The Nursing and Midwifery Council (NMC) has stipulated a series of rules, standards and guidelines to underpin and regulate midwifery practice in the UK (NMC, 2012; 2015). These guidelines set out the context for midwifery practice and focus primarily on what a midwife can, cannot, should or must do. The NMC also sets out a range of competencies and essential skills clusters to be achieved by midwifery students during their education programme for entry onto the professional register (NMC, 2008; 2009). The Quality Assurance Agency for Higher Education (2001), in its subject benchmark statements for health-care programmes, sets out threshold standards against which higher education institutions are expected to benchmark programmes of midwifery education.
Together, these documents provide a map of the boundaries and values of midwifery practice and midwifery education. However, among the broad statements of knowledge, skills, values, behaviour and practice parameters that are outlined in them, none of them seem to distinguish definitively what are the most essential hands-on competencies required of a midwife at the point of registration.
This was identified as a problem in Wales in 2002 and, at that time, midwifery educators throughout the country worked together to produce an All Wales Pre-registration Midwifery Skills Framework to set out all the skills that midwives are expected to be able to undertake, on their own initiative, upon qualifying and registering as a midwife (Darra et al, 2003). Various iterations of the framework have been in use throughout Wales since then and anecdotal evidence demonstrates that it has been very useful in supporting mentors to facilitate skills acquisition by their students. This paper discusses the next stage of this process and explains the development and implementation of an All Wales Pre Qualifying Skills Passport (PQSP).
As part of the ongoing evaluation of the All Wales Pre-registration Midwifery Skills Framework, it rapidly became clear that several Local Health Boards (LHBs) were requiring newly qualified staff to undertake additional post-registration training before being permitted to carry out certain skills. Lead midwives for education (LMEs) were also becoming increasingly concerned that this was a costly—and potentially unnecessarily risky—strategy for the LHBs, the practitioners and the public. This was regularly discussed in the quarterly LME meetings held between all four universities that offer midwifery education in Wales. The risk was related to the potential for newly qualified midwives being expected to, and feeling the need to be able to, undertake certain skills in their new roles, for which they had not had sufficient time to develop and practise.
Four universities in Wales provide pre-registration midwifery education to meet NMC standards (2007; 2008; 2009; 2012; 2015) and it became apparent that in different LHBs and clinical settings some students were being permitted to try to develop these skills, while others were not (Table 1). While students were universally being supported to practise such skills in simulation at university, LMEs were convinced that it would be far more appropriate if students could be supported to develop the skills in real-life situations.
| Standard 17 competency | Essential skills cluster | ||
|---|---|---|---|
| 1 | Speculum examination | Effective midwifery practice 2 | Communication; normal labour and birth |
| 2 | Membrane sweep | Effective midwifery practice 4 | Communication |
| 3 | Venepuncture/phlebotomy | Effective midwifery practice 2 | Communication |
| 4 | Induction of labour with prescribed per vagina medication | Effective midwifery practice 12 | Communication; medical products management |
| 5 | Amniotomy | Effective midwifery practice 4 | Communication; normal labour and birth |
| 6 | Application of fetal scalp electrode | Effective midwifery practice 6 | Communication; normal labour and birth |
| 7 | Episiotomy | Effective midwifery practice 7 | Communication; normal labour and birth |
| 8 | Perineal suturing (not more than 2nd degree/episiotomy) | Effective midwifery practice 9 | Communication |
| 9 | Newborn bloodspot screening | Effective midwifery practice 9 | Communication |
| 10 | Blood sugar monitoring (adults) | Effective midwifery practice 2 | Communication |
| 11 | Administering oral medication to neonates | Effective midwifery practice 12 | Communication; medical products management |
| 12 | Administering topical medication to neonates | Effective midwifery practice 12 | Communication; medical products management |
| 13 | Administering intramuscular vitamin K to neonates | Effective midwifery practice 12 | Communication; medical products management |
| 14 | Blood sugar monitoring (neonates) | Effective midwifery practice 10 | Communication |
| 15 | Preparing intravenous infusions for administration | Effective midwifery practice 4 and 9 | Communication |
| 16 | Adding drugs to intravenous infusions and preparing intravenous infusion pumps | Effective midwifery practice 12 | Communication |
Extensive and intensive communication and consultation was essential during the development of the PQSP, but—with input from the student midwife societies in Wales and the support of the Chief Nursing Officer—we eventually gained agreement from all four universities and seven LHBs to develop an All Wales Passport relating to the development of specific skills. Senior clinical and educational staff from all the Welsh LHBs and universities collaborated to facilitate an effective and deliberate focus on the skills that student midwives needed to achieve prior to gaining their midwifery qualification. Fourteen skills were identified initially; these included undertaking a membrane sweep, applying a fetal scalp electrode, administering vaginal medication for induction of labour (following prescription from an appropriate prescriber) (NMC, 2011) and the administration of intramuscular vitamin K to babies. These were identified through widespread and prolonged consultation with student midwives, mentors, newly qualified midwives, midwifery managers, heads of midwifery (HoMs) and LMEs.
Developing the document
The approach to developing the PQSP was supported by a key educational theory proposed by Vygotsky (1978), who described the zone of proximal development, which identifies a gap in learning as a potential development area that takes place in collaboration with more capable peers. Learning (and development of a skill) is dependent on full social interaction which occurs between the student, the woman and the midwife mentor in the clinical area. Biggs' (1999) theory of constructive alignment also informed the project. This theory takes into account the student's prior knowledge and commitment, combined with mentor expertise. This is an especially useful approach when teaching health professionals where all the elements (prior knowledge and experience in an atmosphere of trust) support learning (Darra and Norris, 2006).
During the design phase for the PQSP, standardisation of content and language in the passport was considered to be essential. It was also decided that it should be loosely based on the style of the procedure guidelines in The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister, 2011). Utilising a democratic approach to its design, it soon became clear that the PQSP should incorporate two distinctive sections for each skill, to support mentors and students in the development and acquisition of the identified clinical skills. Section one related to the theory and underpinning knowledge, which was seen to be the responsibility of the respective universities; section two set out the clinical skill in an easy-to-use, step-by-step manner, which was to be used in practice settings by the midwifery mentors. Appendix 1 is an example of the document (the skill relating to undertaking a membrane sweep).
The planning group also worked together to ensure that the designated clinical skills were mapped against NMC competencies (NMC, 2009).
Heads of midwifery education ensured that LHB clinical policies and guidelines were aligned with the PQSP prior to the pilot phase that commenced in August 2014. It was during this phase that minor amendments were made to the design of the passport.
Implementation of the Pre-Qualifying Skills Passport
The PQSP was officially launched in Wales by Professor Cathy Warwick during a midwifery conference in January 2014. However, full implementation of the PQSP (which included the original 14 identified skills) was challenging, despite all stakeholders appearing to be willing and keen to support it. It became apparent, just before printing the final document, that some LHB policies still prohibited students' practice in some of the skills, such as administration of medicines to neonates. This meant that at that point, five of the 14 skills could not be achievable for all students across Wales. Given that the initial underpinning aim was to have equitable practice across the country, it was decided that the implementation plan should be revised. A pilot phase was set up with a PQSP that included nine skills, for which there was general agreement across the whole country. This was implemented in April 2014, with a planned early evaluation. During this time, heads of midwifery education worked closely with HoMs and partner LHBs to change and develop institutional protocols, policies and procedures that would enable the students' skill development in the other five of the original 14 skills.
During and after the pilot phase, evaluation from third-year student midwives and mentors was overwhelmingly positive in that both groups felt strongly that the PQSP offered them clarity regarding the skills that students were ‘allowed to undertake’ in each clinical area. Mentors who had been unsure of supporting the student to practise certain skills, following the discussion of their theoretical knowledge, now had a structured document that clearly laid out the accepted parameters and enabled students to be ‘signed off’ to allow them to continue to practise and hone these skills prior to qualification as a midwife. Students reported that being able to practise the skill under the supervision of an experienced midwife enhanced their learning of these particular skills, alongside all the other aspects of their midwifery practice.
By August 2014, all the LHB policies had been amended to facilitate students' skills development in practice and, following the successful pilot, the PQSP was rolled out across Wales. While initially it was felt that the PQSP would be given to third-year student midwives for completion, this was reviewed as it was identified that students may need a longer time to complete all the skills as they rotated through different clinical placements. Students also requested that they commence the PQSP earlier. There was, therefore, an agreement to commence the PQSP in the second year of the pre-registration midwifery programme, with the unequivocal premise that students were required to have undertaken the theoretical learning prior to undertaking any of the skills. In August 2015, the PQSP was updated to include all 14 original skills, along with an additional two skills relating to preparing intravenous infusions and pumps. These extra skills were added following consultation with HoMs and at their request.
It is not compulsory for students to complete the PQSP as part of their degree award, but there is an overwhelming agreement from all stakeholders that it is an enabling document, which supports the development of clinical skills in practice. Students have also reported the benefit of being able to present the completed PQSP at job interviews to demonstrate that they have undertaken these skills, which previously required additional post-registration training during their preceptorship period.
Ongoing development
Since 2014, following feedback from practitioners and students, there have been some small adjustments made to the PQSP. For example, there were concerns around the use of the term ‘competent’ in the document (the first version of the PQSP referred to the student as being ‘competent in a skill after having it signed off’). Mentors questioned whether the term ‘competent’ could be applied to student midwives who may have limited opportunity to practise some of the skills in order to reach competence. Some mentors commented that reaching ‘competence’ was unrealistic; therefore, the wording was changed such that a mentor should be able to sign section 2 of a skill when s/he ‘believes that the student has undertaken this skill safely and effectively and is able to continue practising this skill under appropriate supervision’. This modification is being evaluated over the coming months.
As the PQSP has been favourably received by mentors, HoMs and students, there are ongoing discussions with HoMs regarding potentially introducing further skills into the PQSP. Two skills that have been identified through these discussions as being desirable for students to acquire are intravenous cannulation and passing a nasogastric (NG) tube for a term neonate. The skill of intravenous cannulation is perhaps a contemporary innovation and is not considered an essential pre-registration midwifery skill according to the NMC skills clusters as set out in the current NMC (2009) standards for midwifery education. It could be argued that midwives are—and should be—advocates for normal birth, and undertaking this skill may seem at odds with that philosophy. However, what is clear is that midwives need to provide safe care, and that depends on the individual midwife's ability to be vigilant in perceiving and responding to early warnings of any departures from normality. Being able to cannulate may be life-saving in some circumstances, such as when responding to a woman with a severe postpartum haemorrhage in a rural midwifery situation. Being able to insert a venous cannula may also contribute to maintaining continuity of care(r) and promotion of care within a midwife-led setting. An example of this might relate to caring for women who are found to be carriers of Group B streptococcus without any other complicating factors. If such women are considered to be suitable for giving birth in a birth centre, the midwife may be the most appropriate person to insert a venous cannula if it is considered necessary as part of the plan of care.
‘ If the Pre-Qualifying Skills Passport and the acquisition of the identified skills help all student midwives to be safe and effective at the point of registration to support women experiencing normal childbirth, the document is achieving its aim ’
The second proposed skill, of passing an NG tube into the stomach of a term neonate, may be of some use in relation to transitional care for the neonate. It could also contribute to ensuring that women and babies are kept together, to improve outcomes and experiences for women and their babies. If midwives are able to pass an NG tube to help achieve this, perhaps it should be considered a pre-qualifying midwifery skill. It is clear that educationalists must respond to local need. However, one should not lose sight of the fact that the current NMC (2009: 20)Standards for pre-registration midwifery education state:
‘The primary focus of pre-registration midwifery programmes is to ensure that students are safe and effective in practice when supporting women experiencing normal childbirth.’
If the PQSP and the acquisition of the identified skills help all student midwives to be safe and effective at the point of registration to support women experiencing normal childbirth, then the document is achieving its aim. However, the NMC (2009) standards are currently under review. It is not clear whether there will still be such a focus on ‘normal childbirth’ in the new standards, but the PQSP will be easily modifiable to ensure it remains contemporary and responsive to changes in practice.
Preliminary evaluation of the PQSP has been positive, and there has been some interest from other UK universities to include it in their midwifery programmes. In Wales, the Coleg Cenedlaethol Cymraeg (national college) has also provided funding to translate the PQSP into Welsh to support students reading for the Bachelor of Midwifery degree in the Welsh language.
Conclusion
The HoMs and lead midwives of the four universities in Wales that provide midwifery education have a long history of working together to ensure the learning needs of student midwives are met. Achievement of the NMC standards for midwifery education, competencies and essential skills clusters, along with the All Wales Midwifery Skills Framework, ensures that students are prepared to undertake the role and responsibilities of a midwife on completion of the programme.
The All Wales PQSP enhances the ability of newly qualified midwives to undertake the role, providing safe and appropriate care to women and babies in all settings across Wales and the UK.
The PQSP is not intended to replace the preceptorship period following qualifying as a midwife, but to enable newly qualified midwives to undertake their role more effectively, efficiently and with confidence and competence. The PQSP reduces the need for additional training in 16 specific skills, enabling the newly qualified midwife to adapt to her/his new role and then concentrate on other developmental needs, for example, the newborn and infant physical examination screening programme.
It has taken quite some time from commencing the process to ‘completion’; at times it seemed an impossible task and that agreement across Wales would not be achieved. However, the design, pilot and full implementation phase are now complete and the PQSP is used by all student midwives in Wales. Evaluation is ongoing and the HoMs and lead midwives for education in Wales continue to work together in monitoring and developing the passport for application to the ever-changing practice arena.