONAL LIABILITY SECTION SURVEY o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee 28 PROFESSIONAL LIABILITY SECTION SURVEY 29 o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other (please specify) If you selected other, please specify ______________________________________________________________________ CERTIFICATION INFORMATION 4) I am currently a o CNM o CM o CNM and CM 5) Please identify the PRIMARY state where you practice midwifery. Practice encompasses clinical practice, education and/or research. If you practice in a territory, please select 'other' and fill in the name of the territory in the space provided. o o o o o o o o o o o o o o o o o o o o o Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland PROFESSIONAL LIABILITY SECTION SURVEY 30 o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other (please specify) If you selected other, please specify ______________________________________________________________________ PRACTICE INFORMATION 6) Identify your primary clinical midwifery activity from January 2002 through December 2007. o AP, IP, and GYN o AP and IP only PROFESSIONAL LIABILITY SECTION SURVEY 31 o AP and GYN only o IP only o AP only o GYN only o Did not provide patient care during this period 7) Are you currently attending births? o Yes o No 8) Did you ever attend births? o Yes o No 9) At what age did you stop attending births? ____________________________________________________________years (closest whole number) 10) What is the MAIN REASON that you stopped attending births? (Select only one). o Change in professional status/focus o Health related reason o Retirement o Desired more personal time o Fear of litigation o Negative experience with professional liability litigation o Unable to afford malpractice insurance o Unable to obtain malpractice insurance o Other (please specify) If you selected other, please specify ______________________________________________________________________ 11) How many years did you attend births? Please round to the closest whole number. ____________________________________________________________years (closest whole number) 12) How many years were you in practice when you stopped attending births? ____________________________________________________________years (closest whole number) 13) Approximately how many births have you attended? ____________________________________________________________births PROFESSIONAL LIABILITY SECTION SURVEY 32 Answer question #14 ONLY if you are in clinical practice. If you are not currently in clinical practice, leave question #14 blank (do not put zeros in the boxes if you are not in practice) and proceed to question #15. 14) During an average month, how many of each of the following procedures do you perform? Spontaneous vaginal births ___________________________________ Vacuum assisted births ___________________________________ VBACs ___________________________________ Cesarean surgical assists ___________________________________ PROFESSIONAL LIABILITY INFORMATION Note: For the purposes of this survey, professional liability insurance refers to malpractice insurance. 15) Are you currently covered by professional liability insurance? o Yes o No o Not Sure 16) If you do NOT have professional liability insurance at this time, what is/are the reason(s)? Select all that apply. □ □ □ □ □ No longer in clinical practice Cannot afford it It is not required in my state Unable to acquire insurance due to current or past involvement in liability claims I work with individuals whom I believe are not a threat to sue (i.e. non-citizens, Amish, others) □ I personally do not believe in the need for malpractice insurance □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 17) If you do NOT have professional liability insurance, are you covered by any of the following financial mechanisms to help pay for the defense of possible future medical liability claims? If you are not, select 'No" and if you are, please identify your coverage in the space provided. o Bond PROFESSIONAL LIABILITY SECTION SURVEY 33 o Escrow o Pledge of personal assets o No, I am not covered by any of the above o Other (please specify) If you selected other, please specify ______________________________________________________________________ 18) If you ARE covered by professional liability insurance, what is the source of your coverage? o State sovereign immunity o Federal Tort Claims Act o Liability insurance purchased through employer o Self-insured hospital or other organization o Liability insurance - self purchased o Other (please specify) If you selected other, please specify ______________________________________________________________________ 19) What type of professional liability insurance policy do you have? o Claims-made only (covers you for claims made against you while you are employed at the practice covered by this insurance but does not cover you for any claims made after you leave the practice, even if the adverse event occurred while you were employed by the practice). o Claims-made with tail coverage (a ‘tail' covers you for any event that occurs while you have claims-made insurance, even after you leave/resign/retire from the practice). o Occurrence (occurrence insurance is similar to ‘claims-made with a tail' coverage. It covers you for events that occur now while you are practicing, as well as in the future, in the event that a case is brought against you regarding an occurrence/event that occurred while you were employed and covered). o Other o I do not know what type of coverage I have 20) What are the current limits of your ‘per claim' coverage? Please identify the amount that is closest to your insurance coverage amount. o Less than or equal to $99,999 o $100,000 - $300,000 o $300,001 - $500,000 o $500,001 - $1,000,000 o More than or equal to $1,000,000 o I do not know the amount of my per claim coverage 21) What are the current limits of your ‘aggregate' coverage? Please identify the amount that is closest to your insurance coverage amount. PROFESSIONAL LIABILITY SECTION SURVEY 34 o $300,001 - $500,000 o $500,001 - $1,000,000 o $1,000.001 - $2,000,000 o I do not know the amount of my aggregate coverage o Other (please specify) If you selected other, please specify ______________________________________________________________________ 22) Which of the following changes or events (if any) have occurred in your personal practice during 2002 - 2007 as a result of the risk or fear of professional liability claims or litigation? (Select all that apply) □ Decreased gynecologic diagnostic/invasive procedures □ Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) □ Intentionally decreased number of births attended □ Increased number of referrals for Cesarean delivery □ Stopped offering VBACs □ Stopped attending VBACs □ Stopped attending births □ Retired from practice □ Made no changes □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 23) If you have considered retiring from practice, but have been unable to do so, has the cost of tail coverage played any role in this decision? o Yes o No o I have not considered retiring from practice. 24) Which of the following changes or events (if any) have occurred in your personal practice during 2002-2007 as a result of professional liability insurance affordability and/or availability? (Select all that apply). □ Decreased gynecologic diagnostic procedures □ Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) □ Intentionally decreased number of births attended □ Increased number of referrals for Cesarean delivery □ Stopped offering VBACs □ Stopped attending VBACs □ Stopped attending births PROFESSIONAL LIABILITY SECTION SURVEY 35 □ Quicker to consult or refer patients □ Declared bankruptcy □ Liquidated holdings or accessed savings to fund premium increases □ Reduced liability insurance coverage from what I had □ Reduced own salary by greater than 10% in order to fund premium increases □ Secured a loan to fund premium increases □ Other financial changes (please specify in space marked other) □ Other personal changes (please specify in space marked other) □ Retired from practice □ Made no changes □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 25) Have you ever been named in a professional liability claim during your midwifery career? This would include cases that were made and then dropped by the client, cases that were settled with or without payment, or cases that went to trial. o Yes o No 26) In how many liability claims related to your midwifery practice have you EVER been named? This would include cases that were made and then dropped by the client, cases that were settled with or without payment, or cases that went to trial. o One o Two o Three o Four or more For each liability claim in which you were named as a defendant, please provide the information requested in the sections that follow. FIRST LIABILITY CLAIM 27) How many years had you been in practice when the event occurred that led to the first liability claim in which you were named as a defendant? ____________________________________________________________years 28) How many years had you been in practice when you were notified that you were named as a defendant in this first liability claim? ____________________________________________________________years PROFESSIONAL LIABILITY SECTION SURVEY 36 29) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? If you are still involved in this litigation, please enter 99 ____________________________________________________________years 30) To which of the following types of care was this claim mostly related (choose one)? o Antenatal care o Intrapartum care o Immediate post-partum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other (please specify) If you selected other, please specify ______________________________________________________________________ 31) In which type of setting where you working? o Home o Freestanding birth center o Hospital o Health center o Private office 32) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a US territory or foreign country, please identify the location in the space indicated. o o o o o o o o o o o o o o o o Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa PROFESSIONAL LIABILITY SECTION SURVEY 37 o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other (please specify) If you selected other, please specify ______________________________________________________________________ 33) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) PROFESSIONAL LIABILITY SECTION SURVEY 38 o Government (e.g. Medicaid) o Self-pay o Uninsured o I do not know 34) Did you have to give a deposition as a result of this lawsuit? o Yes o No 35) Did you have to testify in court as a result of this lawsuit? o Yes o No 36) Has the case been resolved? o Yes o No 37) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation that is closest to what occurred in your situation (choose one). I was dropped from the case and the case continued without my involvement The case was dropped without a settlement The case was settled prior to going to court or arbitration The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o The outcome of the case is yet to be determined 38) Which of the following helped you cope when you were named in a lawsuit? Select all that apply. o o o o □ Support/working with an attorney □ Support from practice partners and colleagues (midwives, nurse practitioners, physicians) □ Support from other midwives outside of my practice □ Support from family and friends □ Formal counseling or therapy □ Recreational activities such as exercise or socializing □ Change of employment (a new midwifery position) □ Change of career (a position other than clinical midwifery) □ Nothing helped me cope □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 39) How did being named in this lawsuit affect your professional liability status? Select all that apply. PROFESSIONAL LIABILITY SECTION SURVEY 39 □ There was no change in my insurance company nor in the cost of my premiums □ I continued to be covered by the same insurance company, but the cost of my premiums increased. □ I changed professional liability insurance providers because of increased premiums (my choice). □ I changed professional liability insurance providers for reasons other than cost increase (my choice). □ My professional liability insurer dropped me from coverage. □ I have been unable to obtain new professional liability coverage. 40) How did being named in this lawsuit affect your employment status? (Choose one.) o There was no change in my employment status o My clinical privileges were suspended o I temporarily altered clinical midwifery practice (e.g., stopped attending births) o I temporarily stopped clinical midwifery practice altogether o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 41) How did being named in this lawsuit affect your clinical practice? (Select all that apply.) □ Decreased gynecologic diagnostic/invasive procedures □ Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) □ Intentionally decreased number of births attended □ Increased number of referrals for Cesarean delivery □ Stopped offering VBACs □ Stopped attending VBACs □ Stopped attending births □ Retired from practice □ Made no changes □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 42) Were any of the following individuals also named in this lawsuit? Select all that apply. □ □ □ □ □ □ □ □ My collaborating physician(s) My midwifery partner(s) Nurse practitioner(s) Nurse(s) Another physician (non collaborating) Anesthesiologist or nurse anesthetist Neonatologist Medical resident PROFESSIONAL LIABILITY SECTION SURVEY 40 □ Midwifery student □ No one else was named in the lawsuit 43) Have you been involved in a second liability claim? o Yes o No SECOND LIABILITY CLAIM 44) How many years had you been in practice when the event occurred that led to the second liability claim in which you were named as a defendant? ____________________________________________________________years 45) How many years had you been in practice when you were notified that you were named as a defendant in this second liability claim? ____________________________________________________________years 46) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? ____________________________________________________________years 47) To which of the following types of care was this claim mostly related? (Select only one) o Antenatal care o Intrapartum care o Immediate post partum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other (please specify) If you selected other, please specify ______________________________________________________________________ 48) In which type of setting were you working? o Home o Freestanding birth center o Hospital o Health center o Private office 49) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a US territory or foreign country, please identify the location in the space indicated. o Alabama o Alaska PROFESSIONAL LIABILITY SECTION SURVEY o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah 41 PROFESSIONAL LIABILITY SECTION SURVEY 42 o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other (please specify) If you selected other, please specify ______________________________________________________________________ 50) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o I do not know 51) Did you have to give a deposition as a result of this lawsuit? o Yes o No 52) Did you have to testify in court as a result of this lawsuit? o Yes o No 53) Has the case been resolved? o Yes o No 54) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation that is closest to what occurred in your situation (choose one). I was dropped from the case and the case continued without my involvement The case was dropped without a settlement The case was settled prior to going to court or arbitration The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o The outcome of the case is yet to be determined 55) Which of the following helped you cope when you were named in a lawsuit? Select all that apply. o o o o □ Support/working with an attorney □ Support from practice partners and colleagues (midwives, nurse practitioners, physicians) PROFESSIONAL LIABILITY SECTION SURVEY 43 □ Support from other midwives outside of my practice □ Support from family and friends □ Formal counseling or therapy □ Recreational activities such as exercise or socializing □ Change of employment (a new midwifery position) □ Change of career (a position other than clinical midwifery) □ Nothing helped me cope □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 56) How did being named in this lawsuit affect your professional liability status? Select all that apply. □ There was no change in my insurance company nor in the cost of my premiums □ I continued to be covered by the same insurance company, but the cost of my premiums increased. □ I changed professional liability insurance providers because of increased premiums (my choice). □ I changed professional liability insurance providers for reasons other than cost increase (my choice). □ My professional liability insurer dropped me from coverage. □ I have been unable to obtain new professional liability coverage. 57) How did being named in this lawsuit affect your employment status? (Choose one.) o There was no change in my employment status o My clinical privileges were suspended o I temporarily altered clinical midwifery practice (e.g., stopped attending births) o I temporarily stopped clinical midwifery practice altogether o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 58) How did being named in this lawsuit affect your clinical practice? (Select all that apply.) □ Decreased gynecologic diagnostic/invasive procedures □ Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) □ Intentionally decreased number of births attended □ Increased number of referrals for Cesarean delivery □ Stopped offering VBACs □ Stopped attending VBACs □ Stopped attending births □ Retired from practice □ Made no changes PROFESSIONAL LIABILITY SECTION SURVEY 44 □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 59) Were any of the following individuals also named in this lawsuit? Select all that apply. □ My collaborating physician(s) □ My midwifery partner(s) □ Nurse practitioner(s) □ Nurse(s) □ Another physician (non collaborating) □ Anesthesiologist or nurse anesthetist □ Neonatologist □ Medical resident □ Midwifery student □ No one else was named in the lawsuit 60) Have you been involved in a third liability claim? o Yes o No THIRD LIABILITY CLAIM 61) How many years had you been in practice when the event occurred that led to the second liability claim in which you were named as a defendant? ____________________________________________________________years 62) How many years had you been in practice when you were notified that you were named as a defendant in this second liability claim? ____________________________________________________________years 63) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? ____________________________________________________________years 64) To which of the following types of care was this claim mostly related? (Select only one) o Antenatal care o Intrapartum care o Immediate post-partum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other (please specify) If you selected other, please specify PROFESSIONAL LIABILITY SECTION SURVEY 45 ______________________________________________________________________ 65) In which type of setting were you working? o Home o Freestanding birth center o Hospital o Health center o Private office 66) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a US territory or foreign country, please identify the location in the space indicated. o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey PROFESSIONAL LIABILITY SECTION SURVEY 46 o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other (please specify) If you selected other, please specify ______________________________________________________________________ 67) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o I do not know 68) Did you have to give a deposition as a result of this lawsuit? o Yes o No 69) Did you have to testify in court as a result of this lawsuit? o Yes o No 70) Has the case been resolved? o Yes o No PROFESSIONAL LIABILITY SECTION SURVEY 47 71) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation that is closest to what occurred in your situation (choose one). I was dropped from the case and the case continued without my involvement The case was dropped without a settlement The case was settled prior to going to court or arbitration The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o The outcome of the case is yet to be determined 72) Which of the following helped you cope when you were named in a lawsuit? Select all that apply. o o o o □ Support/working with an attorney □ Support from practice partners and colleagues (midwives, nurse practitioners, physicians) □ Support from other midwives outside of my practice □ Support from family and friends □ Formal counseling or therapy □ Recreational activities such as exercise or socializing □ Change of employment (a new midwifery position) □ Change of career (a position other than clinical midwifery) □ Nothing helped me cope □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 73) How did being named in this lawsuit affect your professional liability status? Select all that apply. □ There was no change in my insurance company nor in the cost of my premiums □ I continued to be covered by the same insurance company, but the cost of my premiums increased. □ I changed professional liability insurance providers because of increased premiums (my choice). □ I changed professional liability insurance providers for reasons other than cost increase (my choice). □ My professional liability insurer dropped me from coverage. □ I have been unable to obtain new professional liability coverage. 74) How did being named in this lawsuit affect your employment status? (Choose one.) o o o o There was no change in my employment status My clinical privileges were suspended I temporarily altered clinical midwifery practice (e.g., stopped attending births) I temporarily stopped clinical midwifery practice altogether PROFESSIONAL LIABILITY SECTION SURVEY 48 o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 75) How did being named in this lawsuit affect your clinical practice? (Select all that apply.) □ Decreased gynecologic diagnostic/invasive procedures □ Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) □ Intentionally decreased number of births attended □ Increased number of referrals for Cesarean delivery □ Stopped offering VBACs □ Stopped attending VBACs □ Stopped attending births □ Retired from practice □ Made no changes □ Other (please specify) If you selected other, please specify ______________________________________________________________________ 76) Were any of the following individuals also named in this lawsuit? Select all that apply. □ My collaborating physician(s) □ My midwifery partner(s) □ Nurse practitioner(s) □ Nurse(s) □ Another physician (non collaborating) □ Anesthesiologist or nurse anesthetist □ Neonatologist □ Medical resident □ Midwifery student □ No one else was named in the lawsuit Thank you for taking the time to complete this survey and provide the ACNM with this information. Contact Information For questions about the survey please contact either one or both of the principal researchers: Mamie Guidera, MSN, CNM Member, Professional Liability Section (PLS) American College of Nurse-Midwives [e-mail] Bill McCool, CNM, PhD, FACNM PROFESSIONAL LIABILITY SECTION SURVEY 49 Chair, Professional Liability Section (PLS) American College of Nurse-Midwives [e-mail] If you want to talk to someone other than those working on the study about the investigation, you may contact the Office of Regulatory Affairs at the University of Pennsylvania with any question, concerns, or complaints by calling [phone]. For technical questions about the survey please contact: Kerri D. Schuiling, PhD, CNM, WHNP-BC, FACNM Senior Staff Researcher American College of Nurse-Midwives [e-mail] PROFESSIONAL LIABILITY SECTION SURVEY 50 Appendix B: Suggested Edits from May 2016 PLS Meeting a. b. 1. 1. 2. 3. 4. 5. 1. 2. Reviewed the survey questions Additional questions/topics needed i. #14 - add Circumcision, Ultrasound, forceps assisted birth, well-baby care, colposcopy, gynecology visits, LARC implants (IUD/nexplanon), other with free text box Change time frame to "average year" as opposed to "month" ii. Add "don't know" to #17 and #18 iii. #18 - add department of defense or federal coverage iv. What year were you sued? v. Have you had difficulty getting malpractice insurance? What is cost annually? Are you satisfied with your coverage? maybe include this in the top portion around questions 18-20 vi. In the questions about the claims: Was collaborative or consulting physician involved in litigation? Was it involving home birth, birth center, or transfer? vii. In intro questions Is practice governed by BOM, BON, Board of Health Professions, Dept. of Defense? Did litigation lead to discipline by state licensing board or governing board? Have you been disciplined by licensing/governing board without litigation? Adverse outcome/event that resulted in loss of privileges or sanction or discipline - with or without litigation? Discussed making these questions smart questions as well - how many times, what year, what was the reason? A concern there might not be enough data returned to get information for this viii. Employment categories - full time, part time, split times/slots/job sharing ix. Demographic data needs to be more specific - rural setting, inner-city, private, hospital owned, etc. x. #30 - reasons for litigation Add smart questions based on if you select antenatal care or intrapartum Discussion that we may not have enough data/aggregate for these responses to be meaningful xi. #23 - reword - has tail coverage expense been a factor in your retirement? xii. #31/32 - location of practice, need to include DOD facility xiii. #33 - add Tri-Care as insurance option PROFESSIONAL LIABILITY SECTION SURVEY 51 Appendix C: Pilot Version of Survey Thank you for taking the time to respond to this important survey that will help us to assess the incidence of midwifery claims, characterize risk factors associated with litigation for midwives, and to determine major categories of liability risk for midwives. Benefits and Risks For some individuals, there may be a benefit to completing the survey. Reflecting upon stressful events or critical incidents in one's professional life may provide a means for healing. Toward this regard, participation in the survey may have some therapeutic value, although this is not the intent or goal of the investigation. Possible risk in responding to this survey is psychological distress due to rethinking an event(s) that could have caused emotional concerns at the time when the event occurred. Voluntary and Confidential As with all research of this nature, participation is entirely voluntary, with absolutely no penalty or loss of ACNM benefits to anyone who decides not to participate. Confidentiality of all respondents will be maintained and all data collected de-identified. ACNM Statement on Confidentiality and De-Identification of Membership Data Membership information collected in this survey may be used in research describing membership and workforce characteristics of ACNM members. This information may be used to inform policy makers, legislatures, consumers and others. The information may be published on the ACNM website, in Quickening or professional journals. Data will be de-identified and analyzed in the aggregate to assure confidentiality and maintain anonymity of those responding. Responding to the survey is voluntary and implies consent. This survey has been approved by the University of Pennsylvania IRB. ______________________________________________________________________________ PARTICIPANT DEMOGRAPHICS 1) What is your current age? __________________________________ 2) Please identify your gender. o Female o Male PROFESSIONAL LIABILITY SECTION SURVEY 52 o I choose not to respond 3) Please select the PRIMARY state where you Alabama currently live. If you live in a territory, select Alaska 'other' and specify the territory in the box provided. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota PROFESSIONAL LIABILITY SECTION SURVEY o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other Other residence area, please specify __________________________________ CERTIFICATION INFORMATION 4) I am currently a o CNM o CM o CNM and CM 5) Please identify the PRIMARY state where you Alabama practice midwifery. Practice encompasses clinical practice, education and/or research. If you practice in a territory, please select 'other' and fill in the name of the territory in the space provided. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota 53 PROFESSIONAL LIABILITY SECTION SURVEY 54 o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other Other practice area, please specify __________________________________ 6) Identify the governing body for your practice. o Board of Medicine o Board of Nursing o Board of Midwifery o Board of Health Professions o Department of Defense o Other (please specify) Other governing/regulating body, please specify __________________________________ PRACTICE INFORMATION 7) Identify your primary clinical midwifery activity from January 2010 through December 2015. AP and IP only o AP, IP, and GYN o AP and GYN only o IP only o AP only PROFESSIONAL LIABILITY SECTION SURVEY o GYN only o Did not provide patient care during this period o 8) Are you currently attending births? o Yes o No 9) Did you ever attend births? o Yes o No 10) What is the MAIN REASON that you stopped attending births? o Change in professional status/focus o Personal Health related reason o Retirement o Desired more personal time o Fear of litigation o Negative experience with professional liability o litigation o Unable to afford malpractice insurance o Unable to obtain malpractice insurance o Other (please specify) Other reason you stopped attending births (please specify) __________________________________ 11) How many years did you attended births? Please round to the closest whole number. _________________________________ year(s) 12) How many years were you in practice when you stopped attending births? Please round to the closest whole number. __________________________________year(s) 13) Approximately how many births have you attended? __________________________________ 14)Are you currently in clinical practice? o Yes o No 15) On average, how many of each of the following procedures do you perform? Spontaneous vaginal births per year o 0-5 o 6 - 10 o 11 - 15 o 16 - 20 o 21 - 25 55 PROFESSIONAL LIABILITY SECTION SURVEY o > 25 Vacuum assisted births per year o 0 o 1 o 2 o 3 o 4 o >4 Forceps assisted births per year o 0 o 1 o 2 o 3 o 4 o >4 VBACs per year o 0 o 1 o 2 o 3 o 4 o >4 Cesarean surgical assists per year o 0 o 1 o 2 o 3 o 4 o >4 Circumcision per month o 0 o 1 o 2 o 3 o 4 o >4 Ultrasound o 0 o 20 per week o 20 per month o 20 in 6 months o 20 per year Well-baby care per month o 0 o 1 - 10 o 11 - 20 56 PROFESSIONAL LIABILITY SECTION SURVEY 57 o 21 -30 o 31 - 40 o > 40 Colposcopy per week o 0 o 1-2 o 3-4 o 5-6 o 7-8 o >8 Gynecological visits per week o 0 o 1 - 10 o 11 - 20 o 21 -30 o 31 - 40 o > 40 Long acting reversible contraceptive (LARC) implants (IUD/Nexplanon) per week o 0 o 1 o 2 o 3 o 4 o >4 Other procedures __________________________________ (type and times per year) PROFESSIONAL LIABILITY INFORMATION Note: For the purposes of this survey, professional liability insurance refers to malpractice insurance. 16) Are you currently covered by professional liability insurance? o Yes o No o Not Sure 17) If you do NOT have professional liability insurance at this time, or are unsure about your professional liability insurance status, what is/are the reason(s)? Select all that apply. o No longer in clinical practice o Cannot afford it o It is not required in my state o Unable to acquire insurance due to current or past involvement in liability claims o I work with individuals whom I believe are not a threat to sue (i.e. non-citizens, Amish, others) o I personally do not believe in the need for malpractice insurance o Other If you selected other, please specify __________________________________ PROFESSIONAL LIABILITY SECTION SURVEY 58 18) If you do NOT have professional liability insurance, or are unsure of your coverage status, are you covered by any of the following financial mechanisms to help pay for the defense of possible future medical liability claims? o Bond o Escrow o Pledge of personal assets o No, I am not covered by any of the above o Do not know o Other If you selected other, please specify __________________________________ 19) If you ARE covered by professional liability insurance, what is the source of your coverage? o State sovereign immunity o Federal Tort Claims Act o Liability insurance purchased through employer o Self-insured hospital or other organization o Liability insurance - self purchased o Department of Defense o Federal Coverage o Do not know o Other If you selected other, please specify __________________________________ 20) What type of professional liability insurance policy do you have? o Claims-made only (covers you for claims made against you while you are employed at the practice covered by this insurance but does not cover you for any claims made after you leave the practice, even if the adverse event occurred while you were employed by the practice). o Claims-made with tail coverage (a 'tail' covers you for any event that occurs while you have claims-made insurance, even after you leave/resign/retire from the practice). o Occurrence (occurrence insurance is similar to 'claims-made with a tail' coverage. It covers you for events that occur now while you are practicing, as well as in the future, in the event that a case is brought against you regarding an occurrence/event that occurred while you were employed and covered). o Other o I do not know what type of coverage I have If other type of professional liability insurance policy selected, please specify __________________________________ PROFESSIONAL LIABILITY SECTION SURVEY 21) What are the current limits of your 'per claim' coverage? Please identify the amount that is closest to your insurance coverage amount. o Less than or equal to $99,999 o $100,000 - $300,000 o $300,001 - $500,000 o $500,001 - $1,000,000 o More than or equal to $1,000,000 o I do not know the amount of my per claim coverage 22) What are the current limits of your 'aggregate' coverage? Please identify the amount that is closest to your insurance coverage amount. o $300,001 - $500,000 o $500,001 - $1,000,000 o $1,000.001 - $2,000,000 o I do not know the amount of my aggregate coverage o Other If you selected other, please specify __________________________________ 23) If you have professional liability insurance, what is the annual premium for you or for whomever pays? Please identify the amount that is closest to yours. o $0 - $5,000 o $5,001 - $10,000 o $10,001 - $15,000 o $15,001 - $20,000 o $20,001 - $25,000 o $25,001 - $30,000 o > $30,001 o I do not know. 24) If you have professional liability insurance, are you satisfied with your coverage? o Yes o No If you selected no, please specify reason(s) __________________________________ (Examples: cost, limited coverage, restrictions, etc.) 25) Which of the following changes or events (if any) have occurred in your personal practice during 2010 - 2015 as a result of the risk or fear of professional liability claims or litigation? (Select all that apply) o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery o Stopped offering VBACs 59 PROFESSIONAL LIABILITY SECTION SURVEY 60 o Stopped attending VBACs o Stopped attending births o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 26) Has tail coverage expense been a factor in your retirement? o Yes o No o I have not considered retiring from practice 27) Which of the following changes or events (if any) have occurred in your personal practice during 2010 - 2015 as a result of professional liability insurance affordability and/or availability? (Select all that apply) o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery o Stopped offering VBACs o Stopped attending VBACs o Stopped attending births o Quicker to consult or refer patients o Declared bankruptcy o Liquidated holdings or accessed savings to fund premium increases o Reduced liability insurance coverage from what I had o Reduced own salary by greater than 10% in order to fund premium increases o Secured a loan to fund premium increases o Other financial changes (please specify in space marked other) o Other personal changes (please specify in space marked other) o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 28) Have you ever been named in a professional liability claim during your midwifery career and/or faced professional licensing discipline? This would include cases that were made and then dropped by the client, cases that were settled with or without payment, cases that went to trial, cases that resulted in professional licensing discipline, or cases that didn't face litigation but resulted in professional discipline from licensing/governing board. o Yes o No PROFESSIONAL LIABILITY SECTION SURVEY 61 29) In how many liability claims related to your midwifery practice have you EVER been named? This would include cases that were made and then dropped by the client, cases that were settled with or without payment, or cases that went to trial. o One o Two o Three o Four or more For each liability claim in which you were named as a defendant, please provide the information requested in the sections that follow. FIRST LIABILITY CLAIM 30) In what year did your first liability claim occur? __________________________________ 31) Which category(s) of liability risk did the ligation fall under? Select all that apply. o VBAC o Shoulder dystocia o Error in diagnosis (incorrect or missed) o Fetal assessment and fetal heart monitoring interpretation o Resuscitation efforts o Laceration repair and healing o Issues related to consulting of lack thereof o Other If you selected other, please specify __________________________________ 32) How many years had you been in practice when the event occurred that led to the first liability claim in which you were named as a defendant? __________________________________ (years) 33) How many years had you been in practice when you were notified that you were named as a defendant in this first liability claim? __________________________________(years) 34) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? If you are still involved in this litigation, please enter 99. __________________________________(years) 35) To which of the following types of care was the claim mostly related (choose one)? o Antenatal o Intrapartum care o Immediate postpartum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care PROFESSIONAL LIABILITY SECTION SURVEY o Primary care o Other If you selected other, please specify __________________________________ 36) In which type of setting were you working? Select all that apply. o Home o Freestanding birth center o Hospital/hospital owned o Federally qualified health center o Private office o Rural o Inner-city o Department of Defense 37)Did the event involve transfer of care to a hospital? o Yes o No 38) What was your employment status? o Full-time o Part-time o Split times/slots/job sharing 39) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a U.S. territory or foreign country, please identify the location in the space indicated. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine 62 PROFESSIONAL LIABILITY SECTION SURVEY 63 o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other If you selected other, please specify __________________________________ 40) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o Tri-Care o I do not know o Other If you selected other, please specify __________________________________ 41) Did you have to give a deposition as a result of this lawsuit? PROFESSIONAL LIABILITY SECTION SURVEY 64 o Yes o No 42) Did you have to testify in court as a result of this lawsuit? o Yes o No 43) Has the case been resolved? o Yes o No 44) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation(s) that is closest to what happened in your case. (Select all that apply.) o I was dropped from the case and the case continued without my involvement o The case was dropped without settlement o The case was settled prior to going to court or arbitration o The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o I was disciplined by the state licensing board or governing body o I lost privileges or sanctions o The outcome of the case is yet to be determined o Other If selected other, please specify __________________________________ 45) Which of the following helped you to cope when you were named in a lawsuit? Select all that apply. o Support/working with an attorney o Support from practice partners and colleagues (midwives, nurse practitioners, physicians) o Support from other midwives outside my practice o Support from family and friends o Formal counseling or therapy o Recreational activities such as exercise or socializing o Change of employment (a new midwifery position) o Change of career (a position other than clinical midwifery) o Nothing helped me cope o Other If you selected other, please specify __________________________________ 46) How did being named in this lawsuit affect your professional liability status? Select all that apply. o There was no change in my insurance company nor in the cost of my premiums o I continued to be covered by the same insurance company, but the cost of my premiums increased PROFESSIONAL LIABILITY SECTION SURVEY 65 o I changed professional liability insurance providers because of increased premiums (my choice) o I changed professional liability insurance providers for reasons other than cost increase (my choice) o My professional liability insurer dropped me from coverage o I have been unable to obtain new professional liability coverage 47) How did being named in this lawsuit affect your employment status? Choose one. o There was no change in my employment status o My clinical privileges were suspended o I temporarily altered clinical midwifery practice (e.g., stopped attending births) o I temporarily stopped clinical midwifery practice altogether o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 48) How did being named in this lawsuit affect your clinical practice? o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery o Stopped offering VBACs o Stopped attending VBACs o Stopped attending births o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 49) Were any of the following individuals also named in this lawsuit? Select all that apply. o My collaborating physician(s) o My midwifery partner(s) o Nurse practitioner(s) o Nurse(s) o Another physician (non-collaborating) o Anesthesiologist or nurse anesthetist o Neonatologist o Medical resident o Midwifery student o No one else was named in the lawsuit SECOND LIABILITY CLAIM PROFESSIONAL LIABILITY SECTION SURVEY 66 50) In what year did your second liability claim occur? __________________________________ 51) Which category(s) of liability risk did the ligation fall under? Select all that apply. o VBAC o Shoulder dystocia o Error in diagnosis (incorrect or missed) o Fetal assessment and fetal heart monitoring o interpretation o Resuscitation efforts o Laceration repair and healing o Issues related to consulting or lack thereof o Other If you selected other, please specify __________________________________ 52) How many years had you been in practice when the event occurred that led to the second liability claim in which you were named as a defendant? __________________________________ (years) 53) How many years had you been in practice when you were notified that you were named as a defendant in this second liability claim? __________________________________ (years) 54) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? If you are still involved in this litigation, please enter 99. __________________________________(years) 55) To which of the following types of care was the claim mostly related (choose one)? o Antenatal o Intrapartum care o Immediate postpartum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other If you selected other, please specify __________________________________ 56) In which type of setting were you working? Select all that apply. o Home o Freestanding birth center o Hospital/hospital owned o Federally qualified health center o Private office PROFESSIONAL LIABILITY SECTION SURVEY o Rural o Inner-city o Department of Defense 57)Did the event involve transfer of care to a hospital? o Yes o No 58) What was your employment status? o Full-time o Part-time o Split times/slots/job sharing 59) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a U.S. territory or foreign country, please identify the location in the space indicated. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire 67 PROFESSIONAL LIABILITY SECTION SURVEY 68 o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other If you selected other, please specify __________________________________ 60) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o Tri-Care o I do not know o Other If you selected other, please specify __________________________________ 61) Did you have to give a deposition as a result of this lawsuit? o Yes o No 62) Did you have to testify in court as a result of this lawsuit? o Yes o No 63) Has the case been resolved? o Yes o No PROFESSIONAL LIABILITY SECTION SURVEY 69 64) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation(s) that is closest to what happened in your case. (Select all that apply.) o I was dropped from the case and the case continued without my involvement o The case was dropped without settlement o The case was settled prior to going to court or arbitration o The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o I was disciplined by the state licensing board or governing body o I lost privileges or sanctions o The outcome of the case is yet to be determined o Other If selected other, please specify __________________________________ 65) Which of the following helped you to cope when you were named in a lawsuit? Select all that apply. o Support/working with an attorney o Support from practice partners and colleagues (midwives, nurse practitioners, physicians) o Support from other midwives outside my practice o Support from family and friends o Formal counseling or therapy o Recreational activities such as exercise or socializing o Change of employment (a new midwifery position) o Change of career (a position other than clinical midwifery) o Nothing helped me cope o Other If you selected other, please specify __________________________________ 66) How did being named in this lawsuit affect your professional liability status? Select all that apply. o There was no change in my insurance company nor in the cost of my premiums o I continued to be covered by the same insurance company, but the cost of my premiums increased o I changed professional liability insurance providers because of increased premiums (my choice) o I changed professional liability insurance providers for reasons other than cost increase (my choice) o My professional liability insurer dropped me from coverage o I have been unable to obtain new professional liability coverage 67) How did being named in this lawsuit affect your employment status? Choose one. o There was no change in my employment status o My clinical privileges were suspended PROFESSIONAL LIABILITY SECTION SURVEY o o o o 70 I temporarily altered clinical midwifery practice (e.g., stopped attending births) I temporarily stopped clinical midwifery practice altogether I have permanently altered clinical midwifery practice (e.g., stopped attending births) I have permanently stopped clinical midwifery practice altogether 68) How did being named in this lawsuit affect your clinical practice? o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery o Stopped offering VBACs o Stopped attending VBACs o Stopped attending births o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 69) Were any of the following individuals also named in this lawsuit? Select all that apply. o My collaborating physician(s) o My midwifery partner(s) o Nurse practitioner(s) o Nurse(s) o Another physician (non-collaborating) o Anesthesiologist or nurse anesthetist o Neonatologist o Medical resident o Midwifery student o No one else was named in the lawsuit THIRD LIABILITY CLAIM 70) In what year did your third liability claim occur? __________________________________ 71) Which category(s) of liability risk did the ligation fall under? Select all that apply. o VBAC o Shoulder dystocia o Error in diagnosis (incorrect or missed) o Fetal assessment and fetal heart monitoring o interpretation o Resuscitation efforts o Laceration repair and healing o Issues related to consulting or lack thereof o Other PROFESSIONAL LIABILITY SECTION SURVEY 71 If you selected other, please specify __________________________________ 72) How many years had you been in practice when the event occurred that led to the second liability claim in which you were named as a defendant? __________________________________ (years) 73) How many years had you been in practice when you were notified that you were named as a defendant in this second liability claim? __________________________________ (years) 74) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? If you are still involved in this litigation, please enter 99. __________________________________(years) 75) To which of the following types of care was the claim mostly related (choose one)? o Antenatal o Intrapartum care o Immediate postpartum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other If you selected other, please specify __________________________________ 76) In which type of setting were you working? Select all that apply. o Home o Freestanding birth center o Hospital/hospital owned o Federally qualified health center o Private office o Rural o Inner-city o Department of Defense 77)Did the event involve transfer of care to a hospital? o Yes o No 78) What was your employment status? o Full-time o Part-time o Split times/slots/job sharing PROFESSIONAL LIABILITY SECTION SURVEY 79) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a U.S. territory or foreign country, please identify the location in the space indicated. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee 72 PROFESSIONAL LIABILITY SECTION SURVEY 73 o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other If you selected other, please specify __________________________________ 80) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o Tri-Care o I do not know o Other If you selected other, please specify __________________________________ 81) Did you have to give a deposition as a result of this lawsuit? o Yes o No 82) Did you have to testify in court as a result of this lawsuit? o Yes o No 83) Has the case been resolved? o Yes o No 84) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation(s) that is closest to what happened in your case. (Select all that apply.) o I was dropped from the case and the case continued without my involvement o The case was dropped without settlement o The case was settled prior to going to court or arbitration o The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o I was disciplined by the state licensing board or governing body o I lost privileges or sanctions PROFESSIONAL LIABILITY SECTION SURVEY 74 o The outcome of the case is yet to be determined o Other If selected other, please specify __________________________________ 85) Which of the following helped you to cope when you were named in a lawsuit? Select all that apply. o Support/working with an attorney o Support from practice partners and colleagues (midwives, nurse practitioners, physicians) o Support from other midwives outside my practice o Support from family and friends o Formal counseling or therapy o Recreational activities such as exercise or socializing o Change of employment (a new midwifery position) o Change of career (a position other than clinical midwifery) o Nothing helped me cope o Other If you selected other, please specify __________________________________ 86) How did being named in this lawsuit affect your professional liability status? Select all that apply. o There was no change in my insurance company nor in the cost of my premiums o I continued to be covered by the same insurance company, but the cost of my premiums increased o I changed professional liability insurance providers because of increased premiums (my choice) o I changed professional liability insurance providers for reasons other than cost increase (my choice) o My professional liability insurer dropped me from coverage o I have been unable to obtain new professional liability coverage 87) How did being named in this lawsuit affect your employment status? Choose one. o There was no change in my employment status o My clinical privileges were suspended o I temporarily altered clinical midwifery practice (e.g., stopped attending births) o I temporarily stopped clinical midwifery practice altogether o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 88) How did being named in this lawsuit affect your clinical practice? o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery PROFESSIONAL LIABILITY SECTION SURVEY 75 o Stopped offering VBACs o Stopped attending VBACs o Stopped attending births o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 89) Were any of the following individuals also named in this lawsuit? Select all that apply. o My collaborating physician(s) o My midwifery partner(s) o Nurse practitioner(s) o Nurse(s) o Another physician (non-collaborating) o Anesthesiologist or nurse anesthetist o Neonatologist o Medical resident o Midwifery student o No one else was named in the lawsuit FOURTH LIABILITY CLAIM 90) In what year did your fourth liability claim occur? __________________________________ 91) Which category(s) of liability risk did the ligation fall under? Select all that apply. o VBAC o Shoulder dystocia o Error in diagnosis (incorrect or missed) o Fetal assessment and fetal heart monitoring o interpretation o Resuscitation efforts o Laceration repair and healing o Issues related to consulting or lack thereof o Other If you selected other, please specify __________________________________ 92) How many years had you been in practice when the event occurred that led to the second liability claim in which you were named as a defendant? __________________________________ (years) 93) How many years had you been in practice when you were notified that you were named as a defendant in this second liability claim? __________________________________ (years) PROFESSIONAL LIABILITY SECTION SURVEY 76 94) How many years had you been in practice when you were no longer involved in this litigation (either your name was dropped from the suit or the suit was resolved)? If you are still involved in this litigation, please enter 99. __________________________________(years) 95) To which of the following types of care was the claim mostly related (choose one)? o Antenatal o Intrapartum care o Immediate postpartum care (first 48 hours) o Postpartum care (beyond 48 hours) o Gynecologic care o Primary care o Other If you selected other, please specify __________________________________ 96) In which type of setting were you working? Select all that apply. o Home o Freestanding birth center o Hospital/hospital owned o Federally qualified health center o Private office o Rural o Inner-city o Department of Defense 97) Did the event involve transfer of care to a hospital? o Yes o No 98) What was your employment status? o Full-time o Part-time o Split times/slots/job sharing 99) In what state, U.S. territory, or foreign country were you practicing when the event that led to the lawsuit occurred? If you were practicing in either a U.S. territory or foreign country, please identify the location in the space indicated. o Alabama o Alaska o Arizona o Arkansas o California o Colorado o Connecticut o Delaware PROFESSIONAL LIABILITY SECTION SURVEY o D.C. o Florida o Georgia o Hawaii o Idaho o Illinois o Indiana o Iowa o Kansas o Kentucky o Louisiana o Maine o Maryland o Massachusetts o Michigan o Minnesota o Mississippi o Missouri o Montana o Nebraska o Nevada o New Hampshire o New Jersey o New Mexico o New York o North Carolina o North Dakota o Ohio o Oklahoma o Oregon o Pennsylvania o Rhode Island o South Carolina o South Dakota o Tennessee o Texas o Utah o Vermont o Virginia o Washington o West Virginia o Wisconsin o Wyoming o Other If you selected other, please specify __________________________________ 77 PROFESSIONAL LIABILITY SECTION SURVEY 78 100) What type of health care coverage did the plaintiff have when the event occurred that led to this lawsuit? o Private insurance (e.g. Blue Cross; HMO) o Government (e.g. Medicaid) o Self-pay o Uninsured o Tri-Care o I do not know o Other If you selected other, please specify __________________________________ 101) Did you have to give a deposition as a result of this lawsuit? o Yes o No 102) Did you have to testify in court as a result of this lawsuit? o Yes o No 103) Has the case been resolved? o Yes o No 104) Which of the following describes the outcome for your involvement in this lawsuit? Select the situation(s) that is closest to what happened in your case. (Select all that apply.) o I was dropped from the case and the case continued without my involvement o The case was dropped without settlement o The case was settled prior to going to court or arbitration o The case went to court or arbitration and a decision was made for the plaintiff (the patient or the family) o The case went to court or arbitration and a decision was made for the defendant (you or one of your colleagues) o I was disciplined by the state licensing board or governing body o I lost privileges or sanctions o The outcome of the case is yet to be determined o Other If selected other, please specify __________________________________ 105) Which of the following helped you to cope when you were named in a lawsuit? Select all that apply. o Support/working with an attorney o Support from practice partners and colleagues (midwives, nurse practitioners, physicians) o Support from other midwives outside my practice o Support from family and friends o Formal counseling or therapy PROFESSIONAL LIABILITY SECTION SURVEY 79 o Recreational activities such as exercise or socializing o Change of employment (a new midwifery position) o Change of career (a position other than clinical midwifery) o Nothing helped me cope o Other If you selected other, please specify __________________________________ 106) How did being named in this lawsuit affect your professional liability status? Select all that apply. o There was no change in my insurance company nor in the cost of my premiums o I continued to be covered by the same insurance company, but the cost of my premiums increased o I changed professional liability insurance providers because of increased premiums (my choice) o I changed professional liability insurance providers for reasons other than cost increase (my choice) o My professional liability insurer dropped me from coverage o I have been unable to obtain new professional liability coverage 107) How did being named in this lawsuit affect your employment status? Choose one. o There was no change in my employment status o My clinical privileges were suspended o I temporarily altered clinical midwifery practice (e.g., stopped attending births) o I temporarily stopped clinical midwifery practice altogether o I have permanently altered clinical midwifery practice (e.g., stopped attending births) o I have permanently stopped clinical midwifery practice altogether 108) How did being named in this lawsuit affect your clinical practice? o Decreased gynecologic diagnostic/invasive procedures o Decreased number of high-risk pregnant patients cared for (e.g. pregnant patients with diabetes, hypertension, multiple gestation) o Intentionally decreased number of births attended o Increased number of referrals for Cesarean delivery o Stopped offering VBACs o Stopped attending VBACs o Stopped attending births o Retired from practice o Made no changes o Other If you selected other, please specify __________________________________ 109) Were any of the following individuals also named in this lawsuit? Select all that apply. o My collaborating physician(s) o My midwifery partner(s) PROFESSIONAL LIABILITY SECTION SURVEY o o o o o o o o Nurse practitioner(s) Nurse(s) Another physician (non-collaborating) Anesthesiologist or nurse anesthetist Neonatologist Medical resident Midwifery student No one else was named in the lawsuit 80 PROFESSIONAL LIABILITY SECTION SURVEY 81 Appendix D: Survey Feedback Survey feedback via email: Respondent DW via email: Please share this with your faculty In my opinion, every survey should start by allowing respondents who do not meet your criteria for inclusion to do something that indicates they replied but did not provide data. This survey is a perfect example, find out if I have provided patient care during the time period of your study and when I say know skip me to the last question and let me submit. I represent a CNM who wants to help researchers BUT I am not in clinical practice. There are a lot of us. From my review of your survey, you are correct. If you want to say X responded and of X, Y met criteria then set it up so After I reply that I did not provide care from 2010 to 2015 I get "you do not meet our criteria for participation, thank you, goodbye". If you do not want to count me as a responder, then tell me in the directions to not respond if I do not meet your criteria As you see, there is not an option in the subsequent questions that I can select. In other surveys I had to make up answers as the survey would not move forward without a response! I did not test yours to see if that was the case. Respondent LR via email: I can't remember who her chair is, but can we make sure she got her $$ amounts changed on her questions. She did have a $2 million question. She needs to be asking $1 million per occurrence / $3 million annual aggregate. With or without tail. Otherwise we are not actually educating the chapter we are creating confusion. Survey feedback via survey: Under positive feedback: • • • • • • Good length Length was reasonable, answer options were mostly logical efficiency and timely This survey was shorter than I thought it would be and seemed concise and easy to do. interesting, and very user friendly:) Nice job! Appropriate, the deposition was related to an undetected fetal anomaly in ultrasound Under suggestions: PROFESSIONAL LIABILITY SECTION SURVEY • • • • 82 #14. There is no 'average' and in what time frame?; #15. I'm retired so am no longer covered - none of the answers worked for me; #25 Need a questions about 'Why hasn't tail coverage been a factor?' Should ask how many years in practice or what year was I certified as a CNM. There is no number 16. Change question 21. to 1 million/3 million. 25. Add employer will pay tail. Question 17 - should have an 'NA, I have professional liability insurance.' Or have the survey skip this question if a person answered 'yes' to question 15. Same feedback regarding the specifics on professional liability type, limits, etc. Should have an option to say 'NA, I don't have professional liability insurance' or only ask these questions of respondents who report 'yes' on question 15. Are you currently in clinical practice? this question seems redundant as above questions asked for areas of current practice. I would have phrased: In your current practice which of the following skills do you perform