Journal of Midwifery & Women’s Health
Improving Satisfaction with Care and Reducing Length of Stay
in an Obstetric Triage Unit Using a Nurse-Midwife-Managed
Model of Care
Julie Paul, CNM, DNP, Robin Jordan, CNM, PhD, Susan Duty, ANP-BC, ScD,
Janet L. Engstrom, CNM, PhD, APN, WHNP-BC
Introduction: A quality improvement project was initiated at a tertiary-care center in a suburban area of the northeastern United States to deter-
mine whether length of stay and patient satisfaction in an obstetric triage unit could be improved by using a certified nurse-midwife (CNM) to
manage and organize care in the triage unit.
Methods: Patient satisfaction was measured using a previously validated instrument that consisted of 6 items using a 6-point Likert-type scale.
care received, and overall triage experience. Patient satisfaction was measured before (n = 37) and after implementing CNM-managed care (n =
66) in an obstetrical triage unit. Length of stay in the triage unit was measured during standard care (n = 121) and after the implementation of
CNM-managed care (n = 151) by recording the number of minutes women spent in the triage unit.
Results: Participants in the CNM-managed care group reported increased patient satisfaction with care in 5 of the 6 aspects of satisfaction that
were measured, including wait time for provider (P = .01), time spent with provider (P = .01), length of visit (P = .04), overall care received (P
= .04), and overall triage experience (P = .01). The length of stay was significantly shorter for the women in the CNM-managed group (mean =
94.7 minutes; standard deviation [SD] 50.1) than for the women in the standard care model (mean = 122 minutes; SD = 66.8; P ?.01).
Discussion: The findings from this project suggest that a CNM-managed obstetric triage unit can improve satisfaction with care during the triage
experience and reduce length of stay in the triage unit.
J Midwifery Womens Health 2013;00:1–7c ?2013 by the American College of Nurse-Midwives.
Keywords: certified nurse-midwife, collaboration and midwifery presence, length of stay, obstetric triage, patient satisfaction
Obstetric triage is an area of concern for hospitals and
health care providers as they struggle with time manage-
ment, reimbursement issues, and budgetary constraints.1,2
Obstetric triage units also are troubled with reports of low
satisfaction and long length of stay times.2–4Although qual-
ity of care and patient safety are the primary focus in clin-
ical settings, satisfaction with care is also an important
outcome.5Satisfaction with care will soon be used by third-
party payers to determine the level of reimbursement for
health care service.6,7Satisfaction with care also impacts
consumer health care choices in competitive health care
els for managing obstetric triage units. Recent research sug-
gests that employing nurse practitioners in an emergency
setting reduces patient waiting times, improves patient sat-
isfaction, and is cost-effective.9–12Therefore, using certified
nurse-midwives/certified midwives (CNMs/CMs) and regis-
tered nurses (RNs) to manage an obstetric triage unit in col-
increase satisfaction with care and reduce the length of stay
on the unit. Although the role of the CNM/CM and CNM-
physician collaborative model in providing care in the ob-
stetric triage unit has been described in the literature,1,13–20
Address correspondence to Julie Paul, CNM, DNP, 122 Arborway Drive,
Scituate, MA 02066. E-mail: Julie.Paul@frontier.edu
and this model of care is associated with higher rates of sat-
isfaction in other settings such as ambulatory care and labor
and delivery units,21–24there are no published reports eval-
uating whether CNM/CM models of care are associated with
increased satisfaction with care and reduced length of stay in
was to determine whether a CNM-managed obstetric triage
unit would increase satisfaction with care and decrease the
length of stay in the triage unit.
The obstetric triage setting is an area within the hospital that
provides outpatient care for pregnant women who present to
the unit for the evaluation of labor, assessment of fetal well-
being, and acute obstetric issues.25Often women will first be
evaluated in the obstetric triage unit and then be transferred
to a different location such as labor and delivery, a medical-
surgical unit, or the antenatal unit. Many women are dis-
charged from the unit to return home.
An obstetric triage unit functions in a similar manner to
an emergency department; women are evaluated when they
arrive in the triage unit, and the women with the most acute
or emergent conditions are cared for first.26Since it is not
possible to predict the number and types of clinical issues
that will present in the triage unit at any given time, adequate
c ?2013 by the American College of Nurse-Midwives
✦ Low patient satisfaction and long length of stay times are common in obstetric triage units.
a woman) to certified nurse-midwife (CNM)-managed care (triage unit staffed by CNM who performs evaluation) in a
✦ SignificantlymoreofthewomenintheCNM-managedgroup wereextremelysatisfiedwiththeircarecomparedtowomen
in the standard care group.
✦ The length of stay in the triage unit was shorter with CNM-managed care than standard care.
and informational support.
staffing of the triage unit and timely evaluations27of women
can be problematic.28Therefore, staffing models for the ob-
stetric unit should resemble staffing models used in emer-
gency departments. In addition, the Emergency Medical
Treatment and Active Labor Act (EMTALA) and other reg-
ulatory requirements must be followed in the obstetric triage
unit, as they are in emergency departments.16,26
Additional issues arise when triage units operate in tan-
stetric triage units commonly operate with the on-call health
attending to other responsibilities such as surgery, births, and
other activities. In this situation, nurses and other health care
providers may facechallengesin attendingwomen in a timely
manner and managing workflow on both units. For example,
an emergency in labor and delivery may leave the triage unit
without a health care provider, thereby compromising timely
assessments and workflow. Patient safety also can be com-
promised in these situations. Therefore, a model employing a
and length of stay in the triage unit before and after imple-
menting a CNM-managed care model. At the onset of the
would come to the triage unit from their private office or the
labor and birth unit to evaluate the woman. When the CNM-
in the triage unit from 8 am to 6 pm (4 days/week) and per-
formed the evaluation of women coming to the triage unit for
Sample and Setting
This quality improvement project took place in a level III
hospital hasapproximately 4000birthsper year.29Theobstet-
ric triage unit is a 6-bed unit, averaging 500 to 700 visits per
month. The triage unit was typically staffed with RNs from 7
project, the women admitted to the triage unit were initially
midwife. Thus, the length of time that women waited varied
widely depending on the availability of the care provider.
A convenience sample of women receiving care in the
triage unit at the clinical site participated in this project. The
criteria for participation in this project included women who
spoke English, were currently pregnant, were aged at least 18
years, and received care in the obstetric triage unit during the
for admission to thelabor andbirth or antepartum units were
not included. A total of 272 women received care during that
time, 121 in the standard care group and 151 in the CNM-
managed care group.
Patient satisfaction was assessed using a modified version of
an existing patient satisfaction questionnaire created and val-
idated by Molloy and Mitchell.30The content validity of the
modified instrument was established by having 3 content ex-
perts review the instrument. The instrument consisted of 9
items seeking demographic information and 8 items assess-
ing satisfaction with care. The satisfaction items included 6
tremely satisfied and 6 = extremely dissatisfied). The 6 items
addressed satisfaction with self-perceived waiting times, in-
formation given, amount of time with the provider, length of
the visit, satisfaction with the care received, and overall satis-
faction with the triage experience. There were 2 open-ended
questions that asked the participant to identify what was the
most helpful aspect of the care received in the triage unit and
how the service could be improved.
rival and departure times from the triage unit and calculating
the number of minutes the woman spent in the unit.
care in the triage unit during the first 2 weeks of the project
period. The unit coordinator recorded length of stay in the
Volume 00, No. 00, Month/Month 2013
unit, and the RNs distributed the satisfaction questionnaires
to the women in the triage unit Monday through Friday dur-
ing the hours of 7 am to 7 pm. This time frame was chosen
because it was usually the busiest time of the day for the unit.
During the subsequent 4-week period, the CNM-
managedcaremodel was implemented.A CNM managedthe
triage unit for 4 shifts per week Monday through Thursday
from 8 am to 6 pm (10 hours). Women arriving in the triage
unit were asked by the triage nurse if they were willing to
see the CNM for their care. All women consented to see the
CNM during the project time frame. Women who presented
to the unit for specific care that was to be managed by their
primary obstetric provider were excluded from the project
during both periods. Collaboration between the CNM and
physicians occurred if a woman’s condition exceeded the
CNM’s scope of practice.
Satisfaction questionnaire data were collected on week-
days for both the standard and the CNM-managed care
groups. Data were not collected at night or on the weekends.
The nurses who worked on the triage unit were educated
about the purpose of the project and were responsible for dis-
tributing the questionnaire at the end of each triage unit visit.
The unit coordinator recorded the times the women entered
and left the triage unit. Therefore, the CNM who provided
care was not involved in recruitment of the project partici-
pants and was not involved in data collection.
The project was reviewed and approved by the institutional
review board at Frontier Nursing University. At the clinical
was obtained from the chief nursing officer and the chairper-
son of the Department of Obstetrics and Gynecology. The in-
stitutional review board at the clinical site also reviewed the
project and deemed it a quality improvement project that did
not require further review.
Project participants received a detailed written descrip-
tion of the project when they arrived at the triage unit along
with the questionnaire. The description of the project con-
tions about the project, decline participation, or withdraw
from the project at any time without consequences. Comple-
tion of the questionnaire implied consent. No personal iden-
tifiers or personal health information was retained with the
Quantitative data were analyzed using SPSS version 20
gorical data and univariate statistics for continuous data. The
(extremely satisfied and not extremely satisfied) because al-
most all the responses were in the “very satisfied” and “ex-
tremely satisfied” groups. This is consistent with standard
practice as well; many health care organizations are primarily
interested in the highest level of satisfaction since extremely
satisfied consumers are most likely to return for care and give
Table 1. Description of Project Participants who Completed the
Satisfaction with CareQuestionnaire (N= 103)
(n = 37)
Age, mean (SD), ya
Education (n, %)c
High school8 (22.2)
Associate degree8 (22.2)
Bachelor degree11 (30.6)
Master’s degree9 (25.0)
Provider type (n, %)
CNM and physician6 (16.2)
(n = 66)
Abbreviations: CNM, certified nurse-midwife; SD, standard deviation.
aDue to 1 missing data, n = 65 for CNM-managed group.
bIndependent t test.
cDue to missing data, n = 36 for standard care group and n = 64 for
tremely satisfied” responses are desired.8
Chi-square analysis was used for the categorical data, and
the Fisher exact test was used to compare dichotomous data.
Continuous data that were distributed normally were com-
pared using an independent t test. Data that were not dis-
pared using the Mann-Whitney U test. A level of significance
of .05 was used for all tests of significance.
Qualitative data were analyzed using a simple content
analysis of the participants’ written comments. The 2 open-
ended questions were reviewed to identify themes by the first
author, and then the themes were coded, and the frequencies
A total of 272 women received care in the triage unit during
the study period, 121 in the standard care group and 151 in
the CNM-managed care group. Length of time in the triage
unit was recorded for all of thewomen. Thesatisfaction ques-
tionnaire was completed by 103 women (37.9%), 37 in the
standard care group, and 66 in the CNM-managed group.
The characteristics of the project participants are described
in Table 1. The participants in the standard care and CNM-
Satisfaction with Care
Satisfaction with care for the standard care and CNM-
very satisfied to extremely satisfied with their care from both
the standard care and CNM-managed care. However, signifi-
cantly more of the women in the CNM-managed group were
Journal of Midwifery & Women’s Healthrwww.jmwh.org
Table 2. Comparison ofSatisfaction with CareBetween Standard Care(n = 37) and CNM-Managed Care(n = 66) Groups
Satisfaction IndicatorsDissatisfied Dissatisfied
Overall care received
Overall triage experience
Abbreviation: CNM, certified nurse-midwife.
aFisher exact test comparing the percentage of extremely satisfied to all the other categories combined.
extremely satisfied with their care. The women in the CNM-
managedgroup were significantly more likely to be extremely
satisfied with 5 of the 6 aspects of satisfaction that were mea-
of visit, overall care received, and overall triage experience.
The 2 groups did not differ significantly on satisfaction with
tremely satisfied with the information provided.
Length of Stay
Length of stay time in the obstetric triage unit differed signif-
(Table 3). The mean (SD) length of actual stay time for the
standard care group (n = 121) was 122 (66.8) minutes com-
pared with 94.7 (50.1) minutes in the CNM-managed group
dard care group (P ?.01).
Two open-ended questions sought information on what par-
ticipants found most helpful during their triage experiences
and their suggestions for improvement. The questions were
reviewed to identify themes, and then the themes were
coded and the frequencies calculated. For the question about
what was most helpful in the triage unit 77 (74.8%) of the
103 participants responded; 28 (36.4%) in the standard care
group and 49 (63.6%) in the CNM-managed group. The
most commonly identified themes were the amount of in-
formation/knowledge given/received, reassurance provided
by staff/provider, presence/kindness of nurses/staff, CNM
presence, quick service, ability to schedule an appointment,
became a new dichotomous variable for comparison between
the standard care group and the CNM-managed group.
In response to the question asking what was most help-
ful to them during their triage experiences, women in both
groups noted the elements of emotional support and knowl-
edge provided as being most helpful. In the standard care
group, one woman stated, “The nurses were very comforting,
patient, and kind. I never felt rushed.” A second one stated,
“The nurses were extremely nice and kept me informed as to
responded, “The midwife talking to me made me feel more
relaxed. She was very helpful and answered all my questions.
I was checked on frequently.” Whereas, another woman re-
sponded, “I was provided with an explanation to everything.
Table 3. Length ofStay in ObstetricTriageUnit
Length ofstay, mean
Standard care group
CNM-managed group 151
121 122.0 (66.8) [30-450]
94.7 (50.1) [20-300]
Abbreviation: CNM, certified nurse-midwife.
aMann-Whitney U test.
Volume 00, No. 00, Month/Month 2013
Table 4. ThemesfromResponsestoOpen-EndedQuestion:“What
wasFound MostHelpful duringTriage?” (n = 77)
(n = 28), n (%)
Quick service1 (3.6)
Ability to schedule
Ability to rest
(n = 49), n (%)
17 (34.7) 10 (35.7)
4 (14.3) 13 (26.5)
11 (39.3)5 (10.2)
0 10 (20.4)
0 2 (7.1)
0 1 (2.0)
0 1 (2.0)
Abbreviation: CNM, certified nurse-midwife.
The midwife took her time, and I felt like she really knew me
and my history.”
The second most common theme identified as being
helpful during the participants’ stay in the triage unit was
reassurance provided by the staff/provider. Thirty-one per-
cent of the respondents in the CNM-managed group com-
pared with 10% in the standard care group found that the
information provided by the staff/provider was very helpful.
personalized, and I received unrushed attention. I found it
very helpful as I am feeling very anxious.” Another response
from the CNM-managed group included, “They were very
helpful, patient, and understanding. They truly wanted to put
me at ease.”
to the triage experience elicited only 30 (29.1%) responses
dents (n = 24, 80%) reported that they “would not change
a thing.” Only 6 (20%) of the 30 respondents made sugges-
tions to improve the triage experience including decreasing
the redundancy of questions during history-taking (n = 1,
3.3%), improving preregistration (n = 1, 3.3%), moving the
the standard care group suggested having the CNM or physi-
cian readily available in the triage unit.
Obstetric triage units across the United States are struggling
with how best to staff their units to assure patient safety, effi-
The use of physicians as laborists (whose sole job is to man-
age the inpatient care of pregnant women) has been explored
Journal of Midwifery & Women’s Healthrwww.jmwh.org
as an option; however, more research is needed to determine
the impact of this role in obstetric triage.32This project ex-
amined the use of a CNM to manage the obstetric triage unit
and found that satisfaction with care was increased. The ar-
eas of satisfaction with care that demonstrated statistically
significant improvements with the CNM model were with
time spent waiting for the provider, information given, time
spent talking with the provider, length of visit, overall care
received in triage, and overall satisfaction with the triage
The findings of this project are congruent with the results
of other studies examining women’s satisfaction with mid-
wifery care21–24and time spent on the unit.2,33Specifically,
findings of higher satisfaction with information giving, social
support, and the ability to make decisions are consistent with
midwives provide more face-to-face time and counseling to
thereby improving patient satisfaction. This idea is supported
by Waldenstrom et al,34who also determined that women
experienced increased satisfaction with a midwife-physician
team in contrast to care with only physician management.
Midwifery care for women has been linked to therapeutic
presence, which embodies 3 elements: 1) emotional support
a sense of security; 2) tangible assistance including direct
care and comfort measures; and 3) knowledge support in-
tic presence also decreases pain, anxiety, and fear.38Addi-
tional attributes of therapeutic presence may include meeting
the emotional, spiritual, and psychological needs of a woman
through human presence and social support. Physical pres-
and normalcy.39These attributes of therapeutic presence are
tential pregnancy risk as is commonly seen in obstetric triage
Although thefindingsof thisproject indicatethatwomen
that it was not the midwifery component of the care but sim-
ply having a dedicated provider staffing the triage unit. Other
providers such as physicians or nurse practitioners may have
the same impact on patient satisfaction; however, it would
be more cost-effective to have a CNM/CM as a dedicated
provider than a physician.
In addition to satisfaction with care, length of stay time
on the obstetric triage unit was significantly lower when the
CNM-managed model of care was implemented. These find-
ings are consistent with the studies of emergency department
triage settings, which demonstrated reduced length of stay
times when care was managed by a nurse practitioner.10,12A
dedicated provider in an obstetric triage unit can see women
only have the potential to improve efficiency in the obstetric
triage unit, thereby reducing the cost of care, but also increas-
Another important aspect of obstetric triage is the issue
of patient safety. Since the provider staffing triage would typ-
ically not have additional responsibilities for women in the
providing a more timely assessment.27
A limitation of thisproject wastheuse of a singleCNM asthe
care provider during the project. Using more than one CNM
or other providers such as physicians and nurse practition-
ers during the project may have yielded more broadly appli-
cable results. Taking into account provider variability or a di-
offered more evidence to support what type of provider could
offer the best service at the most efficient price point. Also,
a cost analysis would have augmented the findings. Further
studies are needed to validate the model of CNM-managed
care in other settings with a variety of midwives, and the cost
of this model of care should be examined.
interprofessional midwife, nurse, and physician approach in
the obstetric triage setting. Collaboration encourages shared
decision making and judicious use of resources.20A collabo-
rative, interprofessional, obstetric triage model between mid-
wives, nurses, and physicians allows for more efficient use of
cian for higher acuity patients and allows the CNM/CM the
opportunity to practice to the full extent of her/his scope of
A typical triage visit does not often require the expertise
cause in addition to strong clinical skills, midwives also pro-
hance psychological care and ease anxiety during a time of
crisis.35Registered nurses also add significant contributions
to the team. Their expertise includes strong assessment, com-
be some overlap between CNMs/CMs and registered nurses,
there are differences in their respective scopes of practice.40
But together this collaborative, interprofessional team has the
potential to improve the overall quality of the obstetric triage
A CNM/CM-managed triage model also may benefit
programs. Since an obstetric triage unit functions much like
an emergency department, a provider needs expanded clini-
cal diagnostic and management skills to make effective deci-
sions.3A collaborative care triage model would provide op-
portunities for interprofessional educational experiences for
midwifery, nursing, and medical students as well as obstet-
ric residents. Some of the skills learned in obstetric triage in-
clude the ability to make rapid clinical judgments, conduct a
targeted history and a focused clinical workup, develop and
provide comprehensive education plans, and act quickly if a
Patient safety is a primary concern for all health care
providers. This is especially true in obstetric triage. Timely
assessment of obstetric triage patients can result in improved
patient outcomes. The midwifery-managed triage model re-
into a more timely assessment. These time savings also may
result in cost savings due to provider efficiency and a quicker
bed turnover. Increased reimbursement from having a dedi-
cated provider also may result since the dedicated CNM/CM
would have the time to attend to the necessary paper work.1
In addition to timely assessment, addressing the acuity on a
unit may facilitate patient safety.27Finally, patient assessment
may be enhanced if midwives have received additional train-
ing in limited obstetric ultrasound.41,42Nurse-midwives with
this advanced training have consistently demonstrated com-
petence with ultrasound skills.42
The cost of funding a midwife-managed triage model has
not been fully explored. Future research should focus on ex-
amining coding and billing methods for services in an effort
tain this role. Additionally, a more comprehensive study of
the impact of CNMs/CMs in obstetric triage units should be
of the woman’s experience.
Julie Paul, CNM, DNP, is a course coordinator at Frontier
Nursing University, Hyden, Kentucky, and CNM at Cam-
bridge Hospital and Cambridge Birth Center, Cambridge,
Robin Jordan, CNM, PhD, FACNM, is on the faculty at Fron-
tier Nursing University, Hyden, Kentucky, and is a senior
projects consultant at American College of Nurse-Midwives.
Susan Duty, ANP-BC, ScD, is the nurse research scientist
at South Shore Hospital, South Weymouth, Massachusetts,
and an associate professor at Simmons College, Boston, Mas-
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
Cathy Molloy, RGN, RM, Msc, Bsc (Hons), PGDip,
DPSM/ADM, assisted with the modification of the question-
Volume 00, No. 00, Month/Month 2013
SPECIAL DEDICATION Download full-text
Veronica A. Ravinikar, MD, FACOG, was the chair of the
Department of Obstetrics and Gynecology at South Shore
Hospital. Dr. Ravinikar facilitated the process at South Shore
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