Interview with Dr. Tonya Nicholson, Associate Dean of Nurse-Midwifery and Women’s Health at FNU

Meet the Expert: Dr. Tonya Nicholson

Dr. Tonya Nicholson is the Department Chair of Midwifery and Women’s Health at Frontier Nursing University (FNU). She is a past FNU Program Director and the former Chair of the Directors of Midwifery Education for the ACNM (American College of Nurse-Midwives).

Dr. Nicholson’s areas of interest include communication, civility, and precepting. In addition to her academic appointment, teaching, and speaking, Dr. Nicholson is a practicing nurse-midwife in her hometown of Dublin, Georgia.

Dr. Nicholson holds an MSN from Case Western Reserve University and a DNP from FNU, where she received her midwifery training and has spent 15 years instructing with a focus on clinical practice and prenatal health. In addition to the nurse nurse-midwifery and women’s health care nurse practitioner specialty-tracks that Dr. Nicholson oversees, FNU currently offers two other specializations: family nurse practitioner and psychiatric-mental health nurse practitioner. FNU also offers a doctor of nursing practice (DNP).

Staying True to Their Mission: Letting Go of the ADN-to-MSN Bridge Program

FNU’s mission is based on a commitment to educate competent, entrepreneurial, ethical, compassionate, and truly excellent nurse practitioners and nurse-midwives. They emphasize providing health for diverse, rural, and underserved populations.

That is why the bridge program was started, Dr. Nicholson explained. Someone with an ADN or ASN (versus a bachelor’s of nursing) could go all the way through from the BSN to the master’s degree. At the time of the program’s inception, there were not as many opportunities for nurses without bachelor’s degrees to enroll directly in a graduate program. The bridge program was started to address this educational gap.

So why let it go? Dr. Nicholson elaborated on the factors that led to the decision to its discontinuation:

One thing we do consistently is circle back to our mission: Are we still meeting our mission at its highest level? We started to find that our bridge enrollment had dropped a little bit, so we decided to explore why.

What they found was that there is now a wealth of RN-to-BSN programs that include options for distance learning. So FNU determined that they were not needed in that market anymore and decided to shift their primary goal toward increasing the number of nurse-midwives and nurse practitioners.

Dr. Nicholson illustrated this nationwide trend with an example from her own life:

An example is my little town of Dublin. You can get an RN-to-BSN right here in town. So if you can get it here, you can get it anywhere…Many local and small universities and colleges have an RN-to-BSN program, and there are lots of distance options so there is no longer an access issue.

We’re thankful for that because those ASN and ADN nurses are very valuable, especially in rural areas. They have so much that they can bring to the table by becoming nurse practitioners or nurse-midwives, but they no longer need us for that initial RN-BSN portion.

Trends in Advanced Practice Nursing: Call the Midwife

Midwifery is becoming more recognizable to the general public in the United States. Dr. Nicholson explained that in some regions and eras of American history, nurse-midwifery was not well-known or well-utilized. However, this is beginning to change, in part due to exposure of the field to the general public. Dr. Nicholson revealed with a hint of excitement,

I’ll give a little shout out to Call the Midwife. As people in mainstream America see this program being so well-received and are starting to hear the word “midwife” a bit more commonly, people are starting to ask for midwives. So, that has helped midwifery, especially in areas of the country where nurse-midwives have been underutilized.

All of a sudden there’s more chatter around midwifery. And when you say “I’m a midwife” or “I’m a nurse-midwife,” people are intrigued. There are many parts of the country where it’s common to have midwives practicing, but there are some areas where it hasn’t been. My little hometown is one of them: Dublin, Georgia. I’m the first and only midwife here—and I’m not a rarity in that kind of situation. It is so exciting to be able to offer care in my home community and to increase recognition and understanding of midwifery care.

Dr. Nicholson went on to explain that the trend in increased public awareness of midwifery has resulted in a larger number of nurse-midwifery applicants to Frontier. She shared, “That is good for us, good for midwifery, and more importantly, good for mommas and babies.”

In addition to the more commonly known aspects of midwifery care that involves labor and delivery, certified nurse-midwives (CNMs) are primary care providers. They perform annual exams, write prescriptions, and offer nutrition counseling to women throughout the life cycle. They also provide gynecological services and family planning, including preconception, pregnancy, childbirth, postpartum and newborn care.

Elaborating on the benefits of midwifery care for mothers and infants, Dr. Nicholson highlighted the sad, but true reality of the maternal and neonatal crisis that exists in the United States. Nurse-midwives are playing an important role in providing support to mothers and babies. She explained,

We know that midwives provide excellent care…Over and over in the literature now, we’re seeing midwifery being pointed to as one of the answers, one of the primary answers to the abysmal maternal and neonatal outcomes that we currently have in this country. We have some of the worst maternal and neonatal outcomes in industrialized countries. We spend more than anybody else on healthcare, and yet outcomes in this particular area are really not good.

Nurse-midwives increase access to prenatal care. Dr. Nicholson explained that midwifery care is especially effective when it’s provided within a team that includes women, midwives, physicians, nurses, and social services professionals. She emphasized that when a team approach to care is provided, that’s when women and babies benefit the most: “An integrated, well-functioning team for maternity care leads to the right level of care in the right setting for every woman…And that saves the lives of mothers and babies.”

Civility and Communication in Nurse-Midwifery Care

Dr. Nicholson’s areas of professional focus include the roles of civility and communication in nurse-midwifery care. She explained that sometimes access to midwifery care is about sheer numbers and where the providers are: Are they where clients can access them? Are there enough of them? Is it a positive experience?

If they go into care and have a bad experience—poor communication, lack of communication, or an uncivil environment—then they may be unwilling to access the care or access it in a timely manner.

Timing is also of the essence with regard to having an impact on a mother and her developing child.

It’s much harder when somebody accesses care late in pregnancy. It’s easier at a first visit at 10 or 12 weeks to talk about decreasing their risk by stopping smoking or alcohol use, or leaving a dangerous situation. It’s easier to do that when you’ve got 30 weeks to talk about it than when somebody’s coming in during labor. And that comes with a relationship. So that implies civility and communication. Access to care is partially numbers and partially the way that care is provided.

One of the things that I say to women when they come in for their first visit is, “You as the woman have a hard job. You’re growing a small human. You’re making all the decisions. You have a lot of power over what you eat, who you are around, and whether you’re decreasing your health risk in those ways we talked about. My job really is to be with you.”

This approach to care is embedded in the meaning of the word: midwife literally means “with woman.” If a trusting relationship is established, then the expecting mother is much more likely to heed the midwife’s advice. A trust-based relationship between the woman and midwife also allows her to tell the truth about her life and her health without fear of judgment. Dr. Nicholson elaborated,

It helps her to be able to tell the truth. When we have a relationship and she feels comfortable enough to say to me, “I am using. I know I told you I wasn’t using, but I actually am using. And here’s why.” And then we talk about all the things that surround that use. Not just the use, but what it means in her whole life.

The vulnerability and intimacy in the relationship with the woman and her family allow a midwife to know her intimately and to support her overall health. With that trusting relationship, not only does a woman’s health improve but also the health of her baby and family. Most women are the decision-makers about health in their families, she explained, and that essentially also means that they have an impact on their communities.

Expanding the Reach of Nurse-Midwifery Services

As the largest midwifery program in the country, FNU educates more than a third of the nurse-midwives in the United States each year. Dr. Nicholson shared that she and the Frontier community feel a deep sense of that responsibility. To honor that, Dr. Nicholson explained FNU’s commitment to expanding their reach while maintaining the quality of their program offerings:

What that means is that we are continually looking at our courses. We are continually reviewing them: Do they meet the needs of midwives in all care settings…whether they’re working in a home setting, a birth center setting, or a hospital setting?

In addition to maintaining a high standard of excellence through their coursework, FNU’s educational program also administers a quality enhancement project focused on teamwork. The TeamSTEPPS^Ⓡ model they use was initially created in the armed services and is now being used in multiple hospital settings and in many large medical corporations as well. Its purpose is to teach about how the medical team has to function well in order for optimum delivery of care.

One of the first premises is that the patient is always the center of the team. You don’t just come in and tell the patient what you’re gonna do to them. You work with them to form a plan that they’re on board with, that meets their needs, and that they can actually do.

This means that the individual is included in the goal-making process and able to express what is feasible for them to achieve. She continued,

We set a goal that is reasonable for the client. Then the team members work together to highlight their best attributes. The team that I have with the physicians—the obstetricians that I work with in my little home town here—we each bring our skills.

My skill is to bring normal to even the most abnormal situation. To value the fact that childbirth is a life experience, not a medical occurrence. It’s not something that we’re doing to you. You’re going to come out of this with a child that you need to parent.

It is an experience, so I try, even in the most medically abnormal situations, to bring an element of normal. To bring a relationship to the woman, to value what she finds important, to try to help her to have the kind of labor and birth that she desires within the constraints—if there are constraints—of whatever the medical situation is.

Dr. Nicholson went on to explain that obstetricians are highly trained to diagnose and treat the disease process, while midwives are trained to identify when something needs intervention. Then, either they can intervene themselves or talk with and work with the obstetrician to form the right plan. Ultimately, if a higher level of medical intervention is needed, obstetricians are there to do what they do best. To illustrate this point, Dr. Nicholson shared the following anecdote:

One of the physicians has constantly said to patients, “You’re so blessed that you had a midwife with you because I might have suggested a surgical delivery three hours before that, but clearly you didn’t need to have a C-section. You had your baby. I probably would have intervened because that’s what my specialty is. My specialty is intervention.”

She went onto explain how this differs from the role of a nurse-midwife:

My specialty is not intervention. My specialty is “watchful waiting.” Intervening when needed. Triage. Figuring out when there is actually a need, and if there’s not, just watch. Just keep watching.

Members of the interprofessional medical team bring their specialty to the table making that team richer, fuller, and more competent. And the outcome is that the woman and her family have a better experience and better outcomes.

In the team model, the individual being cared for is at the center of care. Dr. Nicholson added emphatically “It just has to be that way. If it’s not, you’re coming up with all these great ideas that will never go anywhere. The patient’s needs and desires must be the driver of all plans.”

Practice Authority Privileges and the Nurse-Midwife

National certification for advanced practice nurses allows for the broadest scope of practice. Being a holder of national certification says that you are educated to provide care at a given level, which is considered “full scope of practice.”

The next level is the state, which determines the scope of practice where an APRN resides and practices. There are 22 states that currently have full practice authority for advanced practice nurses. There are 28 states that require some sort of supervision or collaborative practice with a physician colleague. And then within that, there are additional limitations as to what can or cannot be done. Dr. Nicholson cautioned that,

Depending upon your licensure and where you’re practicing, and even within a specific job, there may be certain protocols that say, “Here at this institution you can do these things” and it may be a more narrow scope of practice than at the national or state level.

Unfortunately, not every state allows advanced practice nurses, including nurse-midwives, to practice to their full education and certification standards. Dr. Nicholson commented on how much this varies from state to state across the nation:

If my state says that I can’t order X, Y, or Z, then a client who comes to me is gonna have to go somewhere else…It is so frustrating because we know we’re filling gaps in places often that there are not enough care providers.

Advice for Prospective Nurse-Midwives

Despite the frustrations brought on by the limitations to the scope of practice in some parts of the country, Dr. Nicholson’s commitment to nurse-midwifery is unwavering. To those contemplating the career, she advises gaining some labor and delivery nursing experience when possible. Though it is not required of FNU’s CNM program applicants, it’s highly beneficial.

Dr. Nicholson shared that, “The most important thing is to have a heart and a passion for providing the kind of care that midwives provide. That passion goes a long way to the days and nights when you don’t want to study anymore…I think that resilience and that persistence is central to success in an educational program.”

And Dr. Nicholson is one to know. She left us with this final thought:

The passion in my life—besides my own babies—is being with women as they’re growing their families and being with students as they’re growing their dreams to be with women and families … It’s a privilege to get to do what I do. I do not take it for granted. I am thankful every day.