Disruptive Nurses Lead to Better Outcomes

With healthcare reform well under way, now is a good time to come up with alternatives to traditional individual care, one innovative nurse midwife believes.

Lately I've been writing a lot about nurses who think and act creatively to improve patient care and health outcomes. Some of these "positively deviant" nurses break hospital rules when they think it's in a patient's best interest to do so.

Others create innovative programs that help care for caregivers. Still others are actually inventing or improving devices right in the trenches of their work, using only their wits and materials at hand, much like TV action hero MacGyver.

That's why I was intrigued when I came across the Centering Healthcare Institute's upcoming conference, which has as its tagline, "transforming care through disruptive design." The Centering Healthcare Institute's CEO and president, Sharon Schindler Rising, CNM, MSN, is not just thinking outside the box. She's ripping the box to shreds. And that's what disruptive design is all about.

Rising developed the Centering model of healthcare, which provides group healthcare, and first piloted the CenteringPregnancy model in 1993 when she was a nurse midwife.

Here's how the model works: 8 to twelve women with similar gestational ages meet 10 times in a group throughout their pregnancies, learning all the things and getting all the exams they'd get in traditional prenatal care, but with the added benefit of a community setting. It's a model that women and providers love, Rising tells me.

Twenty years later, the Centering model has gained national traction, with multiple new studies proving its effectiveness and CMS grants to create CenteringPregnancy sites across the country.

For instance, a 2007 multi-site randomized controlled trial found that participation in CenteringPregnancy care reduced the risk of premature birth by 33% compared to traditional prenatal care and "resulted in equal or improved perinatal outcomes at no added cost."

Another study, published in May 2012, showed that "participation in group care improves the rate of preterm birth compared with traditional care, especially among black women." And a study in August 2013 issue of the American Journal of Obstetrics and Gynecology showed that the more closely facilitators stuck to Centering model, the better the outcomes actually were.

Rising says she conducted her first pilot of the model at the Waterbury Hospital Clinic in Waterbury, CT, where she'd been providing midwifery care for several years.

"There was appropriate space I could use, the obstetrician in charge thought this was a good idea, and the nurses were on board," Rising told me via email. "In addition, we had education materials that were used for prenatal classes!"

But not every health system would be onboard with upending the traditional models and adopting such a radically different way of providing care.

"I just sort of thought that 'you can go and do this,'" Rising later told me in a phone interview. "I realized that not everybody had a system that was as responsive as the one that I was in."

Providing prenatal care in groups rather than in a one-on-one setting completely "disrupts" the normal model of healthcare delivery in which the clinician is in charge of the encounter in many ways.

First of all, it puts the patient in charge in a big way. And there needs to be different kinds of scheduling, bigger rooms for the meetings, and two-hour chunks of time for clinicians to facilitate the discussions, among other things.

Rising has realized that many health systems just aren't ready for that kind of change; change that's truly disruptive. That's why she's working not only to promote Centering, but also to change health systems.

For example, she says that "systems are very entrenched. Care is given in exam rooms individually… The exam room is the property of the agency… then when the provider goes into the room, it's the provider's space. It isn't a space that patients feel that they own."

Rising believes the time is right for disruption, especially with the relatively new emphasis placed on patient satisfaction, patient engagement, and patient-centered medical homes.

"It is a good time for us, I think, to have an alternative to individual care," Rising says. "We have to rethink how care is provided. We just have to do it. There's opportunity for change."