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number of procedures carried out, and number of referrals requested (Schwartz, 2003). Before the philosophy of cost containment became prominent, health care insurance paid separately for each procedure or piece of equipment the client received. Under managed care, the agency receives a certain sum of money for the client’s care, no matter how many supplies, procedures, or personnel are used in care. In a managed care environment, helping to curtail cost is an important nursing function. Suggestions such as using generic-brand supplies, never breaking into kits of supplies to remove a single item, and urging the use of disposable supplies so that less personnel time will be spent on cleaning and sterilizing are welcome, cost-effective suggestions. Cost containment has had dramatic effects on health care, most noticeably in limiting the number of hospital days and changing the roles of personnel. Before managed care, women stayed in a hospital for 3 or 4 days after childbirth; today, they rarely stay longer than 48 hours. Before managed care, nurses completed all care procedures for patients, no matter how small or unskilled the task. With managed care, ancillary personnel (e.g., unlicensed assistive personnel) perform many tasks under the supervision of the nurse. This system is designed to move the registered nurse (RN) to a higher level of function, because it makes the RN accountable for a fuller range of services to patients. It accentuates point-of-service care. It also increases the accountability and responsibility of RNs to delegate tasks appropriately. As a result of managed care, the new advanced-practice role of case manager has been created. It is important to know the legal aspects of delegation, as identified in individual state nursing practice acts, because some laws address specific tasks and activities that RNs may or may not delegate in that state. Accountability for completion and quality of the task remains with the nurse, so the nurse is responsible for knowing that the condition of the patient and the skill level of the assistive person are conducive to safe delegation. There are four rules to follow when delegating: • Right task for the situation • Right person to complete the task • Right communication concerning what is to be done • Right feedback or evaluation that the task was completed Examples of delegation responsibility that can occur in maternal and child health are highlighted in the Multidisciplinary Care Maps located throughout this text. When managed care was introduced, it was viewed as a system that could lead to poor-quality nursing care because it limits the number of supplies and time available for care. In settings where it works well, however, it has increased opportunities for nurses because it rewards creativity. Alternative Settings and Styles for Health Care The last 100 years has seen several major shifts in settings for maternity care. At the turn of the 19th century, most births took place in the home, with only the very poor or ill giving birth in “lying-in” hospitals. By 1940, about 40% of live births occurred in hospitals, and today the figure has risen to 98% (DHHS, 2005). Today, a less dramatic but no less important trend is occurring: an increasing number of families are once more choosing childbirth at home or in alternative birth settings rather than hospitals. These alternative settings provide families with increased control of the birth experience and options for birth surroundings unavailable in hospitals. One strength of this movement is its encouragement of family involvement in birth. It also increases nursing responsibility for assessment and professional judgment and provides expanded roles for nurse practitioners, such as the nurse-midwife. Of all births in the United States, 5% currently are attended by midwives rather than physicians (Martin et al., 2005). Hospitals have responded to consumers’ demand for a more natural childbirth environment by refitting labor and delivery suites as birthing rooms, often called labor-delivery-recovery (LDR) or labor-delivery-recoverypostpartum (LDRP) rooms. Partners, family members, and other support people may remain in the room, which is designed to be a homelike environment, and participate in the childbirth experience (Fig. 1.5). Couplet care—care for both the mother and newborn by the primary nurse— is encouraged after the births. LDRP rooms promote a holistic, family-centered approach to maternal and child health care and are appealing to many families who might otherwise have opted against a hospital birth. However, LDRPs are not without fault. It has been argued that they are less private for laboring families, tend to be less relaxing for postpartum families, and make it difficult for nurses to manage the needs of women both in labor and after birth. Many hospitals are continuing to search for the best labor, delivery, and postpartum options. Whether childbirth takes place at home, in a birthing center, or in a hospital, the goal is to keep it as natural as possible while ensuring the protection that experienced nurse-midwives or physicians can provide. Health care settings for children are also changing. Clients’ homes, community centers, ambulatory clinics, well-baby clinics, schools, and group homes are some settings in which comprehensive health care may be administered. In these settings, a nurse may provide
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