CURRICULUM TRENDS IN NURSE-MIDWIFERY EDUCATION

Views of Program Directors

Janis P. Bellack, RN, PhD,
Catherine Musham, PhD

FAAN,

David Graber,

ABSTRACT
The purpose of this study was to determine the extent to which
nurse-midwifery education programs are addressing the practice competencies that have been recommended by the Pew
Health Professions Commission and others as essential for
effective practice in the 21st century. This study was part of a
larger survey of eleven health professions education programs.
The 56 nurse-midwifery program directors whose names and
addresses were provided by the American College of NurseMidwives were surveyed by mailed questionnaire, with a response rate of 59% (n 5 33). The study sought to identify
current and ideal emphasis placed on 33 broad topics, most
important curriculum topics, and barriers to curriculum change
as perceived by respondents. Findings revealed that nursemidwifery program directors would like to see greater emphasis placed on every topic except one (tertiary/quaternary care).
Desired increases ranged from .04 to 1.36. The overall mean
rating for all topics was 3.51 for current emphasis (5-point
scale) and 4.18 for ideal emphasis, both of which were higher
than any other survey group. The greatest desired increases (.
1.00) were for primary care, managed care, use of
electronic information systems, and business management of
practice. Respondents identified primary care, health promotion/disease prevention, and accountability for cost-effectiveness and patient outcomes as the most important topics.
The top three barriers to curriculum change were identified as
already crowded curriculum, inadequate funding, and limited availability of clinical learning sites, the last being statistically significant compared with other survey groups. Findings
indicate that nurse-midwifery program directors perceived that
they are adequately addressing most of the curriculum topics,
while continuing to focus on the need for curriculum change as
the health care environment changes. q 1998 by the American College of Nurse-Midwives.

Major and unprecedented changes are occurring in the

U.S. health care delivery system as the 20th century
comes to a close. These changes challenge health professions educators to examine their curricula and teaching practices to ensure that students are being prepared
adequately and appropriately to meet the demands of
the evolving system. Indeed, while public debate on
health care focuses on issues of managed care, cost
containment, and regulation, policy leaders are calling

Address correspondence to Janis P. Bellack, RN, PhD, FAAN, Medical

University of South Carolina, 171 Ashley Avenue, Rm 200G Admin
Bldg, Charleston SC, 29425-1020.

PhD,

PhD,

and

for improvements in the education of the United States

health care workforce (1 4). They suggest that improvements in health care delivery and outcomes ultimately
depend on changes in health professions educational
programs (1,2). It is incumbent on these programs to
assure that graduates are prepared with the competencies they will need to practice effectively in a rapidly
changing health care system. In fact, the continued and
future relevance of health professions education programs will depend on their ability to undertake significant
and substantive reform of curricula and teaching practices (39).
The Pew Health Professions Commission, an early
and influential advocate for reform in health professions
education, recognizes that this will be no easy task (3). In
its report on the implications of managed care for health
professions education,* the Commission acknowledges
that the transformations demanded of health practitioners and the educational programs that produce and
support them are so enormous as to be dislocating (3).
Unless such transformations are realized, however,
health professions education programs risk becoming
increasingly disconnected from those they purport to
serve.
It simply is not possible in the limited span of formal
education programs to teach health professions students
all they must know to practice effectively and successfully
in the emerging health care system. In addition, health
professions faculty members are facing greater pressure
to engage in revenue-generating research and clinical
practice, leaving less and less time available for teaching
and mentoring students. Such forces demand innovative
curricular reforms to ensure that students acquire the
knowledge, skills, and values they need, and that faculty
manage the teaching/learning process in ways that allow
them to fulfill their multiple roles as educators, clinicians,
and researchers.
It is not known to what extent health professions
education programs are responding to these national

*Colleen Conway-Welch, CNM, PhD, FAAN, FACNM, Dean, School of

Nursing, Vanderbilt University, served as a member of the Commissions Advisory Panel on Health Professions Education for Managed
Care.

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

q 1998 by the American College of Nurse-Midwives
Issued by Elsevier Science Inc.

Edward H. ONeil,

341
0091-2182/98/$19.00 PII S0091-2182(98)00031-7

calls with innovative reforms of their curricula and learning experiences. Although there are indications that
some disciplinesincluding nursingare focusing on
increasing the number of learning experiences in community and ambulatory care settings and placing greater
emphasis on primary care and health promotion/disease
prevention, thus far reports of curriculum change have
been largely anecdotal.
Leading nursing organizations, among them the
American College of Nurse-Midwives (ACNM), have
issued position statements, curriculum guidelines, and
descriptions of essential core content and competencies that affirm generic recommendations for change
in health professions education, with specific application to nursing practice (10 16). These leading nursing groups agree on the need for new and expanded
competencies to ensure that advanced practice and
specialty practice nurses* have the requisite knowledge, skills, and values to cope with the challenges
they will face in a constantly changing health care
environment.
Nurse-midwives, as well-established and valued primary care providers, are committed to providing
compassionate, comprehensive, coordinated, and
cost-effective care for women throughout the childbearing cycle. Many nurse-midwives are further expanding their competencies to provide a broad range
of womens primary health care services throughout
the life span (17) and are doing so in ways that are
affordable, accessible, and acceptable to consumers
and payers alike. Today, nurse-midwives must have a
broad repertoire of competencies to provide highquality maternity and womens health care within the
context of an increasingly complex and managed
system of health care.

Janis P. Bellack is associate provost for education and professor

of nursing and health professions at the Medical University of
South Carolina, Charleston. She is also a senior fellow at the
Center for the Health Professions, University of California, San
Francisco.
David R. Graber is associate professor of health administration
and policy at the Medical University of South Carolina,
Charleston.
Edward H. ONeil is co-director of the Center for the Health
Professions, University of California, San Francisco, and
executive director of the Pew Health Professions Commision.
Catherine Musham is associate professor of family medicine and
affiliated with the Environmental Hazards Assessment Program
at the Medical University of South Carolina, Charleston.
* The ACNM also provides for direct entry midwives, but they were
not the focus of this study.

342

ESSENTIAL COMPETENCIES

The competencies demanded by the changing health

care system have been well delineated by the Pew Health
Professions Commission, the ACNM, the American
Association of Colleges of Nursing (AACN), the National
League for Nursing, and others (37,1316). These
reports and position statements were reviewed for competencies that are especially pertinent to primary care
practice, which was the principal focus of this study. A
list of core primary care competencies was derived from
these sources and appears in an Appendix. Each of
these competencies has direct relevance for nurse-midwifery education and practice.
Nurse-midwifery education programs must see to it
that their graduates have had sufficient opportunities to
develop these competencies so they are prepared for the
significant responsibility and accountability they will have
for health care management and decision-making at the
frontline. If nurse-midwives are to continue to be valued
and used in an increasingly managed system of health
care, they must acquire these broad competencies while
learning the specific knowledge and skills for basic
nurse-midwifery practice.
To date, no comprehensive survey of nurse-midwifery
education programs has been conducted to determine to
what extent the identified core competencies (see Appendix) are being addressed. Are nurse-midwifery programs focusing on the expanded competencies demanded by the changing health care environment? To
what extent do programs wish to improve their emphasis
on curriculum topics related to these essential competencies? And what barriers do they perceive in trying to
implement curriculum change?
To determine the extent to which nurse-midwifery
curricula currently include content and learning experiences related to these broad, essential competencies, or
the extent to which program directors ideally would like
to include them, directors of nurse-midwifery programs
were surveyed as part of a larger study of curriculum
trends in health professions education.

STUDY PURPOSE

The purpose of the study reported here was to ascertain

the extent to which nurse-midwifery and other health
professions education programs are addressing the identified core practice competencies. This study was part of
a larger survey of 11 health professions education
programs. Other programs surveyed included those for
allopathic and osteopathic medicine, dental medicine,
nurse practitioner, pharmacy (pharmD), physician assistant, and four primary care graduate medical residency
programs: family medicine, internal medicine, general
pediatrics, and obstetrics/gynecology. These programs

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

were selected because of their focus on preparing graduates for generalist and primary care practice roles.
Given their focus and the increasing emphasis on primary care within the evolving health care system, an
assumption was made that directors of these programs
would be more likely to be responsive to calls for
education reform than those for more highly specialized
programs.
The following research questions provided the framework for this study:
1. To what extent are selected curriculum topics currently included in the required learning experiences of
the program (current emphasis)?
2. To what extent do program directors believe the
selected curriculum topics should be included in the
required learning experiences of the program (ideal
emphasis)?
3. What do program directors believe are the most
important curriculum topics to assure their graduates
are prepared adequately for practice in the evolving
health care system?
4. What do program directors identify as the barriers to
needed curriculum change in their respective programs?
SAMPLE

A total of 1,770 programs were surveyed for the comprehensive study. The target study population comprised
academic deans or program directors in each of the
survey groups. The choice of academic dean or program
director depended on the title of the individual who had
direct responsibility for overseeing the curriculum. Thus,
for undergraduate dental medicine and medicine programs, the academic deans were surveyed. For the other
groups, the program directors were surveyed. The
nurse-midwifery survey was mailed to the 56 nursemidwifery educational program directors whose names
and addresses were provided by the ACNM.
Dillmans Total Design Method was used for the
survey format (18). Dillman recommends using a booklet
format with an illustrated color cover to capture respondents attention. A different color cover was used for
each survey group for coding purposes. Surveys also
were coded by individual program.
The four-page color-coded survey instrument was
mailed with a cover letter, a stamped return envelope,
and an assurance of confidentiality to each nurse-midwifery program director, followed by a postcard reminder 1 week later. A second mailing was sent 1 month
later to those program directors who had not yet responded. Consent to participate in the study was implied
by return of the completed survey.
A total of 966 completed surveys were returned from

all groups, yielding an overall response rate of 55%

(range 36 86%). The response rate for nurse-midwifery
programs was 59% (33 usable returns).

METHODOLOGY

The survey instrument was a 46-item questionnaire that

used a 5-point Likert scale format (Not at all . To a great
extent). An open-ended question also was included to
allow for additional comments. The first portion of the
survey instrument included 33 curriculum topics, arranged in five categories: general, patient-provider relationships, health care delivery settings, organization of
health care, and clinical practice. The identified core
practice competencies common to all health professions
education programs (Appendix) provided the basis for
identifying the 33 curriculum topics that were included
on the survey questionnaire. Program directors were
instructed to respond to the list of curriculum topics
relative to the content and learning experiences in their
respective curricula. Learning experiences were defined to include didactic as well as experiential activities
(eg, clinical practice opportunities, simulations, etc).
For each topic, respondents were instructed to rate
the emphasis they currently placed on the topic in their
programs curriculum (current emphasis), and then to
indicate how much emphasis they would ideally like to
place on each topic in the nurse-midwifery curriculum
(ideal emphasis). Respondents also were asked to circle
the numbers of the three curriculum topics . . . that
you believe are most important to assure that your
graduates are prepared adequately for practice in the
evolving health care system.
The second section of the questionnaire focused on
12 commonly cited barriers to curriculum change. Again
using a 5-point Likert scale, respondents were asked, In
your opinion, to what extent will each of the factors
listed below be a barrier to needed curriculum change in
your program? A 13th item, Other, gave respondents an opportunity to write in an additional factor not
listed and rank it using the 5-point scale.
The same questionnaire was used for all survey groups
on the premise that certain knowledge domains and
competencies, and their related curriculum topics, are
relevant and important across the health professions,
especially those that are preparing students for primary
care practice. Although the knowledge and skills that are
unique to nurse-midwifery practice also are affected by
the changing health care environment, they were not the
intended focus of the study reported herein. Although
discipline-specific competencies also must be addressed
in each particular health professions educational program, the focus of this study was limited to these broad,
cross-disciplinary competencies. The study also focused

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

343

on differences among the survey groups with respect to

the value they placed on the 33 curriculum topics.
The questionnaire was developed by the investigators,
with curriculum topics and barriers selected for inclusion
based on current literature, as well as the frequency with
which they appeared in reports and statements from
such national groups as the Pew Health Professions
Commission, the AACN, National Organization of
Nurse Practitioner Faculties, the ACNM, the Association
of American Medical Colleges, the Association of American Dental Schools, and the American Association of
Colleges of Pharmacy.
The philosophy, core competencies, code of ethics,
and practice standards of the ACNM were reviewed to
determine their congruence with the surveys curriculum
topics. The majority of topics included in the survey
questionnaire were addressed by one or more of these
ACNM documents; however, several topics that were
deemed highly relevant, even essential, in todays practice environments were not addressed explicitly within
the ACNM documents, including Community social
problems, Managed care, Case management,
Health care organization and administration, Health
care economics/financing, Use of electronic information systems, and Business management of practice.
To establish content validity, the survey instrument was
revised following input from a focus group held with
program directors in the investigators home institution
that represented all disciplines included in the study
population, with the exception of osteopathic medicine.
The revised survey was pilot tested with a dozen program directors who represented the groups and modified
based on their suggestions before being mailed to the full
sample.
The questionnaire was designed to examine the perceptions of educational program directors regarding
current emphasis versus ideal emphasis on selected
curriculum topics that have been deemed important for
primary care practice, with one exception. Tertiary/
quaternary care was included to ascertain if the directional change from current to ideal on this topic would
differ from those topics that are more immediately
relevant to primary care. Also, the questionnaire was
designed intentionally to elicit program directors views
on which topics deserve greater emphasis, not which
topics they predict will actually receive greater emphasis.
In other words, respondents were asked to simply rate
current (what is) and ideal (what is desired) curricular
emphasis rather than predict what curricular changes
they believe are likely to occur in their program.
STUDY LIMITATIONS

Several limitations of this study should be noted. First,

the survey was designed to elicit perceptions of nurse-

344

midwifery program directors about current and ideal

emphasis placed on selected general curriculum topics
and was based on the assumption that the program
directors were knowledgeable about the nurse-midwifery
curriculum in their respective programs and that their
perceptions of the curriculum were accurate. The study
did not attempt to verify the accuracy of the directors
perceptions by reviewing such evidence as curriculum
guides or course materials, which was beyond the scope
of this study. Another limitation is that the findings
reflect only the views of program directors, and not the
larger group of nurse-midwifery faculty.
Further, the survey was designed to address broad
curriculum topics pertinent to a wide range of primary
health care disciplines. Some topics, such as Longterm/chronic illness care, may be less relevant to
nurse-midwifery education than to some of the other
groups surveyed. Midwifery practice has never focused
on care of women with chronic or complex health
problems, and in fact the education section of the ACNM
quite recently affirmed its intention to limit the scope of
midwifery practice to essentially healthy women (17).
Finally, the study was limited to specific curriculum
topics and barriers to curriculum change and did not
address the equally important issues of pedagogy, faculty
development, or the organizational forces driving educational change. Despite these limitations, it is hoped that
the survey findings presented herein contribute to an
understanding of current and desired future directions for
nurse-midwifery education and prompt interest in further
research in this area.
FINDINGS

Responses were analyzed using descriptive and inferential statistics. Mean values for each of the 33 curriculum
topics both current and idealand each of the 12
barriers were calculated, and t tests were performed to
compare differences between the nurse-midwifery program directors responses and those of all other disciplines surveyed. Critical values of the t tests were
adjusted for the number of comparisons to maintain the
error rate at 5% (Bonferroni procedure). Responses of
the nurse-midwifery program directors are presented in
three sections: 1) ratings by current and ideal emphasis,
2) most important curriculum topics, and 3) barriers to
curriculum change.
Current Versus Ideal Emphasis
Table 1 depicts the mean values for current and ideal
emphasis rated by the nurse-midwifery program directors for each of the 33 curriculum topics, as well as the
magnitude of difference between current and ideal
ratings for each topic. Respondents indicated they de-

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

TABLE 1

Mean Values for Current and Ideal Emphasis for 33 Curriculum TopicsRanked by Ideal Emphasis*
Curriculum Topic

Current

Ideal

Difference

Patients as partners in health care

Health promotion/disease prevention
Outpatient/ambulatory care
Patient teaching/education
Effective patient-provider relationships/communication
Understanding and utilizing research findings
Care for underserved patients/populations
Clinical practice guidelines
Professional values
Cultural differences (beliefs, values, customs)
Primary care
Interdisciplinary teamwork
Psychosocial care
Accountability for cost-effectiveness and patient outcomes
Community social problems
Use of electronic information systems
Communities as partners in health care
Legal aspects of health care
Biomedical/health care ethics
Health care policy
Managed care
Continuous quality improvement
Case management
Business management of practice
Population-based care
Health care economics and financing
Epidemiology
Health care organization and administration
Environmental health
Tertiary/quaternary care
Home health care
Care of the elderly
Long-term/chronic illness care

4.68
4.58
4.77
4.55
4.39
4.23
4.52
4.55
4.19i
4.16
3.48
4.23
4.29i
3.68i
3.90i
2.90
3.26i
3.55
3.32
3.23i
2.87
3.39
3.13
2.61
3.17
2.90
2.84
3.03
2.60
3.14
2.00**
2.00
1.60**

4.90
4.90
4.81
4.81
4.81
4.74
4.68
4.65
4.65
4.65
4.63
4.61
4.58
4.42
4.39i
4.19
4.17i
4.16
4.16
4.13i
4.06
4.00
4.00
3.97
3.90
3.81
3.77
3.68
3.52
3.00
2.90**
2.52
2.00**

.22
.32
.04
.26
.42
.51
.16
.10
.46
.49
1.15
.38
.29
.74
.49
1.29
.91
.61
.84
.90
1.19
.61
.87
1.36
.73
.91
.93
.65
.92
2.14#
.90
.52
.40

* On a scale of 1 to 5 (1, Not at all; 5, To a great extent), respondents indicated the extent to which each curriculum topic: 1) is currently included
in the required learning experiences (current emphasis), and 2) Should be included in the required learning experiences (ideal emphasis).
The mean difference between current and ideal emphasis for all topics was .62 (compared with .66 for all groups).
Highest among all groups.
Second highest only to nurse practitioner group.
i Second highest only to one other (non-nurse) group.
Difference . 1.00.
# Only topic to show a decrease from current to ideal.
** Lowest or second lowest among all groups.

sired an increase in emphasis for every topic but one,

Tertiary/quaternary care. The magnitude of increase
from current to ideal for the remaining topics ranged
from .04 (Outpatient/ambulatory care) to 1.36 (Business management of practice).
Nurse-midwifery respondents rated five topicsPatients as partners in health care, Health promotion/
disease prevention, Outpatient/ambulatory care,
Patient teaching/education, and Effective patientprovider relationships/communication highest for
both current and ideal emphasis, with only a small
desired increase in the emphasis for any of these topics.

In fact, only two other topicsCare for underserved

populations and Clinical practice guidelines had a
lower mean difference between current and ideal emphasis than the mean difference for the first five topics in
the list (see Table 1).
The discrepancy between current and ideal emphasis
was substantially greater for the remaining topics that
demonstrated an increase, and was greater than one full
point for four topics: Business management of practice (1.36), Use of electronic information systems
(1.29), Managed care (1.19), and Primary care
(1.15).

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

345

TABLE 2

Significant Differences in Mean Ratings of Curriculum Topics (Compared with other survey groups)
More Important (Positive Difference)

Less Important (Negative Difference)

Health promotion/disease prevention (current & ideal)

Cultural differences (current & ideal)
Community social problems (current)
Legal aspects of health care (ideal)
Professional values (current & ideal)
Effective patient-provider relationships/communication (current & ideal)
Patients as partners in health care (current & ideal)
Communities as partners in health care (ideal)
Patient teaching/education (current & ideal)
Psychosocial care (current & ideal)
Outpatient/ambulatory care (current)
Care for underserved patients/populations (current & ideal)
Health care policy (current & ideal)
Clinical practice guidelines (current & ideal)
Accountability for cost-effectiveness and patient outcomes (current)
Understanding and utilizing research findings (curent & ideal)
Interdisciplinary teamwork (current & ideal)

Care of the elderly (ideal)

Primary care (current)
Home health care (current & ideal)
Long-term/chronic illness care (current & ideal)

The nurse-midwifery program directors rated 17 topics (52%) highest or second highest among all survey
groups for current emphasis, a difference that was
statistically significant for 15 (45%) of these topics. They
also rated 19 topics (58%) highest or second highest for
ideal emphasis, a difference that was statistically significant for fourteen (42%) of them.
Overall, the mean rating of the nurse-midwifery program directors for all topics was 3.51 for current
emphasis and 4.13 for ideal emphasis, both of which
are well above the midpoint. Furthermore, there were
statistically significant differences between the nursemidwifery program directors mean ratings and those of
all other disciplines (combined) on 18 topics for current
emphasis and on 17 topics for ideal emphasis. Table 2
lists those topics that were viewed by the nurse-midwifery program directors as significantly more important
(positive difference) or significantly less important (negative difference) than they were by the other groups
surveyed.
Most Important Topics
The curriculum topics identified as most important by the
nurse-midwifery program directors were as follows: Primary care (61%), Health promotion/disease prevention (48%), Accountability for cost-effectiveness and
patient outcomes (36%), and Interdisciplinary teamwork (30%). There was a wide range of responses to
this item among the respondents, with 17 (52%) of the
33 topics identified by at least one respondent as one of
the three most important topics.
Barriers to Change
Table 3 lists perceived barriers to curriculum change,

346

ranked in descending order. Three barriersAn already crowded curriculum, Inadequate funding, and
Limited availability of clinical learning siteswere
viewed as most significant by the nurse-midwifery program directors, with all three rated 3.90 or higher (the
next highest barrier was rated nearly a full point lower).
The difference between the mean rating of the nursemidwifery survey group and all other survey groups for

TABLE 3

Mean Ratings for Barriers to Achieving the Ideal

Curriculum*

Barrier
Already crowded curriculum
Inadequate funding
Limited availability of clinical
learning sites
Professional turf issues
Scheduling conflicts
Lack of faculty expertise
Faculty resistance
Administration resistance
Professional accreditation
criteria
Professional licensing
requirements
Student resistance
Community resistance

Nurse-Midwifery
Program
Directors
All Groups
4.58
4.23
3.90

4.14
3.83
3.14

3.10
3.00
2.90
2.58
2.58
2.57

2.79
3.24
3.01
2.89
2.42
2.52

2.35

2.10

2.23
1.80

2.43
1.85

* Respondents were asked, on a scale of 1 to 5 (1, Not at all; 5, To a

great extent), In your opinion, to what extent will each of the factors
below be a barrier to needed curriculum changes in your program?
Statistically significant difference compared with all other groups
combined (t value 5 3.40, P 5 , .001).
No respondents listed or rated an additional barrier.

Journal of Nurse-Midwifery Vol. 43, No. 5, September/October 1998

the barrier, Limited availability of clinical learning sites,

was statistically significant (P , .001).
DISCUSSION

Findings from this study show that, as a group, the

nurse-midwifery program directors are relatively satisfied
with their programs coverage of many of the topics
surveyed. In fact, for 14 (42%) of the topics, respondents
indicated less than .50 difference between current and
ideal emphasis. For the purpose of this study, a difference of 1.00 or more was accepted as indicative of
relative dissatisfaction with current coverage of the topic.
The nurse-midwifery program directors expressed such
dissatisfaction for only four (12%) of the 33 topics. At
the same time, the nurse-midwifery program directors
wanted to place substantially greater emphasis (..5
difference) on 19 (58%) of the topics (see Table 1).
These findings reflect the traditional strengths of nursemidwifery programs and reveal that nurse-midwifery program directors are aware of the importance of expanded
coverage of topics that have become increasingly relevant
in todays health care system. Further, with the large
number of high ratings for both current and ideal emphasis,
the nurse-midwifery program directors clearly value the
core curriculum topics included in the survey, and by
inference, their related practice competencies.
Nurse-midwiferys professional values place strong
emphasis on concern for the good of women and their
families, client dignity and autonomy, client advocacy,
informed choice, respectfulness, openness, acceptance
of differences, and protection from harm (19,20).
Historically, nurse-midwives have embraced childbearing
as a normal process, emphasizing the importance of
health education, primary health care, and supportive
intervention while providing accessible, client-responsive
care in community clinics and birthing centers and to
underserved populations (19). The nurse-midwifery program directors high ratings of such topicsHealth
promotion/disease prevention, Patient teaching/education, Patients as partners in health care, Psychosocial care, Cultural differences, Community social
problems, and Communities as partners in health
carefor both current and ideal emphasis reflect this
tradition.
An area that only recently has been incorporated into
basic nurse-midwifery practicethe care of healthy postmenopausal and aging womenwas not accorded high
priority by the nurse-midwifery program directors. Although the magnitude of difference from current to
ideal emphasis was .52, Care of the elderly was still
rated well below the midpoint for ideal emphasis. As the
female population ages and birth rates decline, nursemidwifery programs may need to rethink the relative
emphasis they place on this aspect of the curriculum.

Of interest, the nurse-midwifery program directors

rated Patients as partners in health care 4.68 for
current emphasis, one of only two survey groups to rank
this topic higher than 4 on the 5-point scale (the other
group being the nurse practitioner program directors).
Both nursing groups rated this topic highest for ideal
emphasis as well. A similarly noteworthy finding is that
the nurse-midwifery, nurse practitioner, and physician
assistant program directors rated Care for underserved
patients/populations highest among the 11 survey
groups for both current and ideal emphasis, reflecting
the values held by these provider groups. Also, they were
the only groups to rate Patient teaching/education
and Professional values higher than 4, Cultural differences higher than 3.5, and Communities as partners
in health care higher than 3 for current emphasis,
rating them even higher for ideal emphasis.
Thus, the nurse-midwifery program directors perceived their programs as providing satisfactory to above
average coverage of the survey topics in their current
curricula, although they still wished to improve. Comparatively speaking, however, curriculum change related
to these topics will not be as extensive for nursemidwifery education as for some of the other disciplines.
As noted earlier, the nurse-midwifery program directors rated the difference between current and ideal
emphasis greater than 1.00 on four topics. Three of
these topicsBusiness management of practice, Use
of electronic information systems, and Managed
carewere not as important historically as they are in
todays health care environment. The large discrepancy
between current and ideal ratings on these topics may
reflect the nurse-midwifery program directors awareness of the changes that have occurred in these aspects
of the practice environment over the last decade.
The nurse-midwifery program directors mean ideal
rating for Primary care, which also increased more
than 1.00 compared with the current rating, was somewhat surprising. This finding may be related to the
declining length of stay for healthy maternity patients
and their newborns, resulting in less time spent in the
acute care setting. It also may reflect a relaxing of
restrictive practice laws to allow nurse-midwives to provide comprehensive primary care services, including
prescriptive authority. Further, it may be evidence of the
expanding emphasis that nurse-midwifery programs are
placing on womens primary health care across the life
span (14,17).
In summary, the nurse-midwifery program directors
perceived that they are doing an effective job providing
coverage of the vast majority of the essential core
curriculum topics, confirming the Pew Health Profession
Commissions findings (5). The Commissions 1993
report includes the following comment:

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347

As the health care needs of the public have evolved, the

nursing education community has responded by producing
more nurses who are patient advocates, patient care coordinators, nurse midwives, nurse practitioners, home- and
community-based nurses, and patient educators. New demands will continue to be placed on nurses as care in the
hospital becomes more complex . . . and as health care
outside the hospital expands to accommodate a broader
range of needs of the general population. A growing
pressure for more cost-effective and consumer-responsive
health care, delivered in a system better managed than ever
before, will cause important changes in the role of nurses
and their relationships with patients. The . . . Commission
believes the profession will face these challenges from a
position of strength, since nursings skills of collaboration,
effective communication, and teamwork will be needed to
support practice in a changed system (5).

The nurse-midwifery program directors responses also

reflected their awareness of the need to continue to
improve their curricula in response to an ever-changing
health care environment. Their recognition of this challenge is evident in their ideal ratings of the topics, for
which they indicate a desire to provide more coverage in
every instance but one. However, the barriers to achieving the desired curricular improvements may be significant.

cians to provide care to this childbearing population

group. The growth of managed care has changed that,
with many physician groups eagerly and successfully
competing for Medicaid managed care contracts, and
thereby limiting or eliminating access of nurse-midwives
to this patient population.
The problem is further compounded by the fact that
academic health centers typically have provided much of
the maternity care to underinsured, uninsured, and Medicaid patients. As private physician provider groups have
acquired Medicaid managed care contracts, fewer childbearing women are seeking maternity services from
academic health centers for normal, uncomplicated
pregnancy. Because the majority of nurse-midwifery
education programs are based in or affiliated with academic health centers, they often find themselves competing with the obstetric medical residency program for
access to a dwindling number of healthy maternity
patients and the clinical learning experiences they afford.
All groups, however, viewed Inadequate funding as
a significant barrier to instituting curriculum change,
rating it second highest. The nurse-midwifery program
directors concurred. This concern may be related to a
variety of issues currently facing health professions education programs:
The intensifying demands of clinical practice related to

ADDRESSING BARRIERS TO CHANGE

Respondents were quite clear that three barriers in

particular are likely to pose the greatest impediments to
curriculum change: An already crowded curriculum,
Inadequate funding, and Limited availability of clinical
learning sites, all of which they rated 3.90 or higher.
The barrier rated next highest was rated nearly a full
point lower at 3.10 (Professional turf issues). The two
top-rated barriers paralleled those rated highest by all
survey groups.
The nurse-midwifery and nurse practitioner program
directors rated the barrier, Limited availability of clinical
learning experiences, higher than any non-nurse group.
In fact, the nurse-midwifery directors rating of this
barrier was .76 higher than the mean rating for all
groups, a statistically significant difference (P , .001),
indicating real concern about access to clinical settings
for student learning experiences. The nurse-midwifery
program directors high rating of this barrier may reflect
the increasing competition for primary care settings for
student learning experiences, as more and more disciplines move into community settings for such experiences. Another contributing factor may be the rise of
Medicaid managed care plans. Childbearing women who
are covered by Medicaid traditionally have been one of
the major groups served by nurse-midwives, largely
because there was little economic incentive for physi-

348

managed care mandates and the pressure to generate

clinical revenue
A need for more faculty as learning experiences move
into the community, such experiences being more
time and labor intensive
Rising costs associated with community-based and
primary care learning experiences, including the use
of educational technologies (Internet, compressed
video, phone conferencing) to link students in remote
clinical settings to the home institution
Demands by clinical sites that they be reimbursed for
the additional costs associated with educating students
Declining federal funding for nurse-midwifery education programs

This barrier is likely to grow in significance for all groups,

especially with regard to clinical experiences in nonacute
care settings, as managed care and federal and state
reimbursement policies place increasing pressure on
providers to deliver quality care at lower cost, with no
allowances or incentives for educating and precepting
students (21).
Perhaps the greatest challenge facing nurse-midwifery
programs is reflected in the respondents strong agreement
that the curriculum is already too crowded; however, trying
to add new content or lengthen the program is not likely to
be a reasonable, realistic, or cost-effective solution. Nursemidwifery educators must sooner or later address the issue
of program reform. For example, to what extent do

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contemporary nurse midwifery curricula and learning experiences emphasize time-limited, discrete content instead
of focusing on helping students learn how to access,
interpret, and use this information when and where they
need it? The latter competency will ensure that practice
remains current in a constantly changing, often unpredictable health care system long after specific content has been
forgotten or become obsolete.
Nurse-midwifery educators should critically examine current nurse-midwifery curricula, including content and teaching/learning strategies, and strike an appropriate balance
between the specific knowledge and skills needed for
clinically competent practice and the broader essential
competencies demanded by todays health care environment. As one respondent commented, Current [nursemidwifery] licensing and certification criteria state that
clinical competence is adequate for success. I think it is
necessary but not sufficient. We must upgrade our skills and
savvy to survive in the marketplace and public policy
arena.
This comment points to a need to begin incorporating
broader topics and experiences in the nurse-midwifery
curriculum, such as managing a populations health,
partnering with managed care, and making effective use
of information and communication technology, all of
which are necessary competencies in todays practice
environment. If nurse-midwives are to position themselves effectively for success in an unpredictable and
rapidly changing health care system, the nurse-midwifery curriculum must incorporate both the specific
knowledge and skills needed for competent, safe nursemidwifery practice and the broad competencies that
build the capacity for continual learning throughout
ones professional career.
One final finding is worth commenting on. External
barriers, such as accreditation criteria, licensing regulations, and community resistance, were not viewed by
nurse-midwifery program directors as particularly significant obstacles, despite the fact that the former two are
often cited as reasons faculty find it difficult to institute
curriculum changes.

promotion/disease prevention, Patient teaching/education, Care for underserved patients/populations, and

Clinical practice guidelines, for which they rated themselves as already strong in current emphasis; or on Tertiary/quaternary care, Home health care, and Longterm/chronic illness care, which they did not consider to
be as relevant or important.
In summary, the findings of this study confirm that
nurse-midwifery program directors are aware of calls for
curriculum reform, and in many instances, are responding
to them. The findings also reveal significant discrepancy
between actual and desired emphasis on a number of
topics, areas that will require more attention to change.
Nurse-midwifery program directors are in a key position, individually and collectively, to directly influence
and shape curricula and the professions national standards and curriculum guidelines. Given the increasing
demand and acceptance by the public and by public and
private insurers for nurses who can provide primary care
services (22), nurse-midwifery education programs must
ensure that they are producing graduates who have
acquired the broad, essential competencies to meet
these demands, and whose practices conform with the
ACNMs standards of care (23).
Clearly, nurse-midwifery educational programs are leading the way in health professions education in assuring that
their graduates are indeed prepared with these broad
competencies. This progressive position is likely to be
useful in helping nurse-midwifery programs compete for
institutional resources given the strong evidence, revealed
by this study, of their relevance and responsiveness to the
changing health care environment.

Partial funding for this study was provided by the National Fund for
Medical Education through the Center for the Health Professions,
University of California, San Francisco.
The authors gratefully acknowledge the statistical assistance of Carol
Lancaster, PhD, and the research support activities of Dylan Holmes
and Marcia Higaki, all of the Medical University of South Carolina.

REFERENCES
CONCLUSION

This study explored limited but significant questions pertaining to change in nurse-midwifery education, specifically, what do nurse-midwifery program directors want to
emphasize in their curricula? It may be argued that all topics
except Tertiary/quaternary care represent positive curriculum changes for nurse-midwifery education programs;
however, findings suggest clear differentiation. As a group,
the nurse-midwifery program directors clearly are more in
favor of increasing the emphasis on Business management of practice, Use of electronic information systems,
Managed care, and Primary care than on Health

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APPENDIX.
ESSENTIAL CORE COMPETENCIES FOR PRIMARY CARE PROFESSIONALS
Care for the health of the community by establishing

Practice effectively in integrated systems of health care

partnerships with and providing service to community.

Provide population-based health care based on an
understanding of clinical epidemiology.
Improve the availability and accessibility of health
care, especially for underserved populations.
Provide primary care services that are coordinated,
continuous, comprehensive, and compassionate.
Interact and communicate effectively, respectfully, and
sensitively with patients, families and other professionals.
Emphasize the promotion of health and the prevention of disease, using primary and secondary prevention strategies.
Educate patients about environmental health hazards.
Involve patients and families in making informed
decisions about their health care.
Convey sensitivity and respect for differences related
to age, sex, culture, race-ethnicity, socioeconomic
status, and ability.
Demonstrate awareness of potential conflicts of interest
between professional ethics and values, patient preferences, system regulations, and health care resources.
Adhere to professional standards and a professional
code of ethics.
Understand the ethics of health care, and counsel
patients and families when ethical issues arise to
ensure informed decision making.
Work effectively in interdisciplinary teams, and collaborate appropriately with professional colleagues.

and across the continuum of care settings (outpatient

and ambulatory, long-term care, home, and as appropriate, acute care).
Demonstrate awareness and understanding of health
policy and legislation, health care economics and financing, and health care organization and administration.
Continuously work to improve the delivery of health
care.
Accept accountability for cost-effective, appropriate,
and high-quality health care as an individual professional and as a member of team, institutional, professional, and system levels of health care.
Employ a cost-effective approach to the use of technology in providing patient care.
Manage large volumes of scientific and patient information, selecting, analyzing, and applying that which
is relevant and appropriate.
Use electronic information and practice management
systems to access needed and relevant information,
support clinical decision-making, and take advantage
of professional literature and learning resources for
clinical application and continuing competence.
Use accepted clinical practice guidelines in daily practice.
Ensure continuing clinical competence in accordance
with professional values and standards and accepted
practice.
Value lifelong learning and professional development.

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