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education links National Review of Nursing EducationMidwifery EducationLiterature Review and Additional Material (Revised Edition)5. Discussion
5.1 Issues in Midwifery Education that Australia Shares with Other CountriesThe chapters in this Review that give an overview of midwifery in other countries – the UK, New Zealand, Canada, the Netherlands and the USA - suggest that there are many issues that are common to both Australia and these other developed nations. In considering common themes the reviewers have decided to include, as an appendix, the Association of Radical Midwives A Vision for Midwifery Education (ARM 1999): Appendix E. This document is already informing policy direction in the same way that the ARM seminal text, The Vision: Proposals for the Future of Maternity Services (1986) drove policy, not only in the UK, but also in other the countries included in this literature review (personal communication, Ishbel Kargar, Secretary to ARM). The themes addressed in the ARM document (1999) are included here along with other issues of common interest that were identified during the course of carrying out this literature review. 5.2 Support and Education for Midwives to Address New Models of CareThe need to design continuing education programs to address the needs of midwives working in new models of care has been articulated in all western countries including Australia (NSW Health 2000c, Leap 1999, Pope et al 1996, UKCC 1999, Mason & Freeman 2001). A significant large research and development project was commissioned by the English National Board (Pope et al 1996) to identify the changing professional development needs of midwives following the publication of Changing Childbirth (DOH 1993). A multiple case study approach including all key stakeholders in maternity service provision identified issues that may affect midwives from carrying out the full range of activities for which they are trained and elicited the midwives’ identified learning needs. Graham et al (1999) have described the qualitative methods used in this comprehensive study that involved questionnaires, focus groups, and individual interviews. The main areas identified were research skills, clinical skills and counselling and communication skills (Pope et al 1996). The findings were used for the primary purpose of developing a distance educational package (English National Board 1996). As articulated in the AMAP Education Survey and in Appendix E (ARM 1999) placements for students in midwifery practices or models where midwives have caseloads and can foster an apprenticeship or mentorship relationship are optimal. This model not only prepares graduates who can care for women in women-centred services, it enables students to identify and meet their own learning needs and promotes lifelong learning skills. 5.3 Midwifery Teaching and Learning FrameworksThere is common agreement in midwifery curriculum documents that an evidence-based approach to midwifery is essential. Page (2000) describes the ‘Five Steps of Evidence Based Midwifery’. Homer and Leap’s paper (2001) describing how this model can be used as a framework for midwifery education programs within a ‘woman centred’ philosophy has been included in Appendix F as an example of a model of excellence. This framework encourages preparation for clinical decision-making using ‘real cases’ (Homer and Leap 2001, Cioffi 1998, ARM 1999). The term ‘problem based learning’ is considered inappropriate for midwifery models of practice and education since the name suggests pathology, therefore the terms ‘situated learning’ (personal correspondence Dr. Kathleen Fahy) and ‘Inquiry based learning’ have been adopted as alternative nomenclature to describe a similar method of teaching and learning. The University of Southern Queensland innovations in teaching and learning and flexibility of approach could inform much needed educational innovation nationally [Section 3.2.3]. Methods of teaching and learning also need to assist in the development of the personal and interpersonal skills outlined in Appendix E (ARM 1999). Sharing of personal experience, birth stories, peer review and reflection are all valuable learning tools in midwifery courses (ARM 1999). Shared learning with inter-disciplinary, multi-professional groups can provide diverse understanding of different view points and should be developed with clear educational objectives as opposed to in response to cost-cutting (ARM 1999). 5.4 Supporting Student MidwivesSeveral studies have highlighted the need to support and nurture student midwives (Begley 1999a 1999b, 2001, Jackson 1995, Yearley 1999) and address the potentially stressful nature of student midwives’ experiences, particularly around the hostility of qualified staff (NSW HEALTH 2000b, Begley 2001). Other sources of stress cited by student midwives include anxiety regarding finding work on completion of study, organisation of the learning environment, perceptions of poor practice, long hours, poor job prospects, inadequate funding of educational resources, low wages, poverty and home versus study demands (Cavanagh 1997a, 1997b, Wallis 1996). Litchfield (1997) acknowledges the stress of being a student midwife and suggests careful time and task management as strategies to reduce stress and enhance confidence. Students have also raised concerns about inappropriate clinical experience, over assessment and lack of uniformity between courses (Jackson 1996). The increasing use of technology in childbirth and escalating caesarean section rates limit the opportunity for students to learn about normal childbirth (Davies 1996, Hunt 2000). An Australian study (Barnes 1997) discusses student midwives’ concerns about the struggle to develop a distinct professional identity and a woman-centred approach in the light of realities of medical dominance, the increasing use of technology and restricted choices for women. Barnes suggests an acknowledgment of power in relationships and a re-conceptualisation of the boundaries of knowledge and expertise within a clear midwifery philosophy as a first step to addressing the disjunction between ideology and practice expressed by students. The lack of collaboration between the health industry and universities appears to exacerbate student isolation and does not assist them feel or become members of a team. The lack of investment of skills and resources in programs now in universities is to the detriment of quality of caring for students who are potential colleagues and midwives. The supernumerary status of students can contribute to this. 5.5 Supernumerary versus employed statusSome midwifery educators have advocated for students to have supernumerary status in both the UK and Australia. This is in order to avoid situations described in studies by Begley (1999a, 1999b) in Ireland and Chamberlain (1997) in the south of England or Australia in the early 1980’s (Barclay 1985). Students described seeing themselves as part of the workforce and believed that their educational needs were denied. Much of their learning took place by ‘trial and error’. Both studies highlight the need for mentorship/preceptorship in clinical areas and more support in terms of their teachers being present and competent to practise. Some midwifery course coordinators in the AMAP education survey recognised the need to avoid situations where students are used ‘as another pair of hands’ but highlighted situations where students with supernumerary status are disadvantaged through being marginalised and excluded, and not getting experience of the culture of midwifery or clinical leadership through being actively involved and ‘part of the team.’ The UTS program runs jointly with industry and demonstrates the issue is more complex than simply employment status. It is about how little or much of the learning of students is valued in the clinical field where they are placed. 5.6 Midwifery Competency AssessmentIn recent years it has become widely accepted in many countries that the midwifery profession needs a comprehensive definition of competence to ensure that its practitioners are safe and able to meet the identified needs of childbearing women (UKCC 2001, Worth-Butler et al 1994, Worth-Butler et al 1996, Phillips et al 2000, Fullerton 1994, Govaerts et al 2001, Fraser 1997a, 1997b). The task of arriving at a comprehensive method of competency assessment in midwifery has been identified as problematic and complex (Worth-Butler et al 1994, Peters 1993). As Page (1993) states, there is a need to develop midwifery practitioners ‘who are able to balance a triangle of intellectual, personal and clinical skills… woven together in subtle ways… competent midwives are able to be skilled, wise and able to work in friendship with the woman and her family.’ Assessing such attributes is clearly a challenge. In evaluating three-year midwifery education programs, Fraser and colleagues (1998) designed a conceptual model of competence required by a midwife at the point of initial registration, against which assessment strategies could be evaluated and developed. This followed an extensive review of the literature to arrive at a theoretical framework to consider competence in midwifery as well as an extensive review of all stakeholders’ opinions, including relevant professional bodies, teachers, practising midwives and women and their families. Hindley (1996) also identified the need to link competencies to specific standards. In considering assessment of clinical competence from the point of view of both assessors and student midwives in a small study, she recommends that educators look beyond creating a theoretical framework for assessing competency to providing a practical framework for its use (Hindley 1999). She identified a lack of time, staff and resources as factors that inhibit learning and competency assessment. It is interesting to note that the New Zealand Standards for Registration of Midwives addresses only four broad competencies:
(Nursing Council of New Zealand. Standards for Registration of Midwives 1996) 5.7 Attraction, Attrition and Retention of Midwives5.7.1 Attrition of Midwifery StudentsThe AMAP education survey demonstrates that the major reason for student attrition is financial hardship. Students, who are employed, (eg. UTS midwifery students are employed 4-days a week) do not have these problems and have an excellent exposure and competence development with health services employed educators. Similar problems of student hardship are described in other countries where students receive little or no funding for undertaking midwifery education. Mander (1986) describes various studies in Scotland that have showed that the majority of qualified midwives are working outside of midwifery and that only a quarter of those who are qualified are still practising midwifery. A longitudinal study of the employment decisions of nurses who undertake midwifery education began in late 1980. The respondents suggested changes to the organisation of midwifery services as the main strategy to address retention. Lack of support for new graduates featured large in the interviews as it did in the study of new graduates carried out recently in New South Wales (2000b). Mander’s (1986) study demonstrated that new midwives with longer nursing experience are more likely to leave midwifery and that the converse holds, in that those with little nursing experience are significantly more likely to practise as midwives. Student midwives with higher educational attainment were significantly more likely to practise midwifery on qualifying and the study suggested that lower age may be associated with continuing midwifery practice. 5.7.2 Attraction and Retention of Midwifery StudentsIn all countries whose three and four year programs are offered, demand exceeds the number of places available. Tracy et al (2000) suggest in their recent paper that it appears that a B Mid might attract a new category of student, help address the shortage of those going into programs and accelerate graduation rates. Strong evidence of this has been provided by an 'e-mail' request for information generated for the purpose of this Review. This confirmed considerable support for the program in the community. For example Victorian information showed one university alone had in excess of 580 students expressing interest through Victorian Tertiary Admission Centre (VTAC). In South Australia, the University of South Australia and Flinders University, Adelaide each had over 200 ‘first choice’ applicants for the places they initially offered in the new 3 year Bachelor of Midwifery.1 Competition was equally as keen in the new BMid courses in Victoria. In NSW and ACT as elsewhere, and despite no publicity for the program, there are regular and frequent inquiries about the program. The University of Technology, Sydney, Canberra University and Southern Cross University are responding to high interest by forming a partnership to develop Bachelor of Midwifery programs in 2003. 5.8 Part-time versus Full-time StudyGlover (1992, 1999) has advocated strongly for part-time midwifery education in Australia. Educators involved in 4-day employed programs would strongly disagree. Part-time study is not an option in three and four-year programs in Europe although the ARM report (1999) suggests that part-time study should be an option. In reviewing midwifery development in Canada, Tyson (2001) suggests that part-time study should be phased out, as it is inappropriate for primary care provider programs. She identifies that part-time study increases attrition and distraction of focus for students and that it takes many years to develop a midwifery identity. She questions the quality of clinical learning when there are long periods of time between introductory subjects and practice subjects and suggests that part-time study contributes to the problem of insufficient midwifery population, not to the solution. 5.9 Selection of StudentsSteele (1998:268) suggests that academic achievement as a gateway to the profession needs careful consideration if universities are to compete with other professions ‘to attract bright students with excellent communication skills and a level of compassion that will facilitate sensitive practice’. She highlights growing concerns in the UK about the increasing trend not to interview candidates for midwifery programs due to constraints of time and expense. She suggests a combination of academic achievement, personal statement, group interview and face-to-face interview and the involvement of as many midwifery teachers and clinicians in the process as possible as the ideal. In her opinion, group interviews enable applicants to demonstrate their communication and interpersonal skills and one-to-one interviews give them an opportunity to demonstrate a genuine interest and enthusiasm for midwifery from a position of strength. Midwifery educators in New Zealand, Canada and the Netherlands would agree with Steele (1998) in thinking that selection processes should include interviews, personal statements and group exercises (field notes on study tours, personal communications). The ARM document (1999) suggests that potential students should submit a "portfolio" ‘of evidence of a vocational calling to midwifery’. The experience of starting the first 3-year Bachelor of midwifery programs in South Australia has demonstrated resistance from universities to the idea of any of these selection processes on grounds of equity. Attention needs to be given as to whether previous academic achievement is the only criteria to be addressed in selecting students for midwifery programs in Australia. 5.10 Regulation for Midwifery EducationAn important publication arising from the AMAP study, Contemporary Issues in Australian Midwifery Regulation, has recently been published in The Australian Health Review (Brodie & Barclay 2001). Following examination of all state and territory regulations, in regard to the approval of courses and institutions the authors conclude:
The authors point out that all current assessment regulations for midwifery fall well short of those required by the regulating bodies of other industrialised countries. They cite as an example the requirement in Europe for midwives to participate in at least 40 births and in Canada 60 births before receiving registration. They also point out that in the United Kingdom, Canada and New Zealand, regulatory Boards use agreed national criteria to accredit not only curricula but also teachers, facilities and services:
All Nurses Acts in Australia currently see midwifery as a ‘branch’ or ‘specialty’ of nursing and therefore refer to midwives as nurses. According to Brodie and Barclay, this has serious implications for the regulation of those midwives who have never been nurses and who would not seek to hold themselves out as nurses. The authors cite anecdotal reports of increasing numbers of ‘direct entry’ midwives from countries such as England, New Zealand and Canada seeking and obtaining registration in Australia. They highlight the potential dangers of a situation where, in some cases, these persons are being ‘licensed’ to practise both as midwives and as nurses and suggest that serious attention needs to be given to such matters to ensure that regulation in all states and territories, truly ‘protects the public’ and addresses consistent standards. Clearly, the imminent introduction of the 3-year BMid across Australia will focus attention on the inadequacy of regulation for midwifery that is embedded within nursing regulation that addresses standards in nursing education and practice. As the authors point out:
As has been highlighted in the section of this review that addresses the introduction of the 3-year Bachelor of Midwifery across Australia, the ACMI National Bachelor of Midwifery Taskforce has been developing standards for the accreditation of the new courses. The aim is to ensure national consistency and international compatibility. This also means graduates of the courses are not disadvantaged should they wish to work overseas. A first draft of these standards was circulated recently to all regulatory authorities for comment. In principle these standards were received with enthusiasm and comments were fed back to the ACMI via the Australian Nursing Council Incorporated (ANCI). A second draft is in preparation and will be circulated for comment along with a suggested structure of how the regulatory Boards might work in conjunction with the ACMI to accredit BMid programs and ensure that all BMid curriculum documents meet these new national standards. Documents from the ACMI regarding the development of accreditation standards for midwifery education have made it clear that the overall aim of the ACMI is that these standards should eventually apply to all education programs leading to initial license to practise midwifery. Consideration of this will challenge universities who provide programs for nurses wishing to become midwives. For example, currently none are able to meet standards such as the clinical practice requirement for students to follow at least 20 women through their experience of pregnancy, labour and the early postnatal period; or to ‘receive the baby2 for a minimum total of 40 women giving birth3 (ACMI draft Standards for the Accreditation of 3-year Bachelor of Midwifery programs March 2002). At a recent AMAP meeting, midwifery managers who were present as industry partners representing ‘Women’s Hospitals Australasia’, welcomed the development of these standards, especially the intended minimum clinical requirements. They expressed concern that these standards should apply to all courses, not just the 3-year BMid, in order to raise the quality of all graduates of midwifery education throughout Australia. The ACMI is currently also engaged in re-writing the ACMI Competency Standards for Midwives with the aim of these being adopted by all regulatory authorities in the future. It is proposed that these competency standards will also be compatible with international competency standards for midwives. ACMI initiatives to develop standards, such as those outlined here are severely hampered by the lack of statutory provision for midwifery involvement, consultation and ownership in regards to regulation in all Australian states and territories (Brodie and Barclay in press, 2001). Often committees with responsibility for designing and implementing regulation that pertains to midwifery have token representation from midwives or the ACMI, or no representation at all. Thus, regulation continues to treat midwifery as a speciality of nursing and in so doing, hampers the development of appropriate education for contemporary practice and protection of the community. 5.10.1 International policy directions related to regulationAn important inquiry in Britain, The Bristol Royal Infirmary Inquiry (2001), confirms the parlous state and need to improve, for patient safety, the oversight of systems that control the education of health workers. This report suggests radical reforms in regulation that are worthy of consideration in Australia, particularly when considering the collaborative role of midwives: This includes a system of regulation in place to ensure that health care professionals acquire and maintain professional competence. In their terms, regulation includes education, registration, training, continuing professional development, revalidation and discipline. The inquiry also states that Continuing Professional Development (CPD), periodic appraisal and evaluation must be compulsory for all health care professionals. Foot Notes: 1.In the first courses, the University of South Australia offered 25 places and Flinders University, Adelaide offered 50 places in the new 3 year BMid. 2.‘Receiving the baby’ is used by the ACMI in these standards in the interest of developing woman centred language in midwifery. It replaces the commonly used phrase ‘delivering the baby’. It generally means receiving the woman’s baby from her at the moment of birth and includes working with the woman to birth her placenta. It does not include ‘receiving the baby’ at caesarian section, instrumental birth, or any situation where the student is not the primary birth attendant. 3.Currently in Australia, the minimum requirements vary in each state and territory. No regulations require students to ‘receive’ more than 20 babies as the primary birth attendant. |
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