This work belongs to Lulu 34 it is provided purely as a guide to
other student nurses. It should in no way be copied or passed off as belonging to a 3rd party.
It is protected under the UK and international law of copyright.
This work belongs to Lulu 34 it is provided purely as a guide to
other student nurses. It should in no way be copied or passed off as belonging to a 3rd party.
It is protected under the UK and international law of copyright.
Midwifery Management
The purpose of
this assignment is to appraise management issues in midwifery care and more
specifically to critically discuss the statement “The
maintenance of Professional skill is the most important factor in the delivery
of high quality midwifery care” This will be
done by defining the terms ‘professional skill’ and ’high quality
midwifery care’ and will go on to look in more detail at the relationship
between high quality midwifery care and clinical governance, and incorporate the
issues of evidence based practice and clinical audit. Clinical
governance was introduced to the NHS through a programme of modernisation in
1997, to improve standards and was the umbrella term which incorporated the
existing areas of risk management, lifelong
learning, clinical audit and evidence based practice and in addition to this
self governance and clinical effectiveness and quality control
(Curley et al 2002). The
words midwife, practitioner and professional are used interchangeably through
out.
Professional
Skills Professional
skill, as a term, is difficult to define, however Tiran (2003) establishes that
a professional is characterized as an individual who will have gained advanced
education at a higher educational institute and who is committed to attaining a
credible knowledge base with ongoing learning and indeed should have a greater
knowledge than the clients in their care (Sullivan 2005). Sullivan (2005) goes on to differentiate between knowledge
and skills concluding that skills are seen as an experiential form of knowledge.
Therefore professional skill could be deduced as the skills and knowledge
belonging to that profession. However ‘standards of proficiency’ is the
expression used by the Nursing and Midwifery Council (NMC) to portray the skills
and abilities required at the point of registration (NMC 2004a).
These standards
not only apply directly to the practical skills within the midwifery sphere of
effective practice but also to skills required to achieve quality care,
professional practice, and to develop ones self as a midwife (NMC 2004a). Given
that the NMC use the term standards interchangeably to mean skills and abilities
(NMC 2004a) could it therefore be taken that the Nursing and Midwifery Council
whose motto advocates ‘protecting the public through professional standards’
(NMC 2004b), can be interpreted as protecting the public through professional
‘skills’? This suggestion gives
credence to the proposal that professional skills are those skills belonging to
a said profession and also takes into account that professional skills are more
advanced in nature than those of clinical skills, for example being accountable
for actions and inactions, updating knowledge and competencies, utilising
evidence based practice, mentoring and minimizing risk to self and others (NMC
2004b). This directs us to the
Midwives Rules and Standards, which if the same reasoning applied would be a
benchmark of skills specific to midwifery practice incorporating supervision (NMC
2004c).
High Quality
Midwifery Care Pittrof et al
(2002) examined quality from an international perspective and discovered there
were a number of definitions of quality care varying from strongly biomedical
definitions regarding utilising medical science to those involving user
satisfaction or the best use of resources. Martin-Hirsch and Wright (1998) offer
a theory that intangible experiences such as midwifery care are less likely to
result in complaints about quality than tangible causes. They proceed to
highlight that this intangible characteristic is what makes quality care hard to
define and although intangible, it is dynamic and therefore also difficult to
measure (Martin-Hirsch and Wright 1998). However
they purport that quality or lack of it comes from the difference between
patient expectation and patient experience, this an opinion shared by Tinkler
and Quinney (1998). Pittrof et al (2002) support the view that the biomedical
definitions could risk the over-medicalising of maternity care and consequently
lead to iatrogenic effects of medical management and unnecessary use of
resources and thus developed this definition “High
quality of care in maternity services involves providing a minimum level of care
to all pregnant women and their newborn babies and a higher level of care to
those who need it. This should be done while obtaining the best possible medical
outcome, and while providing care that satisfies women and their families and
their care providers. Such care should maintain sound managerial and financial
performance and develop existing services in order to raise the standards of
care provided to all women.” (Pittrof
et al 2002 page 278) Favourably this
definition of quality incorporates the intrinsic elements of clinical
governance, through efficiency, risk management, user and clinician
satisfaction, audit, and evidence based practice and could also incorporate life
long learning if the development of existing services included developing
practitioners skills. However a disadvantage is it fails to mention the
professional level or expertise of the care provider.
Clinical
Governance The NMC
Standards of proficiency for pre-registration midwifery education clearly state
that high quality care is a key factor of clinical governance (NMC 2004a),
indeed, the Department of Health (DH) proclaimed that through clinical
governance quality services could be guaranteed (DH 1997). However in their
research carried out in spring 2001, Curley et al (2002) exposed the issue that
the majority of respondents were either not aware of, or did not understand the
meaning of the components of New NHS (DH 1997), such features as clinical
governance and confidential enquiries. Although
some 58% of the professionals taking part were midwives, worryingly less than
20% of respondents actually knew what the confidential enquires audited. However
the authors blamed the locality factor for this as the research was based in
Northern Ireland the professionals questioned were not so aware of national
policies as those implemented locally.
Disturbingly
the authors anticipated that this issue could therefore be demonstrated in
Scotland if the research were to be replicated, as it too has a devolved
parliament. Lewis (2004) emphasises that the majority of maternal deaths occur
in women who have consulted midwifery services. She pinpoints the important role
midwives play as they can be the practitioner who identifies patient
complications, but not only that they are lead professional in 70% of births and
involved to some extent in the births of the remaining 30% (Lewis 2004).
Sidebotham (2004) highlights the need for critical incident reporting and
training in order to reduce intrapartum related deaths. The consequence of
midwives not adhering the clinical governance framework through poor knowledge
magnifies the need to have clinical governance in the first place. Congdon
(2004) testifies that in the UK the confidential enquiry is the most significant
factor in improving clinical practice. As Lewis (2004) determines over 60% of
direct deaths were due to poor quality care. This is something the World Health
Organization (WHO) observed internationally in 1994 ‘The
practice of high quality midwifery care, subject to systematic assessment and
continuous improvement, is a potent force in reducing maternal mortality and
morbidity, (WHO
1994 page 7) Although
the findings of the WHO report are aimed primarily at developing countries with
generally poorer maternity outcomes the sentiment that they describe in that
high quality care can prevent illness and save lives could be perceived as
universal. Certainly the Reduction
in Maternal Mortality document (WHO et al 1999) reports on the fact that
worldwide one woman dies every minute from complications of childbearing but
goes on to develop the idea that professional midwifery care allied to quality
is the central aspect of reducing the maternal mortality figures in the UK and
across the globe. This is an area the government was hoping to address by
ensuring every patient should expect high quality care and as such all members
of the NHS are providers of such care and are responsible for delivering it
through clinical governance and the new NHS (DH 1998).
Thomas
(2000) infers that the main element of delivering high quality care in midwifery
is with good communication and keeping the women informed. This is a view shared
by Tinkler and Quinney (1998) from a qualitative study they carried out, in
their analysis they identified adequate antenatal information, the opportunity
to make decisions about their care and relationships with midwives as having a
bearing on whether they felt they received quality care or not. Communication or
lack thereof is a crucial feature that Lewis (2004) affirms is responsible for
adverse outcomes in maternal health from substandard care. In an early study by
Procotor (1998) she indicated that women were seldom asked to review the quality
of the service but more often to review the quality of childbearing.
The Changing
Childbirth report and survey (DH 1993a, DH1993b) first highlighted the
requirement to have greater openness with women about their care and in addition
the need for satisfaction from the service they were receiving.
Some of the main findings from the report were the need for continuity of
carer, more choice and better information.
With the implementation of clinical governance it has opened the doors to
women to make decisions about their care for example choosing a hospital or home
birth (Raynor and Bluff 2005), and feel better informed for instance about
whether to opt for screening tests. Issues of continuity of carer have attempted
to be addressed with team midwifery and named midwife schemes (Scottish
Programme for Clinical Effectiveness in Reproductive Health [SPCERH] 1999)
Evidence
Based Practice Thomas (2000)
asserts that to childbearing women the midwife ‘being nice’ to them is the
true art of midwifery care and declares that women place less focus on the
scientific elements of midwifery such as evidence-based practice.
Cluett (2005) opposes this view advocating that evidence based practice
is a fundamental element of quality care provision.
Fraser and Cooper (2003) believe that informed choice is the vital factor
contributing to quality care although they accept and appreciate the relevance
and need for evidence, knowledge and audit to achieve a high level of informed
choice, by involving service users and gaining patient feedback.
According to the
document A First Class service in the new NHS (DH 1998) there are inequalities
in the care provision and in the outcomes of this care, causing variations in
quality throughout the UK. Pittrof et al (2002) believes that in the UK it is
essential to ensure quality in order to thinly spread the limited resources of a
public funded health service across many areas.
The DH proposed to set national standards grounded in an evidence based
approach combined with the professional’s own clinical judgement in the form
of clinical governance (DH 1998).
According to
McKenna et al (1999) evidence based practice is not necessarily research, but
research is a component part of evidence based practice, along with expert
opinion, traditional interventions and interventions that are known to cause
harm. Thomson et al (2002) disputes this arguing that evidence incorporates
research, experience, resources and patients informed choice. Kopp (2001a) considers expertise, patient preferences and
research available when decision-making based on evidence.
Fraser and Cooper (2003) and Duerden (2003) point out that not all
research is relevant or useful and not all can be appropriately put in place.
Cluett (2005) sums this up in that the evidence itself does not inform
practice, it is how the evidence is used that does. What is also important to
remember is that a midwife has to have good critiquing skills, in order to
analyse if the research is of value (Fraser and Cooper 2003).
The inequalities
in care provision can come from too wide an evidence base causing midwives too
much choice between option whereas in other areas the evidence base might be
sparse leaving professional with limited options to offer women (Downe and
McCourt 2004, DH 1998). For example there is a dearth of reliable evidence
available on areas such as home births after caesarean, whilst treatment and
care of the perineum is varied and wide ranging. Midwifery itself is fairly new
to the concept of evidence based practice (Bojö et al 2004),
as the skills originated in traditions passed through the generations and with
early supervision coming from non professional sources the need for evidence was
not at that time apparent (Duerden 2003). Now however as evidence is forever
being updated best practice is always changing in line with this (Cluett 2005)
leading to revising or changing of standards and policies, which in turn require
to be audited.
Audit Audit
can be defined as an assessment of practice to ensure
that the highest quality care is delivered to patients (Cooper
and Benjamin 2004, Kopp 2001b).
Clinical governance introduced a means of joining the independent services of
audit, evidence, lifelong learning to help in measuring quality (Cooper and Benjamin
2004). Kopp (2001c)
acknowledges the link between patient satisfaction and audit, providing feedback
to improve quality via complaints, developing the service and patient
satisfaction married to achieving the standards of audit.
Audit
is a clinical initiative, which uses a systematic approach to analysing care
(Kopp 2001b). It utilises a 6 stage cyclical framework that originates with
selecting an area that needs to be addressed, this is followed by setting
relevant standards, then collecting the data, after which, the data must be
measured against the set standards in the framework, the final two stages are
making changes and starting the process over (Kopp 2001b).
Beake et al (1998) reveal that not all audit tools, which have gone
through this process will actually be effective in measuring quality.
Although
the ultimate aim of audit is to ensure quality care, it carries other benefits
such as improved team work and communication skills, better use of resources and
time, enhanced personal and professional satisfaction (Cooper and Benjamin
2004).
Conclusion
If professional
skills are merely clinical skills then they would not be considered the most
important aspect of midwifery care, as other non-clinical skills such as working
as a team, maintaining confidentiality and consent might not be deemed thus and
omitted. It is known they are of importance as major elements of the code of
conduct and midwives rules (NMC 2004b and NMC 2004c)
However from the
literature it becomes apparent that this is a very simplistic idea of
professional skills, which would appear to exclude areas such as audit and
evidence based practice along with things like supervision, post registration
education and practice etc which form part of clinical governance (NMC 2004a DH
1998). Additionally other non-professional care providers share in the provision
of clinical skills indicating that they are not exclusively carried out by
professionals, and therefore cannot be assumed to be professional skills. These
non-professional carers however do not carry out all the true professional
skills, although they may be involved in, or experience the effects of
implementation by a midwife or other professional care provider.
Just proclaiming
to have a professional skill, or knowing how to do it also does not mean that
the individual will have the experience or expertise to carry it out.
It is therefore important also to have supervision in place to be able to
be assessed and evaluated so that skills are being carried out at a high level
in order to deliver quality care as the evidence base in midwifery is ever
changing and the standards achieved at the point of registration need to be
maintain and improved upon.
An
emerging theme become evident from the assignment: women want better
communication to improve quality care while professionals view a foundation in
science such as research, evidence, learning and audit as the means to
excellence in practice as advocated by the Department of Health (1998). However
to provide women with high quality care and better communication and choice the
midwife must have the knowledge and skills to offer the woman the information
she requires. This is achieved through the intrinsic elements of clinical
governance.
last updated 12/03/06
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Introduction
Discussion