Engaging critically with the concept of advancing professional practice

Midwifery frameworks

The midwifery career frameworks in all four UK countries identify a range of levels of practice and the need to develop new, and redesign existing, career pathways (Scottish Executive, 2001; Department of Health, 2004; Northern Ireland Practice and Education Council for Nursing and Midwifery, 2006; Welsh Assembly Government, 2009). The frameworks have a dual purpose of meeting the needs of service users and promoting the continued professional development of NHS staff. They describe and define the knowledge and skills required to deliver high-quality, evidence-based patient care to meet employer requirements as well as outlining a step-wise career progression. While the frameworks are concerned with the application of knowledge and levels of proficiency, there is little detail of midwifery-specific knowledge (Jasper, 2006). The overall content is concerned more with meeting user expectations than professional development.

Other more practical, outcome-based frameworks such as the National Leadership and Innovation Agency for Healthcare (NLIAH, 2010) Advanced Practice Framework in Wales is more focused on the acquisition and application of advanced knowledge and skills necessary to complement medical practitioners. As a result, this model offers more commonality with advancing midwifery practice because of the overlapping of medical roles and the autonomous decisionmaking within midwifery.

Advanced vs advancing professional practice

The concept of advancing professional practice is pivotal to the development of midwifery practice and has been translated into a number of different formats depending on its context. To some, it is synonymous with the work of the specialist or consultant midwife (Fulbrook, 1998), while others view it as a process of continuing professional development (CPD) and skills acquisition (Wilson-Barnett et al, 2000; Por, 2008). However, it is evident that a dichotomy exists between what advanced and advancing practice are; this has led to confusion in both the health care literature, where the terms are often used interchangeably, and among the nursing and midwifery profession itself (Por, 2008; Smith et al, 2010). Por (2008) uses the term advancing ‘nursing’ practice in the context of discussions on expert practice based on a specialist or generalist approach and further clarifies that it encompasses advanced ‘nursing’ practice.

In midwifery the use of the concept ‘advanced practice’ is controversial with a dearth of literature on midwifery roles in advanced practice. In a systematic review comparing midwifery roles in the US and the UK, Jones (2005) concluded that ‘standard’ midwifery roles in the UK could be considered advanced roles. Midwife-led models of care where the midwife is the lead professional in the care of women during pregnancy and birth could be an example of midwives practicing at an advanced level and meeting the core competencies of advanced practice (Mantzoukas and Watkinson, 2007). In essence this would mean that there are no levels of midwifery practice, with midwives being competent to practice from the day of registration (Sookhoo and Butler 1999; Lewis 2003). This position is based on a binary scale of competence; either the midwife is competent to practice or she isn't. It conflicts with the Dreyfus Model of Skill Acquisition (Dreyfus and Dreyfus, 1980) that Benner applied to the profession of nursing, where competency is viewed on a scale (Benner, 1984).

Application of the Dreyfus Model of Skill Acquisition (Dreyfus and Dreyfus, 1980) for midwives' professional practice would demonstrate their progression through five stages:

This would support the view that on qualification the midwife has a basic level of competence that develops over time through experience and exposure to practice, implying that levels of practice do indeed exist in midwifery (Smith et al, 2010). The strength of this model for midwives is the emphasis it places on clinical care, which promotes holistic care as being more significant than task orientation. However, many of the vignettes portrayed within Benner's (1984) work are little more than reflections on the ability to undertake a task, what Rolfe (1998) describes as propositional ‘knowing-how’ knowledge. There is little offered in the way of a deeper portrayal of knowledge or the identification of new knowledge, which would be expected at an advanced level. It could be argued that this is the very nature of Benner's intuitive ‘expert’ practitioner because the requisite knowledge is so deeply embedded in practice that it is often difficult to communicate how decisions are reached and how care is planned. While this may not pose an issue for the practitioner in terms of carrying out their day-to-day role, it may make teaching and communicating their role difficult. Rolfe's typology illustrates that if the practitioner cannot explain what they practise, it fails to equate to a comprehensive understanding of the situation. Rolfe describes the culmination of theoretical and empirical knowledge based on personal, experiential and scientific knowledge as the ‘knowing that’ of the advanced practitioner (Rolfe, 1998; Rolfe et al, 2001).

A recent Department of Health report (2010) sought to clarify the issue on the core roles distinguishing specialist and advanced midwifery practice and defined advanced midwifery practice roles as those with high levels of clinical skill, competence and autonomous decision-making. In addition, advanced practitioners would normally be educated to masters level (Department of Health, 2010). It is important to highlight that nurses and midwives have long been conditioned into believing that a title will convey their level of authority within an organisation. However this may not necessarily represent the level of competence inherent in that role (Castledine, 2003). Some midwives may hold job titles that imply an advanced level of knowledge and competence that may be beyond the level they hold. While confusion reigns over the origins of the specialist title (Hamric, 1989) there is agreement that there was a rapid growth in specialist posts in the UK in the 1980s (Castledine 2003). This growth in ‘specialists’ was an attempt to address the changes and developments in health care and enabled some midwives, for example, diabetic specialist midwives, to take on roles that extended their scope of practice beyond that of their initial registration. The concern is that the public cannot be sure that the level of expertise and competence of the professional providing care is commensurate with their title (Nursing and Midwifery Council, 2005: 3).

Implementation of the European Working Time Directive reducing junior doctors hours (Olson and Chioffi, 2005; Por, 2008), role reconfiguration for junior doctors, medical shortages and provision of midwifery care out of the hospital setting such as birth centres, has meant it is now common place for midwives to develop new skills which were originally undertaken by doctors (Manley, 1998). An example of this is the full physical examination of the newborn, which was traditionally undertaken by the paediatrician within the first 72 hours of birth, before transfer home and is now performed by midwives. This change originally came about in the guise of being able to provide continuity of care [Benner's holistic care], indeed the Royal College of Midwives advocated that this should be the only motivation for adopting this new role (RCM, 2000). However, failure to adequately define the role has meant it has been quickly overshadowed by an emphasis on substitution of the paediatrician with the midwife (Bryant-Lukosius et al, 2004). This situation has also been perpetuated by medical staff shortages and capacity issues. In some maternity units in England, midwives have set up midwife-led clinics for this purpose, with midwives shown to provide care of comparable quality to their paediatrician counterparts (Rogers et al, 2003; Townsend et al, 2004). Some may equate the additional skill of performing the newborn examination to mean that they are practising at an ‘advanced’ level or that they are advancing practice. However, it can be argued that the type of role undertaken by a paediatrician is different, rather than superior, to the role undertaken by a midwife and while advanced or advancing practice may contain some additional practical skills, it must not be seen as synonymous with extending the role of the midwife. Both Donnelly (2003) and Manley (1998) express concern when advanced ‘nursing’ practice is subsumed by medical functions and state that more emphasis should be made on developing new ways of working that fully utilise [midwives] skills and knowledge. There is also a fear that midwives may be leaving behind their legitimate work in a rush to take on tasks that they regard as more ‘glamorous’ (Marshall, 2010).

It is recommended internationally that nurses and midwives working at advanced practice level should hold a Master's degree (Sheer and Wong, 2008). This is often seen as a luxury rather than necessity, something that needs personal investment both financially and in time. It has been argued that the consultant midwife role represents the highest level of clinical midwifery practice (Booth et al, 2006; Coster et al, 2006). The evidence demonstrates that those in consultant roles struggle if they have not undertaken education to at least Master's level (Maylor, 2005). This does raise the issue currently highlighted in the media of a perceived academic prowess that nurses and midwives are now ‘too clever to care’. However, this mantra implies that caring skills do not require expertise, intelligence and education and devalues the core caring competencies of nursing and midwifery.

Conclusion

There are both practical and semantic difficulties when attempting to understand the ambiguous concept of advancing professional practice, not least due to the differing context and terminology used in the health care literature. It could be argued that the term ‘advancing’ is not explicit enough; however, it is evident that advancing practice is more than acquiring experience, qualifications, length of service or a job title. While not easy to define, it is distinguishable by a number of higher-level characteristics including: academic enquiry, research skills, publication, consultation, clinical and professional leadership, multi-professional and cross boundary working and expert clinical practice.