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Supervisor of midwives

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).

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My reflection on this issue:

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

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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.

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Donnison J 1988 Midwives & Medicine Men : A history of inter-professional rivalries and women's rights Heineman, London 1988

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