Midwives Accountability as an Autonomous Practitioner - Essay Example

Midwives Accountability as an Autonomous Practitioner Introduction A midwife is defined by RCM (2005) as a person who undergoes an educational programme, duly recognised in the country, and successfully completes the prescribed course of studies in midwifery thus acquiring the requisite qualifications to be registered and/or legally licensed to practise midwifery. The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period; to conduct births on her own responsibility and to provide care for the newborn and the infant (RCM, 2005). RCM (2006) states that " the role of the midwife is to ensure that women and their babies receive the care they need throughout pregnancy, childbirth and the post natal period". Much of this care is provided directly by the midwife whose expertise lies in the care of normal pregnancy, birth and the post natal period, and the diagnostic skills to identify deviations from the normal to be referred appropriately. In the UK midwives work independently or along with other healthcare professionals to best meet the needs of the woman and the family they care for. According to NMC (2006) midwives also "work in the community and in stand-alone birth centres...and some have their own businesses on a self-employed basis". The purpose of this paper is to gain an insight into what, and how the autonomous midwife practitioner is accountable for. This is a serious area of concern since the autonomous midwife practitioner may not have as imposing a reporting pattern found in hospitals however it does not mean that she is not answerable for her actions. Midwifery supervisors are appointed by NMC to support and direct the work of independent midwives. As an autonomous practitioner a midwife still owes professional accountability to the women who she cares for. Clark (2000) explains that "professional accountability means that the professional takes a decision or action not because someone has told him or her to do so, but because, having weighed up the alternatives and consequences in the light of the best available knowledge, he or she believes that it is the right decision or action to take. The professional who has made the decision or taken the action is expected to be able to 'account for' or 'answer for' his or her behaviour Accountability also covers omission, that is 'not doing'; failure to act may be just as significant as a positive action". NMC, defines accountable as "responsible for something or to someone"(NMC,2002, p.10). Autonomy is defined as "self government or the right of self government; self determination" (OED, 2002). Clearly autonomy does not imply lesser responsibility. The reason why this topic is worth evaluating can be explained from the historical perspective. Classic work of Walker (1972, 1976) on accountability in midwifery explains that each midwife considers herself accountable for the care of women experiencing uncomplicated childbirth but it is the medical staff who perceive themselves as having an overall responsibility and exercise it at will (cited by Tilley, 2004). Walker's work indicates that it was the medical colleagues who seemed less clear about the accountability of midwives and not the midwives themselves. A contrary opinion is reflected by a recent NMC online poll of more than 800 nurses and midwives showed that 34 per cent were not confident they knew what was in their Code (NMC, 2008a). It indicates that midwives may not understand exactly what they are accountable for. In order that healthcare teams function effectively all members need to grasp the role and responsibilities of the members involved. The purpose of the new code is to clarify expectations; define what is expected of nurses and midwives as professionals, and show the public the standard of care they can expect to receive. The new code comes into effect on 1 May 2008 (NMC, 2008b). The accountability for autonomous midwife practitioners is discussed in the light of the new code, and with regard to the seven parameters listed below: 1 1. Record Keeping 2 2.HomeBirths 3 3.Working in remote areas 4 4.Midwife led units 5 5. Communication to the wider healthcare team 6 6. Importance of seeking help when outside the realms of normality 7 7. Importance of attending study days and practising fire drills to prepare for emergencies. Record Keeping Record keeping is essential for any professional practice. For midwives it implies taking notes of discussions with women and other carers, and listing the details of care provided. It is not uncommon to view record keeping as an administrative burden and not part of the core competency of a midwife. However, NMC (2007) states that record keeping is part of the care process and not an "optional extra". Good record keeping helps to protect the welfare of patients by promoting high standards of clinical care, better treatment and the ability to identify risks in case of any problems (NMC, 2007). UKCC even provides guidelines for record keeping (Dimond, 2002). Davis (2007) points out the importance of record keeping by emphasizing "that containing clinical risk in midwifery practice involves a complex process of clinical decision making and action. The reason for its complexity is that it involves logical, analytical, rational and sequential thought combined with the less tangible elements of intuition, emotions, interpersonal relationships, within the context of the surrounding environment. In a fast moving clinical environment, it is often difficult to record why particular decisions were made. Yet, it is absolutely essential to account for all decisions to ensure safety". The new code of professional conduct emphasizes the need to provide a high standard of practice and care at all times. According to the new code midwives need to (NMC 2008b): Keep clear and accurate records of the discussions they have, the assessments they make, the treatment and medicines they give and how effective these have been Complete records as soon as possible after an event has occurred and ensure that they do not tamper with original records in any way Ensure that any entries made in someone's paper records are clearly and legibly signed, dated and timed and entries made in someone's electronic records are clearly attributable to them Maintain security and confidentiality of all records NMC (2007) points out that the best records are usually those that are prepared in consultation with all members of the inter-professional health care team and the patient or client. Any healthcare professional must be able to deliver care from any step in the care process based on these records. NMC (2007) even gives details on the principles of record keeping: Content and style: This requires that records be accurate, factual, should not be changed without record of change, no abbreviations, readable when photocopied or scanned. They must provide evidence of care planned and decisions made. Auditing of records- A system of audit like peer review must exist. It helps to promote quality and serves as a key component of the risk of management process. Rule 10 of the NMC Midwives rules and standards (2004) permit supervisors of midwives to request that audit of midwives records. This is primarily to confirm they are being kept as required by Rule 9 and to assist the midwife in making records. Legal matters and complaints: The records may be required when supervisors of midwives or local supervising authority midwifery officers carry out investigations into critical incidents involving maternity care. They may also be used in evidence by the NMC's Fitness to Practice committees, which consider complaints about registrants. The approach to record keeping that courts of law adopt tends to be that 'if it is not recorded, it has not been done'. Ownership of records: Registrants working in independent practice own the records, as they are self-employed. Patients/clients however do have the right to be provided with copies of their notes and the same principles of confidentiality apply. Retention of records: Supervisors of midwives are required to retain the supervisory files of their supervisees for seven years. Midwifery/maternity records are required to be retained for a period of 25 years. Jones and Jenkins (2004) points out that midwives consider record keeping as a defense activity to protect themselves against any litigation. While records may be necessary in case a litigation claim arises, it is also essential for the midwives so that they can ensure clarity and continuity of care. The most common reason for midwives to appear before NMC professional conduct committee is due to their inability to maintain adequate records (Jones and Jenkins, 2004). NMC may view good record keeping as commensurate with the level of care that is provided (Jones and Jenkins, 2004). Home Births Midwives' accountability for only undertaking duties for which they have competencies, is governed by Midwives' Rules and Standards (Kapitibirthing, 2008). Midwife practitioners need to be competent within the home birth environment. This may require enhancement or updating of their existing midwifery skills prior to providing any services. What midwives need to understand is that home birth is not just about managing home deliveries but being prepared. According to Boyle (2002) the "Report on Confidential Enquiries into Maternal Deaths" is a useful resource for midwives and especially those who work as autonomous practitioners. This document provides midwives with an opportunity to learn lessons from others high risk situations. For instance, midwives need to be able to deal with breech delivery at home. As majority of the breech presentations are born by caesarean, midwives rarely experience vaginal breech births. They therefore, need to review this topic and ensure that their skills are up to date, and especially so if they lack practical experience. Midwives not only need to be able to act appropriately in case of a high-risk situations, but they must also be able to identify a high risk situation. A frequent review of uncommon events may therefore be necessary for autonomous midwife practitioners. Autonomous midwife practitioners, as part of their accountability to the woman they are caring for, also have the responsibility to challenge medical decisions if they believe it is in the interest of the woman they are caring for. Boyle (2002) states that there are 12 cases of severe maternal morbidity for every 1000 deliveries. These life threatening events could have long term physical effects. The most common is manifested as psychological trauma which could lead to decisions against further pregnancies. Situations where women experience powerlessness and lack of control are commonly seen to precede a psychological trauma (Gould, 2000). Midwives in addition to delivering babies have the responsibility to debrief after birth and a postnatal discussion is seen as a vital part of after care. Midwives are responsible to ensure that the women they care for are active participants in decisions that affect their health. Their views and opinions are necessary regarding options for care. It helps to create a shared philosophy between the woman, midwife and the maternity team (Davis, 2007). Working in Remote Areas Working in remote areas can sometimes create situations that are high risk. Midwives, in such situations may need to coordinate care with the healthcare team and make the best utilization of available resources. The NMC code guides the midwives towards this goal. It emphasizes the importance of providing a high standard of practice and care at all times and using the best available evidence. NMC Code (2008b) advises the midwives to: Deliver care based on the best available evidence or best practice. Ensure that any advice given is evidence based if certain healthcare products or services are recommended Ensure that the use of complementary or alternative therapies is safe and in the best interests of those being cared for In order to manage risks, the midwives are advised by NMC Code (2008b) Act without delay if they believe that the woman being cared for is being put at risk Inform someone in authority if there are problems that prevent the midwife from working within this code or other nationally agreed standards Report concerns in writing if problems in the environment of care put people at risk Mid Wife Led Units For midwife led units, midwives need to be concerned with not just births but also other concerns related with pregnancy and women centric care. Today's midwives have a public health role to play. This relates to their role as an advisor on strategies to reduce teenage pregnancy, or involvement with schools to ensure that young mothers can continue their education. They can carry out research in areas such as breast-feeding and smoking during pregnancy and serve as key members of primary health care teams (Hilpern, 2003). However there is a divergence in how midwives perceive their status, and how those in the healthcare profession perceive the midwives status. There exists the challenge of managing situations where midwives believe that they have done enough, and are of the opinion that the women are no longer their responsibility, versus situations where midwives worry that their concerns are being ignored by medical staff (CEMACH, 2007). Be that as it may, midwives play a crucial role in identifying when a medical opinion is appropriate. CEMACH (2007) points out that midwives can help women experiencing domestic abuse, those seeking asylum or who misuse substances or those who have suffered female genital mutilation. Communication to the Wider Healthcare Team According to Quality Assurance Agency for Higher Education (2002) "legislation enables midwives to carry out their role autonomously, while expecting them to work in partnership with others and across professional boundaries when this is in the best interests of women and their families". According to CEMACH (2007) "communication to the wider healthcare team forms a very important component of both professional accountability and competence". A case that illustrates the importance of communication with the wider healthcare team is described below: "An older parous woman who was obese, smoked, had a long gap since her last pregnancy and a blood pressure of 150/89 mm/Hg was booked for midwifery led care. She presented with severe headaches and vomiting near term which required opiates for relief. On admission her midwife was unhappy with the junior doctor's lack of concern but resigned herself to the fact that he knew best. A subarachnoid haemorrhage was eventually diagnosed but she deteriorated and died a few days later" (CEMACH, 2007). The case highlights the importance of seeking a consultant opinion by midwives and even obtaining a second opinion if there are continuing concerns about women in their care. If a midwife expresses concern following discussion with a medical consultant, support can be gathered from a supervisor of midwives and the midwifery manager. Midwives have a duty of care for women, even when the pregnancy deviates from normal. This is reiterated by the Nursing and Midwifery Council, which states: "you are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional". CEMACH (2007) recommends care pathways in ensuring effective communication across disciplines. A good example of care pathway is the Wales Normal Birth pathway, which includes telephone advice, a patient information sheet, an active labour pathway and partograms. CEMACH (2007) also points out that when midwives refer for a medical opinion they are often not included in subsequent discussions that take place between hospital staff and GP and this needs to change. Midwives need to be recognized as equal partners in care and should be included in all communication. If they have to be accountable for who they care for then this is a necessary step in the woman centric care. NMC Code (2008b) also specifies in connection with the need for communication, that midwives need to share information with their colleagues, work effectively as part of a team, even delegate effectively and manage risk by alerting whoever is in authority. Importance of Seeking Help when Outside the Realms of Normality There are several cases where midwives are unable to grasp the seriousness of the mother's condition and show a lack of insight and experience (CEMACH, 2007). This is more evident in cases where women have complex pregnancies and the lack of baseline observation, poor midwifery care, poor communication between professionals jeopardizes the care of the woman being attended to. CEMACH (2007) lists key parameters that indicate that a woman's condition may need immediate medical referral. A heart rate over 100 beats per minute (bpm) A systolic blood pressure over 160 mm HG or under 90 mm/HG and/or a diastolic blood pressure of over 80 mm/HG A temperature of over 38 degree Centigrade A respiratory rate over 21 breaths per minute. The respiratory rate is often overlooked but rates over 30 per minute are indicative of a serious problem. A correct emergency response is crucial. There are cases where midwife is found not knowing emergency telephone numbers to get help or paediatric emergency team, is called for in case of maternal collapse, which only results in a crucial delay in resuscitation. Midwives have a responsibility to ensure that they are familiar with emergency procedures but as noted by CEMACH (2007) it is often found "difficult to ensure". Importance of attending study days and practising fire drills to prepare for emergencies CEMACH (2007) describes a case of 12 women whose deaths were classified as being directly related to pregnancy and these cases were midwifery led. Three out of these 12 cases were assessed substandard because of poor midwifery practice. This is enough to reveal how important it is for midwives to upgrade their skills and always stay prepared. Midwives are responsible for ensuring competence in their practice, and they need to highlight any perceived training needs during their supervisory review. Study days are available on several topics and depending on their areas for improvement, midwives could attend these to improve their professional skills. Dawson (1993) points out that "midwives' current attitudes to quality assurance are incompatible with this enhanced role" and suggests that midwives "have an opportunity to regain professional control of midwifery practice, which will be lost unless they are prepared to take responsibility for evaluating the standards for which they are accountable" Given the infrequent yet serious nature of eclampsia, maternity services cannot afford to wait for a genuine case to test the quality of emergency care. The importance of fire drill cannot be overstressed. Fire drill used at a local level helps improve confidence, team working skills, maternal mortality and deaths in infancy. It ensures that midwives continuously hone and improve the way in which they provide maternity care, and ensure that safety is paramount. Lessons learnt on midwifery supervision and peer review must be shared with the midwives to improve quality assurance. Conclusion While midwives' accountability for the women in their care is unquestionable, it is also important to realize that accountability does not come without freedom and respect given to these professionals. For autonomous midwife practitioners to be recognized as true professionals, midwives need to focus on working as part of a healthcare team and constantly honing their skills. References 1 Boyle, M. (2002) Emergencies Around Child Birth: A Handbook for Midwives. Radcliffe Publishing: UK 2 CEMACH (2007) Midwifery Chapter 16 [online]. Available from < http://cemach2007.interface-test.com/chapter-16/introduction.html> [Accessed 12 April 2008]. 3 Clark, J. (2000) Accountability In Nursing. Swansea University, Wales. 4 Davis, K. (2007) Midwives and midwifery: their place in safe delivery. Safe Delivery - Reducing Risk in Maternity Services in a Time of Change[online].. The Healthcare Commission and the National Patient Safety Agency. Speech to the NPSA and Healthcare Commission Available from < http://www.rcm.org.uk/info/docs/GS_SPEECH.doc> [Accessed 12 April 2008]. 5 Dawson, J. (1993) The role of quality assurance in future midwifery practice [online]. Available from < http://www.blackwell-synergy.com/doi/abs/10.1046/j.1365-2648.1993.18081251.x> [Accessed 12 April 2008]. 6 Department of Health and Social Security Standing Maternity and Midwifery advisory committee (1970) Domiciliary Midwifery and Maternity Bed Needs. HMSO, London. 7 Dimond,B. (2002) The Legal Aspects of Midwifery. British Library: UK. 8 Gould, D. (2000) Normal Labour: a concept analysis. Journal of Advanced Nursing 31(2) p. 418-427. 9 Hilpern, K. (2003) New help for helping hands [online].Available from [Accessed 12 April 2008]. 10 Jones, S.R. & Jenkins, R. (2004) The law and the Midwife. Blackwell Publishing: Oxford, UK. 11 Kapitibirthing (2008) Homebirth [online]. Available from http://kapitibirthing.org/home-birth/homebirth> [Accessed 12 April 2008]. 12 Maternity Matters (2003) A Framework for Maternity Services in Scotland. Overview report of the expert group on Acute Maternity Services, Scottish Executive Board. 13 NMC (2007) Record Keeping, Record Keeping Advice Sheet New Template. UK 14 NMC (2006) What does a Midwife Do [online].Available from < http://www.nmc-uk.org/aArticle.aspxArticleID=2099> [Accessed 12 April 2008]. 15 NMC (2008a) Patients Help Crack Nurses' And Midwives' Code [online]. Available from [Accessed 12 April 2008]. 16 NMC (2008b) The Code in Full[online]. Available from < http://www.nmc-uk.org/aArticle.aspxArticleID=3056> [Accessed 12 April 2008]. 17 NPEU (2007) Recorded delivery: A national survey of women's experience of maternity care. 18 OED (2002) Online English Dictionary [online]. Available from < http://www.dictionary.com/> [Accessed 12 April 2008]. 19 Quality Assurance Agency for Higher Education (2002) Scottish subject benchmark statement Midwifery [online]. Available from [Accessed 12 April 2008]. 20 RCM (2005) Definition of the midwife [online]. Available from < http://www.rcm.org.uk/info/docs/260905154704-376-1.doc> [Accessed 12 April 2008]. 21 RCM (2006) Royal College of Midwives Position Paper 26.Refocusing the role of the Midwife. RCM : London 22 Tilley, S. (2004) Accountability in Nursing and Midwifery. Blackwell Publishing :Oxford, UK. Read More