A reflective appraisal of the Supervisor of
midwives role in the current health care and political context.
The midwifery profession is
arguably the most securely regulated profession amongst healthcare
professionals. (Donnison J 1988)
The practising midwife must adhere
to the statutory code of Midwife's rules which were enacted in the 1902
Midwives Act together with its subsequent amendments. The Supervisor of
Midwives is a post that was generated by that Act, and the Supervisor's role is
a statutory one that guarantees a supervisory capability over all midwives (
whether NHS or independent) (Thomas P 1998), to make sure that all practice
under their supervision is both up to date and within the particular midwife's
sphere of competence. (Fraser D et al 1997)
The role of the Supervisor of
Midwives was redefined and consolidated in the Nurses, Midwives and Health
Visitors Act 1997 [section 15.3] (N &MC 2002) and this Act now also stipulates
that a midwife who wishes to assume the mantle of the Supervisor of Midwives
must not only fulfil the criteria stipulated in Rule 44 of the MRCP (Midwife's
Rules and Code of Practice), but they must also be appointed by, and be
responsible to, their Local Health Authority.
Although I have outlined the
supervisory capacity of the Supervisor of Midwives, the role is, in practice,
much wider than that. It is important not to get the supervisory role confused
with the management role. Many Supervisors of Midwives will actually wear both
hats but the functions are, from both a statutory and a practical point of view,
fundamentally different. (Gabe et al. 1991). One major difference is that the
Supervisor (as we have already observed) is responsible for the supervision of
both the NHS and the independent sector of Midwives. The managerial capacity,
if they are shared by the same person, only extends however, to the NHS staff.
On a fundamental level the
Supervisor of Midwife's responsibility is to see that the quality of care given
in a professional capacity to women and their babies is constantly improving.
This may ostensibly be through direct supervision of a midwife's practice, but
equally it can be in other ways by, for example, providing counselling,
support, guidance or simply a knowledge resource. (Page L 1995)
With this in mind, the title of
this essay calls for a reflective appraisal of the role of the Supervisor of
Midwives (Gibbs 1988). Reflective consideration is thought by some to be a
passive process of consideration. The original concept, first articulated by
John Dewey (1933) was indeed a rather passive concept of just stopping and
considering the grounds that support the idea. Later writers (Atkins et al.
1993), reviewed the literature and came to the conclusion that reflection was
undoubtedly an active process which required both a structured approach and
considerable positive input from the thinker.
In
order to reflect, and run through the process of Description, Feelings
Evaluation, Analysis, Conclusion & Action Plan which constitutes the
complete cycle, it is appropriate that I must initially describe the parameters
of the Supervisor of Midwives' role
Having therefore presented the
historical aspects of the role, I should now actively reflect on the other
qualities that a Supervisor of Midwives should have, or could be expected to
have, by those who are nominally under her charge. If we consult the literature
on this issue, we seem to find fairly unanimous agreement on many of the
qualities required. Focault is fairly typical of many in this regard.
Clearly such a person should have
both a minimum number of personal and professional attributes. Given that I
have established some of the qualities necessary for the job I also believe
that other necessary attributes could perhaps include
.
approachable
.
committed to woman-centred care
.
a source of professional knowledge and expertise
.
visionary and inspiring
.
able to resolve conflict
.
motivated and thorough
.
articulate
.
trustworthy
.
sympathetic and encouraging
.
fair and equitable
(after Foucault M 1994)
In addition to these attributes, it
is of paramount importance that the Supervisor of Midwives should be able to
maintain appropriate confidentiality.
I can point to further
authoritative opinion of the current role and activities of a Supervisor of
Midwives. A number of various Local Authorities publish their particular
requirements and job description. (Agenda for Change 2004) The list below is
gleaned from a number of Authorities together with appropriate guidelines from
the Department of Health
Activities of a Supervisor of
Midwives should include promoting safety of mothers and babies by:-
.
supporting best practice and ensuring evidence based care
.
being a confident advocate for midwives and mothers
.
acting as effective change agents
.
providing leadership and guidance
.
acting as a role model
.
undertaking the role of mentor to trainee supervisors
.
empowering women and midwives
.
facilitating a supportive partnership with midwives
.
supporting midwives through dilemmas
.
helping midwives personal and professional development
.
facilitating midwives reflections on critical incidents
.
supporting midwives through supervised practice
.
maintain an awareness of local, regional and national NHS issues
.
giving advice on ethical issues
.
liaising with clinicians, management and education
.
maintaining records of all supervisory activities - separate to
management records
(DH 1999)
In this essay I intend to consider
the role of the Supervisor of Midwives in the political as well as the personal
and professional context. Healthcare professionals in the NHS have been subject
to a wealth of reforms, guidelines, targets and quotas. All, generally have
been designed to improve the standard of patient care and should therefore be
generally welcomed. (Bryant P 2005).
To a large extent they have been
set out fairly comprehensively in the Government White Paper A First Class
Service (NHS 1998). These reforms are clearly largely aimed at the NHS in
general terms but the midwifery services are also affected by their
ramifications and implications as much as any other branch of the service.
A First Class Service (NHS 1998),
is a consultative document which is primarily concerned with quality of care.
At the centre of the thinking behind the document is the statement:
The achievements of the NHS have been immense. At
best, the NHS is the envy of the world. But not all of its services are up to scratch.
There are unacceptable variations in performance and practice. These variations
in care are wasteful and unfair. And widely differing performance saps the
confidence of the public in a National Health Service.
In order to address this problem of
variability of performance and practice, the paper sets out the provision for
a number of far-reaching reforms. It starts with the very perceptive comment
There is no place in the modern NHS for the
piecemeal adoption of unproven therapies, or for hanging on to outdated,
ineffective, treatments. Better guidance is needed on what works for
patients.. ..The Government's intention is to ensure clear, national
standards for services, supported by consistent evidence-based guidance to
raise quality standards.
It is this call for a return to
evidence based medical practice that was a welcome clarion call to a great many
in the NHS. (Merry 1998). One only has to consider the list produced above even
on a purely superficial level to appreciate that, of the activities of the
Supervisor of Midwives listed, at least 50% would need to have a firm evidence
base before reliable advice could be given. (after Sackett 1996).
The requirement to facilitate
midwife's reflections on critical incidents is one such requirement which
cannot realistically be completed without a thorough knowledge of the evidence
base. Advice given without this knowledge is clearly reduced in value.
Part of the Government's commitment
to reintroduce an evidence base comes in the shape of the National Institute
for Clinical Excellence (NICE) which has a mandate to research and publish the
evidence base on which good practice can be founded. It has already produced
a great many studies (viz NICE 2004) which bear testament to that mandate.
(Shannon C 2003)
One other main plank of the
Government White Paper's strategy was the establishment of the National Service
Frameworks which aimed to set goals, targets and standards in a number of
areas. ( Rouse et al 2001). With specific reference
to National Service Framework standard 11 (Maternity Services) (NSF2004), it is
almost unique amongst the Framework Standards as it is based on a care pathway
approach which is used to illustrate and chart a patient's progress and access
to the various services that are available. (NHS KSF 2004).
These care pathways are
particularly useful tools for this purpose as they can record and depict fluid
processes such as the variable trajectories taken by patients through maternity
units. By examining the resources such as these pathways, managers (such as the
Supervisor of Midwives), can assess the scope for improvement in the quality
of service provided. (Wierzbicki et al 2001)
To return to our consideration of
the First Class service paper, it has other areas of recommendation which we
should consider in passing. Of great potential importance to my considerations
here is the issue of Professional self-regulation. Part of the management role
of the Supervisor of Midwives is an initial appraisal of the self-regulation
process.
They would be expected to resolve
issues and correct deficiencies at a local level, but equally, if a serious
situation presented itself, as a line manager, they would be expected to pass
consideration of the problem further up the chain. At the top level, the
Government White Paper calls for Government to liaise with the relevant
professional bodies in order to maintain standards and, arguably more
importantly, public confidence in those standards. (Bennis et al.1999)
It should be noted that, running in
parallel with this mechanism for self-regulation for quality control, are three
other independent mechanisms. In a move that rather resembles the concept of
overkill, the Government has also set up three further bodies for standard
monitoring, namely:-
A Commission for
Health Improvement,
A National
Framework for Assessing Performance,
An annual
National Survey of Patient and User Experience.
All of these bodies will be
effectively charged with improving quality standards by identifying and
confronting poor performance. By any stretch of the imagination, active
reflection on the issue would suggest that any one of these four mechanisms
would be appropriate with possibly a second as a fail-safe mechanism.
(Thompson 1992).
It would seen to me that the person
in the role of Supervisor of Midwives is actually ideally placed to oversee the
quality of care of midwives in her charge. If, for any reason she was not able
or unwilling to resolve any issues of quality then mechanisms of line
management are already in place to deal with such an eventuality. (Nickols F
2004). Given the fact that I have been asked to present a reflective appraisal
of the role of the Supervisor of Midwives in the political climate of today,
this seems to be a perfect example of an exemplary concept (one of increasing
quality provision), that has been moderated by political expediency( Newell
& Simon 1992).
There seems little need for these
four bodies to monitor overlapping aspects of the same quantum of care, but
there is certainly the suggestion of politicians being able to point to high
profile bodies that they have created, as a demonstration that they have
actually done something positive.( Moss and McNicol 1995).
As a healthcare professional who
has been working in the NHS for (Client to fill in) X
years, I would be amongst the first to acknowledge the huge strides forwards
that have been made in the functioning and performance of the NHS in the past
two decades. I have also been working long enough to see the degree of waste
that occurs when change is instigated without proper management. (Gilbert T
1995) One only has to look back to see the debacle that followed the
introduction of the Griffiths Report (1983) and then the Davidmann review
(Davidmann 1988) that was set up in order to have a Commission to report on why
the reforms did not work.
One lesson the NHS must have
learned over the last two decades is that change management is a very specialised
and professional occupation. A body as unwieldy and so full of inertia as the
NHS takes a great deal of input to make it change direction. I have always
believed in co-operation and consultation rather than compulsion and coercion
(Marinker 1997), as being the best tools to effect change. My reflection upon
the role of the Supervisor of Midwives confirms my thoughts in this direction.
The political climate, and indeed the professional climate, is currently very
unforgiving of mistakes and lapses in quality.( Foucault M 2001).
Quite apart of any potential
consequences for the patient and the always attendant problems of litigation,
there are the more indirect consequences for the reputation of the NHS in
general.( Gabe et al 1991). It is in everyone's interests ( that includes both
the patient and the healthcare professional), that the reputation of the NHS
is kept as high as is possible. Some would argue that it is part of the
professional remit of each healthcare professional working in the NHS today
(Garcia et al 1999).
also
leads me to suggest that the issues that confront the maternity services in
particular, and the NHS in general, must be addressed, and I am certainly not
against either progress or reorganisation. I am however, generally suspicious
of the huge volume of documents, Consultative papers and Advisory Documents
etc. that appear to emanate from the Department of Health. Reading these, I am
generally disappointed to find that the statements that they make and the plans
that they outline are seldom attributed.
As I have discussed earlier, it is
vital for any change to be made on a strong evidence base (Sackett 1996). In
the field of midwifery, one is used to critically appraising the literature
base in reflecting on one's own practice. It is very much more difficult, as in
the context of this essay, to make a critical appraisal of political issues
when the evidence base is often less than clear.
References
Agenda for Change 2004 23 November 2004, Government White Paper: HMSO 2004
Atkins, S. & Murphy, K. (1993) Reflection: A Review of the Literature. Journal of Advanced Nursing. 18(8),
1188-1192.
Bennis,
Benne & Chin (Eds.) 1999 The Planning of Change (2nd
Edition).. Holt, Rinehart and Winston, New York: 1999.
Bryant P 2005
None so naive as the
well meaning
BMJ, Jan 2005; 330: 263
Davidmann 1988 Reorganising the National Health Service: An
Evaluation of the Griffiths Report HMSO : London 1988
Dewey, J. (1933) How We Think. A restatement of the relation
of reflective thinking to the educative process (Revised edn.), Boston: D. C. Heath.
DH 1999 Department of Health (DH) 1999 Making a Difference HMSO, London 1999
Donnison J 1988 Midwives & Medicine Men : A history of
inter-professional rivalries and women's rights Heineman, London 1988
Foucault M 1994 wo lectures in : Kelly M (eds) Critique and Power : Recasting the Foucault/
Habermas Debate >USA, MIT Press : 17-46
Foucault M 2001 Michel Foucault : Power the
Essential Works 3 (eds JD Faubion) London: Allen Lane, The Penguin Press
Fraser D et al 1997 Outcome Evaluation of the Effectiveness of
Pre-Registration Midwifery Programmes in Education Research Highlights, London ENB 1997
Gabe, Calman & Bury 1991 The Sociology of the Health Service London, Routledge Publications 1991
Garcia J, Kilpatrick R &
Richards M 1999 The Politics of Maternity Care :
Services for childbearing women in the twentieth century Britain Oxford Univ. Publications 1999
Gibbs, G (1988) Learning by doing: A guide to Teaching and
Learning methods
EMU Oxford Brookes University, Oxford. 1988
Gilbert T 1995 Nursing : Empowerment and the
problem of power Journal of Advanced Nursing 21 (5) : 865-871
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