Newly-qualified midwives are expected to be safe, competent practitioners and are responsible for providing high standards of care for women and babies (Phelan et al, 2014); however, for many midwives it can be a particularly vulnerable point in their career. Although newly-qualified midwives have achieved the professional standards required to become autonomous practitioners (Reynolds et al, 2014), many doubt their capabilities and decision-making skills, often comparing their limited clinical experience to that of senior midwives (Wain, 2017). As a result, it may prove challenging to ensure that evidence-based practice and the professional standards promoted by the Nursing and Midwifery Council (NMC) (2018a) are upheld when confronted with attitudes resistant to change in practice.
This article will discuss these challenges for the newly-qualified midwife. This was motivated by an experience in clinical practice that caused one midwife, Ruth*, who at the time was on the verge of qualification, to consider the challenges of transitioning to registrant status. The article will explore the promotion of evidence-based practice when providing breastfeeding support and advice; dealing with poor professional practice; and the stigmatised issue of whistle-blowing.
Although it may be more acceptable to write about clinical experiences using a reflective style of writing, this article is written as a descriptive narrative to maintain the level of objectivity and reduce bias. The experience that created the impetus for writing is described below.
*Names have been changed to protect confidentiality in accordance with NMC (2018a) recommendations.
Case study
While practising on a busy postnatal ward, Ruth worked with Marnie, a midwife with more than 15 years' experience. However, Ruth had concerns about Marnie's attitude to women and her clinical practice. Ruth regularly observed Marnie being sharp with women, dismissing their requests for assistance and giving inappropriate advice to women who wished to breastfeed. Other experienced midwives in whom Ruth had confided dismissed her concerns, saying, ‘That's just Marnie, you'll get used to it’.
The case study shows evidence of several professional issues: Marnie's dismissive attitude to women; a failure to provide women with appropriate, evidence-based advice on breastfeeding; and an evident hierarchy in the postnatal ward, culminating in a reluctance to raise concerns about poor practice. Although postnatal issues such as reduced hospital stay, increasing demand for beds and dwindling staffing levels may be potential barriers to effective care, the midwife maintains a professional responsibility to advocate for women (Morrow et al, 2013).
‘Ruth worked with Marnie, a midwife with more than 15 years' experience. However, Ruth had concerns about Marnie's attitude to women and her clinical practice. Ruth regularly observed Marnie being sharp with women, dismissing their requests for assistance and giving inappropriate advice to women who wished to breastfeed. Other experienced midwives … dismissed Ruth's concerns, saying, “That's just Marnie, you'll get used to it”’
Promoting evidence-based midwifery practice
Evidence-based practice is a fundamental component of effective midwifery care. The NMC (2018a) recommends that all midwives practise with the best available evidence to maintain the knowledge and skills necessary for safe, high-quality practice. According to Barends et al (2017), evidence-based practice is defined as the process of making decisions through the conscientious and judicious use of the best available research to increase the likelihood of a positive outcome. In order to uphold the standard of professional practice for registration, it is essential that midwives continually strive to improve their practice by integrating the best available research evidence, reviewing updated clinical guidelines and using their own expertise to make an informed clinical decision (Farokhzadian et al, 2015).
In addition to enabling midwives to evolve into critical thinkers and reflective practitioners (Sidebothem et al, 2014), evidence-based practice also ensures that midwives are able to provide credible evidence if their practice is challenged, as there is arguably heightening pressure for midwives to be held accountable for their actions (Veeramah, 2016). This is especially important in the NHS, where cost-effectiveness and professional accountability are of prime consideration. There is more pressure on accountability, and nurses and midwives must be able to provide credible evidence when they are challenged.
Evidence-based practice and breastfeeding
Marnie failed to implement the best available evidence in her clinical practice, as her inappropriate advice did not sufficiently support women by giving them the necessary skills to sustain successful breastfeeding.
Midwives play a crucial role in determining and implementing high quality standards of clinical practice, particularly in relation to breastfeeding advice and support. It is the midwife's professional responsibility to ensure that women are aware of the health benefits of breastfeeding so that they are able to make an informed decision. According to Spiro (2017), exclusive breastfeeding is associated with a variety of maternal health benefits, including reduced risk of type 2 diabetes and breast and ovarian cancer. Pérez-Escamilla et al (2016) also highlighted the positive health outcomes of breastfeeding for infants, arguing that it is associated with lower incidence of sudden infant death syndrome, respiratory infections and gastroenteritis.
In order to practice in line with the best available infant feeding evidence, many hospitals have altered their practice to attain the Unicef ‘Baby Friendly Hospital Initiative’ designation, which aims to support women in achieving the 6 months of exclusive breastfeeding recommended by the World Health Organization (Lundeen et al, 2016). In a Canadian study (Groleau et al, 2017), women who received breastfeeding support and advice from midwives educated under the Baby Friendly Initiative were better prepared to cope with the potential difficulties that may arise during breastfeeding such as exhaustion, pain and negative attitudes surrounding their choice (Groleau et al, 2017; Gustafsson et al, 2017). Under the initiative, midwives must encourage early breastfeeding initiation; support women with correct latch and attachment; avoid recommending infant formula, teats or pacifiers; and advocate for women to stay in the same room as their babies throughout their hospital stay (Unicef, 2017). Promoting evidence-based advice through the Baby Friendly Initiative is therefore a practice that provides women with the knowledge to prolong exclusive breastfeeding.
Midwives should work in partnership with women and empower them to make decisions about their own care (NMC, 2018a). Midwives are in a unique position to hinder or promote breastfeeding with the quality of their support and evidence-based practice (McFadden, 2016). Marnie's inappropriate advice, for example, resulted in many women in her care resorting to bottle-feeding, despite their initial intentions to breastfeed. Although Ingram et al (2015) found that many new mothers required evidence-based information and practical advice from midwives in order to successfully initiate and sustain breastfeeding, James et al (2017) reported that emotional support, consistent advice and breastfeeding education were frequently neglected on the postnatal ward. Some studies (Astrup, 2015) have highlighted that resource constraints and relentless demands of the postnatal ward can often present as a barrier to effective breastfeeding support, while others (Debevec and Evanson, 2016) have argued that it is less about time constraints and more about the midwife's attitude towards breastfeeding and their ability to implement evidence-based practice. Exclusive breastfeeding can often be hindered by conflicting advice from midwives and a lack of continuity of care, leading to artificial supplements being given or resulting in the cessation of breastfeeding completely (Battersby, 2014). In order to sustain breastfeeding efforts, the midwife must establish a rapport with women and provide them with the skills to breastfeed efficiently and independently (Swerts et al, 2016). Although the midwives in the case study dismissed Marnie's behaviour, this does not reflect the expected standard of practice, as all midwives should encourage breastfeeding using structured, evidence-based practice (National Institute for Health and Care and Excellence (NICE), 2015).
Midwives' use of evidence-based practice
Edwards et al (2018) have suggested that midwives can lack confidence in the busy postnatal ward and can develop low self-efficacy in relation to their skills and autonomy, which results in formula-feeding being viewed as a more convenient option. In addition to individual barriers, numerous organisational issues, such as readiness and resources for change, also hinder evidence being translated into practice (Renolen et al, 2018).
Lawton and Robinson (2016) highlight that postnatal wards are under increasing strain due to an acute shortage of beds and available midwives. Nevertheless, midwives have a professional responsibility to ensure that each woman receives the highest standard of individualised care, regardless of the pressures and time constraints of the postnatal ward (Symon, 2015), and there is little excuse for the inadequate midwifery care, minimal breastfeeding support and disrespectful attitudes identified in the case study above (Bostock-Cox, 2015). Midwives should continue to develop their breastfeeding knowledge and skills through education and research, in order to enhance their professional development and their role as an advocate for breastfeeding (Schmied and Bick, 2014), as midwives who incorporate evidence-based practice in their care can facilitate the decision-making process when faced with clinical uncertainty (Warren, 2015). Many health professionals initially struggle to incorporate evidence-based research into their daily clinical practice as the process requires considerable time and skill (Nilsen et al, 2017); however, Mackey and Bassendowski (2017) emphasise that the implementation of evidence-based knowledge in routine practice gradually becomes habitual through the process of adaptive learning.
Deery and Fisher (2017) argue that in order to work as an autonomous professional and ensure high-quality care, it is essential that midwives personalise their care and that each woman feels valued. Similarly, Dean (2017) states that genuine emotional attachment to work is associated with heightened professional commitment. Consequently, midwives who implement evidence-based practice and ensure a compassionate, professional attitude demonstrate that they value the women in their care.
The challenge of ‘whistle-blowing’ in professional practice
Whistle-blowing is defined as an act of disclosing information with the purpose of revealing cases of professional misconduct or malpractice to those who may be able to initiate change (Kumar and Santoro, 2017). Whistle-blowing is a subject that remains an under-researched yet unwavering issue in professional midwifery practice, and emerges as primary theme in the case study above. Ruth was confronted with the dilemma of whether to report concerns about Marnie's dismissive attitude with women and inappropriate advice in relation to breastfeeding, both of which were examples of substandard midwifery care.
Ruth's whistle-blowing responsibility
Although the NMC (2018b) states that it is essential to act without delay if there is a risk to the safety of women, and to escalate concerns about the level of care received, whistle-blowing is often a tentative and difficult process. Milligan et al (2017) argued that whistle-blowing was invaluable for improvements in quality of care and was central to maintaining a firm culture of safety in midwifery. However, Alnaqi et al (2017) found that many midwives were reluctant to raise concerns in relation to malpractice and poor professionalism for fear of negative repercussions, such as potential scrutiny in their working environment and uncertainty in relation to job security (Jackson et al, 2014). Milligan et al (2017) also found that midwives were reluctant to come forward with genuine concerns, as many feared appearing treacherous to their fellow colleagues; while others (Hyde, 2016; Glasper, 2017) have suggested that whistle-blowers are often victimised, with many midwives experiencing bullying, threats and scapegoating as a result of raising legitimate concerns surrounding practice.
In the case study, Ruth was faced with a dilemma: to act out of concern for the welfare of the women and uphold the advocacy role of the midwife by raising concerns of substandard practice; or to remain silent, for fear of causing tension in the team. Ciasullo et al (2017) found that health professionals often initially preferred to informally confront internal issues, rather than escalating concerns; however, when confiding in the other midwives in the case study about Marnie's attitude and refusal to assist women on the ward, Ruth's concerns were dismissed. Molina et al (2016) found that this was often not an isolated professional issue, and that a poor rapport and a lack of respect for the needs of women were recurring complaints in practice. According to Ekström and Thorstensson (2015), the ‘breastfeeding antipathy’ in the case study was an evident failure to meet the professional standards of care required by regulatory bodies (NMC, 2018a). As a result, Marnie's insufficient knowledge and aversive reactions to breastfeeding were disempowering for the woman.
Hall and Mitchell (2017) argue that midwives' attitudes affect the quality of care and support, stating that poor communication, lack of respect and ineffective listening have been linked with increased morbidity and mortality for mother and baby. Ruth's role as a whistle-blower was therefore fundamental to protect the welfare of the women in Marnie's care (Barker, 2015). Although the nature of whistle-blowing can be controversial, it is often considered a last resort and generally occurs as a result of organisational failings in which the practitioner feels that the issue will continue to remain unresolved unless reported to a higher authority (Beretta, 2017). Whistle-blowing therefore forms part of the midwife's role as an advocate, as the midwife has a professional, moral and legal obligation to act in the best interests of the woman and report any identifiable failings in her care (Bradfield et al, 2018).
Supporting the newly-qualified midwife as catalyst for change
Hunter and Warren (2014) highlight the importance of managers and colleagues supporting newly-qualified midwives, who are at a vulnerable point in their career, in their decision to report poor professional practice. Newly-qualified midwives may frequently doubt their decision-making skills when questioned or dismissed by more experienced senior midwives (Wain, 2017); however, they have the necessary skills, knowledge and judgement to practice safely and should learn to become increasingly assertive in their clinical actions (Carolan, 2013; Barker, 2014). In order to diminish the professional hierarchy in midwifery practice, a supportive environment is required, in which senior midwives or authority figures are easily approachable if midwives have concerns about poor midwifery care (Jones and Kelly, 2014). Barker (2015) argues that a significant cultural change is required in midwifery practice, including an open working culture in which all midwives are actively encouraged and supported when raising concerns about women's welfare will improve future professional practice. Similarly, Newdick and Danbury (2015) recommended that whistle-blowing should be viewed as a positive way to improve care rather than a criticism, suggesting that managers should consider measures such as additional training to improve practice and extending legal protection to support team members who raise concerns. This training could also be incorporated into pre-registration midwifery education programmes in preparation for the transition from student to registrant status (Astrup, 2018). Simulation could also be used to effectively manage situations in which poor midwifery practice has been identified (Ruyak et al, 2018).
The nature of whistle-blowing is diverse: it may involve raising concerns about a recurrent, widespread problem with poor practice and substandard care across an organisation, such as in the Francis Report (Simpson and Morris, 2014), or it could be applied to an individual case and a specific practitioner, as in the case study above. The NMC (2018b) states that midwives must provide honest, accurate and constructive feedback to colleagues when appropriate, particularly if a midwife's individual practice could result in adverse events in a woman's care. As a result, Ruth may have initially chosen to discuss her concerns with Marnie in a professional and non-accusing manner. If this situation proved difficult or Marnie refused to alter her practice, it would be Ruth's duty as a registered professional to escalate concerns (Foster, 2016). The Royal College of Midwives (RCM) (2015) and NMC (2018b) have produced guidance for reporting instances of poor care. According to NMC (2018b) guidance, issues should initially be raised with a senior colleague. If the response is unsatisfactory, the NMC recommends that midwives should escalate their issues further to a senior manager in the department, such as the ward manager. The RCM (2015) advocates that up-to-date and robust policies on raising concerns should be developed and communicated widely. Access to an RCM workplace representative may be an additional source of support for the newly-qualified midwife seeking to raise concerns about poor professional practice.
Senior clinical colleagues, such as the Professional Midwifery Advocate (PMA) in England (NHS England, 2017), are also available, providing essential support for newly qualified midwives and women by supporting choice, communicating preferences and addressing poor practice (Stalberg, 2017). However, midwives should also be aware of their local Trust policies and external agencies when raising concerns.
Conclusion
Newly-qualified midwives have a responsibility to ensure that each woman receives the highest standard of care, regardless of pressures and time constraints. Postnatal wards are under increasing strain, but this provides little excuse for the inadequate midwifery care identified in the case study above. The effective delivery of evidence-based practice depends on midwives' motivation and ability to implement clinical knowledge into daily practice. Each midwife should therefore strive to incorporate evidence-based research into practice to provide the high-quality, personalised care to every woman.
There is a need for greater transparency and a more open environment when raising concerns during clinical practice, and the process of whistle-blowing remains a misunderstood and taboo in healthcare. Despite this, newly-qualified midwives are beginning to challenge the accepted standards of practice. If provided with sufficient support from senior staff, newly-qualified midwives are in a position to change whistle-blowing culture by confronting questionable practice and standing as ‘tall poppies’. To prevent the ‘culture of fear’ around that appears throughout the midwifery profession, experienced midwives can support for newly-qualified midwives in confronting concerns in practice. To promote a change in the outdated dynamics of the whistle-blowing culture, senior staff should also encourage an open working environment, rather than silence it.