Midwives are responsible for undertaking a preliminary examination of the newborn at birth to ascertain any obvious signs of abnormality and, thereafter, to undertake a daily examination in accordance with Article 40 of the EU Directive for midwives 2005/36/EC (Nursing and Midwifery Council (NMC), 2009). The more detailed newborn infant physical examination (NIPE), colloquially known as the ‘discharge examination’, has traditionally been performed only by junior paediatricians or GPs. It has long been argued that inclusion of the NIPE within their sphere of practice is a logical step for midwives, as experts in the care of normal childbirth (Rose, 1994; MacKeith, 1995; Michaelides, 1997), and is pivotal to delivering a personalised service, encompassing the known benefits of continuity of carer as outlined in the NHS National Maternity Review (2016).
In recent years, opportunities have arisen for midwives to train to become NIPE practitioners. In the early years of this century, a study was undertaken to explore the cost-effectiveness of NIPE-trained midwives and senior house officers (Townsend et al, 2004). Known as the EMREN study, it found a significant increase in maternal satisfaction when the NIPE was performed by a practitioner known to the woman. Moreover, the economic evaluation undertaken by Townsend et al (2004) showed significant cost savings for the health service, with an estimated saving of £4.30 per baby examined by a midwife compared to a senior house officer (now known as an F1 or F2); given that the study is more than 10 years old, this amount may now be substantially higher. The EMREN study made some important recommendations in regard to the development of the midwife's scope of practice to include preparation to perform the NIPE (Rogers et al, 2003; Townsend et al, 2004). These recommendations formed part of policy recommendations for the preparation of midwives (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). While concerns were raised about increased workloads and pressure to adopt new roles, the NIPE was generally believed to be easily incorporated into midwifery practice without jeopardising overall standards of care (Rogers et al, 2003; Townsend et al, 2004).
More than a decade after the EMREN study, a UK-wide research project was commenced to assess the scope of NIPE practice by midwives and to explore the provision of NIPE education for pre- and post-registration midwifery students. This was undertaken as an online survey in two phases between autumn 2014 and spring 2015. Phase one surveyed all heads of midwifery in the UK (Rogers et al, 2015). A key finding was that, despite a growing acceptance of midwives undertaking NIPE as part of their enhanced role (Baker, 2010; Mcdonald, 2013), only 13.7% of UK midwives are currently NIPE-trained, and a high proportion of these are undertaking a significant number of NIPEs while others are doing few, if any, examinations on a regular basis (Rogers et al, 2015). The implication is that the NIPE workload is unevenly spread, with some NIPE-trained midwives taking on much of the workload previously only done by junior doctors, while others are not being facilitated to maintain their NIPE skills.
The authors argue that if pre-registration midwifery programmes were enhanced to include the full neo-natal examination as part of the standard curriculum, this would greatly increase the number of NIPE-trained mid wives in the NHS, and thus spread the workload. It would also embed the NIPE as part of normative midwifery practice rather than being seen as an ‘add-on’. Phase two of the project, therefore, surveyed all NMC-approved education institutions (AEIs) to explore the extent of provisions for NIPE education. The findings are reported in two parts: this paper details the pro vision, drivers, structure and requirements of NIPE edu cation in the pre-registration midwifery curriculum; the second part (to be published in a future issue of BJM) will report similarly on the post-registration NIPE programme, and will present the similarities and differences around pre- and post-registration preparation requirements.
Methods
A questionnaire was developed by a team of midwifery educationalists utilising some of the content from a tool devised from the initial phase of this study (Rogers et al, 2015). A pilot study was undertaken in a single AEI, after which the questionnaire, accompanying letter and instructions underwent minor modifications to improve clarity and ease of completion. The Bristol Online Survey (BOS, 2016) tool was used to distribute the questionnaire to all lead midwives for education (LMEs) in the UK, as listed on the NMC website. All LMEs were sent a link to the online tool during the spring of 2015 and were invited to forward the questionnaire to those individuals in their AEI who were best placed to supply the information. This was followed up by two email reminders to non-responders. The survey was also discussed as an item for ‘any other business’ at a national LME strategic reference group meeting in March 2015, to encourage outstanding non-responders to participate.
‘If pre-registration midwifery programmes were enhanced to include the full neonatal examination as part of the standard curriculum, this would increase the number of NIPE-trained midwives in the NHS, and spread the workload’
Data were analysed using the BOS analysis function and via detailed analysis by the chief investigator (CR). Data were also cross-checked by the other investigators in order to enhance analytical rigour.
Findings
Pre-registration provision of NIPE education
Responses were received from 40 out of a possible 58 AEIs (68.9%). Of the four UK countries, responses were received from Wales, Scotland and the highest response rate was from England; the exception was Northern Ireland, from which no responses were received. NIPE training was reported as being included in 10 pre-registration midwifery programmes (25.0%); however, one AEI offered the NIPE as part of an optional module for third-year student midwives. Only one of the 40 AEIs included NIPE as part of the shortened midwifery programme; the others included it as part of the 3-year programme. The first AEIs to implement the NIPE did so in 2011. One AEI reported that NIPE had been validated within a newly validated pre-registration midwifery curriculum in 2014 and was due to commence in 2016. An additional 15 AEIs (37.5%) stated that they were planning to implement the NIPE as part of pre-registration programmes within the next 2–5 years, with 12 (30.0%) reporting that they had no plans to include the NIPE and seven (18.0%) uncertain as to its inclusion in future.
Rationale for including NIPE as part of pre-registration midwifery programmes
Of the 10 AEIs that included NIPE in pre-registration curricula, nine commented on their rationale for doing so. Thematic analysis of the comments was undertaken and three broad themes were identified:
NIPE skills are consistent with the philosophy of midwifery
Several comments reflected the view that the NIPE was integral to the role of the midwife and thus essential to enable midwives to provide continuous and holistic care. Opinions on this matter were strong, and several respondents commented that it was essential that midwives were qualified in NIPE at the point of registration.
NIPE education meets service needs
Several respondents noted that directors of maternity services would value a midwifery workforce with NIPE skills from the point of registration. Respondents recognised that the needs of individual Trusts varied, including the need for a midwifery workforce prepared to work in contemporary practice and the requirement for cost-effectiveness to reduce their education budget. It was also identified that changing patterns and places of care have increased demand for the availability of NIPE practitioners to work in a variety of settings, including the community.
NIPE education helps to provide a responsive maternity service
The requirement to ensure the midwifery workforce is fit for purpose and is able to meet the demands of a modern maternity service resonated in several of the comments. A number of respondents stated that completing the NIPE enabled midwives to act as the lead professional, as well as ensuring that midwives could meet the demands of working in the current practice environment. Important drivers included the findings of previous research such as the EMREN study (Townsend et al, 2004), and the recommendations of Midwifery 2020 (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010) and the National Screening Committee (Public Health England, 2016). An additional driver for some AEIs was the need to ensure that the curriculum is current and that students are given the opportunity to enhance their practice.
The experience of NIPE as part of pre-registration midwifery programmes
Respondents were invited to comment on their experience of offering the NIPE as part of pre-registration training. Of those who currently incorporated NIPE into their programmes, only four had students who had actually completed such a programme. In two of these AEIs, a staged approach was in place; this involved students completing the theoretical component and then undertaking a practical element following NMC registration. The reason stated was that a lack of NIPE-qualified practitioners meant that students could not be supported in practice during their undergraduate programme. In the two remaining AEIs, students were assessed as competent to perform the NIPE at the point of registration; both stated that the introduction of the NIPE was extremely successful. The quote below exemplifies how one AEI developed a forward-planning strategy to cope with the perceived impact of the innovation on practice partners:
‘Following the validation of NIPE in pre-registration midwifery programme in addition to existing post reg[istration] NIPE students, the [name of institution] implemented a succession plan for midwifery lecturers to undertake the NIPE training to work in collaborative partnership with NIPE practitioners in our partner trusts. To date 50% of the midwifery academic staff have undertaken the post-registration NIPE training to ensure adequate individual NIPE student support in practice to boost existing NIPE practitioners.’ (AEI 11)
NIPE education core content, structure and assessment
Among the 10 AEIs that provided pre-registration NIPE education, seven stated that there was an education lead for NIPE, while three had no identified lead. Overall, 74 (19.6%) AEIs employed midwifery lecturers who were NIPE-qualified. A number of questions were asked relating to the requirements of NIPE training, including support in practice and assessment of competence. With the exception of the two AEIs that offered the theoretical component only, a wide variation existed in the number of supervised NIPEs that students were required to complete to develop their competence. This ranged from no specific number to between 5 and 50, with the majority reporting between 11 and 30 examinations.
A range of NIPE practitioners was identified as being permitted to verify students' NIPE experiences (Table 1). A variety of academic credit awards and different levels existed for students completing the NIPE. In one AEI, the NIPE was not linked to any specific module and thus did not carry any credits. In eight AEIs, the assessment comprised both theoretical and practice components, while for the remaining two, assessment was purely theoretical. A range of assessment strategies was employed to measure the learning outcomes (Table 2).
| Job or role | n * | % |
|---|---|---|
| Paediatric SHO | 1 | 10.0 |
| NIPE-trained link lecturers | 4 | 40.0 |
| NIPE-trained neonatal nurses/advanced practitioners | 6 | 60.0 |
| Midwife with NIPE and mentorship qualification | 7 | 70.0 |
| Midwife with NIPE qualification | 7 | 70.0 |
| Paediatric registrar | 7 | 70.0 |
| Consultant paediatrician | 8 | 80.0 |
| Total | 10 | 100.0 |
NIPE newborn infant physical examination
SHO senior house officer
| Response | n * | % |
|---|---|---|
| Objective structured clinical examination | 3 | 33.3 |
| Presentation | 1 | 11.1 |
| Professional discussion | 1 | 11.1 |
| Reflective essay/case study | 4 | 44.4 |
| Written examination | 1 | 11.1 |
| Other | 3 | 33.3 |
| Total | 9 | 100.0 |
Regarding the practice-related assessments, only one AEI reported grading the practice assessment, stating the reason as being for ‘better levels of competency’ (AEI 6), whereas the other six assessed practice solely on pass/fail criteria. Assessment of student competencies for undertaking NIPE in practice were verified by various practitioners, including NIPE-qualified clinical mentors, NIPE-qualified link lecturers, paediatric consultants/registrars and advanced neonatal nurse practitioners.
AEIs that did not currently offer NIPE within the pre-registration midwifery programme were asked about the content of their standard midwifery programmes in relation to the care and examination of the neonate. Sixteen responses were received and the results are grouped under five main themes (Table 3). It is notable that, although these AEIs do not currently include NIPE education in the pre-registration curriculum, the existing content of their midwifery programmes already covers much of the theory required for NIPE competence, including the NIPE screening programme and the midwife's enhanced role as a NIPE practitioner.
| 1. Fetal anatomy and physiology of the newborn and adaptation to extrauterine life |
| Fetal development and the fetal environment, teratogenicity |
| An introduction to genetics |
| Fetal circulation and adaptation to extrauterine life |
| 2. Care of the newborn |
| Thermoregulation, jaundice, physiological changes, examination of the newborn |
| Health promotion |
| 3. Infant feeding |
| Theories of attachment |
| UNICEF breastfeeding outcomes and Baby Friendly Initiative standards |
| 4. Neonatal disorders and the compromised newborn |
| Infection, congenital abnormalities, birth injuries, jaundice, preterm infant and near-term issues, infant of the diabetic mother |
| Neonatal resuscitation at birth |
| 5. Neonatal surveillance/screening |
| NIPE screening programme |
| Overview of the extended role of the midwife with regard to NIPE; heart, hip, testes and eye examination |
NIPE newborn infant physical examination
Among the 30 AEIs that did not currently include the NIPE, 15 reported that they were planning to include it at a later date, and the remainder were either undecided (n = 7) or had no intention of including it (n = 8). One response from the ‘undecided’ category was uncertain, stating:
‘We are considering it but feel it warrants careful assessment in a programme with significant demands on the student and practitioners.’ (AEI 35)
AEIs that were not planning to include NIPE as part of their pre-registration midwifery programmes were asked the reasons for this; 16 replies were received (Table 4). There were six responses in the ‘Other’ category, which offered a range of reasons. In two cases, the discussions were ongoing and related to the possibility of the NIPE being included as part of an MSc programme. Other factors related to the maintenance of skills of the midwifery lecturing team, including concerns about lecturers maintaining their NIPE skills if they were to train. There was ongoing debate between AEIs and partner Trusts about the feasibility of supporting a perceived additional service impact:
| Response | n * | % |
|---|---|---|
| Not an NMC requirement | 5 | 31.3 |
| The AEI does not consider it part of the core pre-registration curriculum | 5 | 31.3 |
| There is no room to include it in the curriculu | 5 | 31.3 |
| Insufficient suitably qualified staff on clinical sites | 4 | 25.0 |
| Insufficient suitably qualified staff at AEI to provide training | 3 | 18.8 |
| Lack of support from clinical partners | 1 | 6.3 |
| Other | 6 | 37.5 |
| Total | 16 | 100.0 |
AEI approved education institution NIPE newborn infant physical examination NMC Nursing and Midwifery Council
‘Although clinical partners were keen to include it, it was felt that there were insufficient [numbers of] staff with the qualifications and experience in practice to adequately support and assess student midwives to achieve competence within the timeframe of the programme.’ (AEI 33)
‘We currently believe that practical elements of the NIPE are not achievable in a pre-registration programme.’ (AEI 38)
‘There was already appropriate content to equip students to provide care as newly qualified is included in the programme.’ (AEI 9)
Discussion
Respondents acknowledged that the inclusion of the NIPE within the pre-registration programme enables providers to better meet service demands; a finding that echoes earlier arguments for incorporating NIPE into the midwife's role (MacKeith, 1995; Michaelides, 1995; Seymour, 1995). However, while AEIs recognise this benefit, few have acted on it. This may be a result of professional legislative changes that have led to more pressing demands on pre-registration midwifery education, i.e. the removal of statutory supervision of midwives and the revoking of the Midwives rules and standards (NMC, 2012) with effect from 1 April 2017. Moreover, EU moves to extend the length of the shortened midwifery programme may be having an impact on the development of local curriculum initiatives, as wider strategic changes demanding compliance with NMC quality assurance processes take precedence. Another confounding factor may be the uncertainty surrounding the date of publication of the revised NMC standards for pre-registration midwifery education, which might curtail innovative curriculum development. However, NIPE is not currently an NMC requirement for registration as a midwife.
Aside from the impact of national professional regulatory changes, the findings of this study illustrate some practical barriers to incorporating NIPE into pre-registration programmes. NMC (2009) standards stress the importance of the practice learning environment; however, there is a notable theory/practice gap between AEIs and practice partners, specifically the lack of appropriately trained NIPE mentors to support students' practice development. While this may have been previously accommodated in the clinical areas for the relatively small numbers of qualified midwives undertaking NIPE training, the significantly larger number of pre-registration students presents a problem in terms of ensuring adequate supervision and practice support. This was a prohibitive factor for some AEIs, as many placements were at full student capacity; thus, despite the known benefits of expanding the NIPE training into the pre-registration midwifery curriculum for student learning, service delivery and families (Townsend et al, 2004), many AEIs are currently unable to implement this.
The findings of this study also showed that forward-thinking AEIs took proactive steps to support their practice partners by increasing the level of practice support for students through the role and activity of link lecturers. Resources were invested for midwifery lecturers to undertake NIPE training and to provide additional practice support as an interim measure, thus relieving pressure on clinical NIPE practitioners and enabling pre-registration students to achieve the necessary competencies. These AEIs recognised that, on the point of qualification, newly qualified midwives would be NIPE-trained, making them very attractive to future employers. As a consequence, numbers of NIPE practitioners in practice partner Trusts would increase annually—which, in turn, would increase the resources to support subsequent cohorts of pre-registration students.
Another barrier to some AEIs' adoption of NIPE training was the perception that current pre-registration programmes had no room to include it in the curriculum. However, the findings revealed that the AEIs that currently do not include NIPE training provide a comprehensive programme for students in relation to neonatal health, wellbeing and surveillance as part of their standard undergraduate curricula. Clearly, such institutions would need to provide enhanced education on the four key areas of screening (i.e. the heart, hips, eyes and testes), but with some imagination and resourcefulness, it is possible that AEIs could enhance their existing programmes, utilising current curriculum content to form the core of a NIPE programme. This survey did not investigate the differences between the content of the curricula of the AEIs that either did or did not provide NIPE education, and this area could be further explored.
Variations in standards of supervision in practice and in practical assessments were identified. This is not surprising, as there are currently no national standards in relation to the assessment and supervision of NIPE practitioners. Findings showed that NIPE practitioners were permitted to support, supervise, verify and assess pre-registration students' NIPE skills in practice. Unlike the midwifery sign-off mentor, whose role is to assess students' midwifery skills and competencies, the NIPE is a role undertaken by members of the multidisciplinary team and crosses professional boundaries. This may present challenges in ensuring consistency in assessment of practice standards. Only one AEI reported grading the NIPE practice; all others reported that practice was assessed as pass/fail only.
The Code (NMC, 2015: 7) states that it is the responsibility of the practitioner to ‘maintain the knowledge and skills you need for safe and effective practice'. The findings of this study revealed a variety of assessment strategies across different AEIs, including practice assessment, practice simulation, professional discussion, objective structured clinical examination (OSCE) and online resources. A wide variation in academic levels and credit awards was also noted.
The number of NIPE examinations expected to be undertaken by pre-registration students to gain competence varied significantly, and some programmes had no set number. However, while a guide number of NIPEs can provide useful direction for students, the premise that the individual is best placed to assess his or her own level of skills and competency is empowering for students as adult learners. Furthermore, the complexity of practice learning is multifaceted and is individual to each learner; it cannot be assured solely by achieving a defined number of examinations.
Conclusions
The findings of this study (part A) have highlighted some of the ongoing challenges of bridging the theory/practice gap in providing NIPE training as part of the standard pre-registration midwifery curriculum. Part B will explore the education provision of NIPE as a post-registration module. Current national standards relate solely to the four screening components of the examination: heart, hips, eyes and testes (Public Health England, 2016). National standards for the preparation and assessment of practitioners to perform the NIPE would not only reduce the current variation in practice identified by Rogers et al (2015), but may also mitigate some of the perceived barriers identified in relation to the feasibility of including it in the pre-registration programme. In view of the findings and recommendations of the EMREN study (Townsend et al, 2004) together with previous evidence and current government policies highlighting the benefits of continuity of care (National Maternity Review, 2016), it is concerning that so few AEI programmes are embracing preparations to include the NIPE in their pre-registration midwifery programmes.